An interesting case of neuropathy with skin lesions.

1. The Case
of Ms. SI
John Angelo Luigi S. Perez
June 19, 2015
St. Luke's College of Medicine

2. 48/F
Right-Handed
Roman Catholic
Kasambahay
Old Balara, QC

3. Foot Numbness

4. History of Present Illness
2
weeks
Ascending extremity paresthesia
R then L
LE then UE
1
week
1
day
A
No headache, dizziness,
slurring of speech, pain. (+) pruritus, pain

5. History of Present Illness
2
weeks
Ascending extremity paresthesia
R > L
LE > UE
1
week
Ascending extremity weakness
R > L
LE > UE
● Tripping
● Steppage gait
1
day
A
No headache, dizziness,
slurring of speech, pain. (+) pruritus, pain

6. History of Present Illness
2
weeks
Ascending extremity paresthesia
R > L
LE > UE
1
week
● Tripping
● Steppage gait
Legs gave way
(+) Fall
1
day
A
No headache, dizziness,
slurring of speech, pain. (+) pruritus, pain
Ascending extremity weakness
R > L
LE > UE

7. ● Hypertensive
 Amlodipine, uncompliant
● Non-diabetic
● Non-asthmatic
● No CA
● Unremarkable family history

9. Review of Systems
● Palpitations● Intermittent knee pains
● Pruritic rashes on legs
● Pruritic hands

10. Physical Examination
● Sallow skin
● Erythematous cheeks and
nose
● PPC, AS
● Moist mucosa, (+) ulcers
● No CLADs
● SLE, CBS
● AP, no murmurs, regularly regular
● Flat, soft
● Normoactive, non-tender
● Pulses full and equal
● Grade 2 bipedal edema
● Multiple, hyperpigmented,
lichenified lesions

11. MMSE
Cranial Nerves
I
II
III, IV, VI
V
VI
VII
VIII
IX
X
XI
XII
Neurologic Examination – Cranial Nerves

12. Neurologic Examination – Somatic Motor
55
54
44
55
33
0 2
Good tone and bulk
No fasciculations
Good irritability

13. Neurologic Examination – Tendon Reflexes
+++
+
++
0 0
(-) Toe extensor
+

14. Neurologic Examination – Somatic Sensory
90%
10%
60%
60%
10%
60%
100%
100%
30%
50%
50%
20%
(+) Romberg's sign
Cerebellum intact

15. Where do we localize the lesion?
Levelize?
Lateralize?
Localize?

16. Mononeuritis
Multiplex
● Asymmetric
● Asynchronous
● Painful
● Separate nerves

17. Salient Features
Subjective Objective
● 48/F
● 2 weeks
weakness and
numbness
● Palpitations
● Joint pains
● Pruritus
● Stable VS
● Sallow skin
● Facial erythema
● Rashes
● Buccal ulcers
● Bipedal edema
● Mononeuritis
multiplex

18. Mononeuritis Multiplex
+
Skin Lesions?

19. We have 3 differential diagnoses
● Diabetic Neuropathy
● Guillain-Barré Syndrome (AIDP)
● System Lupus Erythematosus

20. Diabetic Neuropathy

21. Guillain-Barré
Syndrome
(AIDP)

22. Systemic Lupus
Erythematosus

23. SLE is a multisystemic disease

24. Neuropsychiatric SLE (NPSLE) is
a recognized entity
62%
18%
8%
5%
5%1%
Headache
Seizures
CVD
Psychosis
Neuropathy
Movement
Muscal and Brey. Neurol. Clin. 28(1) 2010

25. Peripheral neuropathy attributed
to SLE is rare
96%
4%
SLE Related
Related
Florica et al. Semin. Arthritis Rheum. 41(2) 2011
Asymmetry 59%
Distal weakness 34%

26. Salient Features
Subjective Objective
● 48/F
● 2 weeks
weakness and
numbness
● Palpitations
● Joint pains
● Pruritus
● Stable VS
● Sallow skin
● Facial erythema
● Rashes
● Buccal ulcers
● Bipedal edema
● Mononeuritis
multiplex

27. Mononeuritis
Multiplex
secondary to
Systemic Lupus
Erythematosus

28. SLE is diagnosed using a set of
clinical and laboratory criteria

29. Various autoantibodies are useful
in the SLE workup
Harrison's Principles of Internal Medicine, 19th
Ed.

30. Complete Blood Count

31. Urinalysis

32. Renal Function and Electrolytes

34. Our patient's 2D echo showed
decreased heart function
● EF 43/39%
● Hypokinesia in inferior and
inferlateral wall of LV

35. Autoimmune Workup

36. Autoimmune Workup

37. EMG-NCV

38. Our patient satisfies the SLICC
criteria

40. The pathogenesis of SLE is
complex
Harrison's Principles of Internal Medicine, 19th
Ed.

41. SLE is managed according to the
severity of the disease

42. Course in the Wards
HD
1
D
Guillain-Barre
Syndrome
HD
11
HD
5
HD
3
HD
2
HD
4
HD
7
HD
6
HD
8
HD
9
HD
10

43. Course in the Wards
HD
1
D
Guillain-Barre
Syndrome
HD
11
HD
5
HD
3
HD
2
HD
4
HD
7
HD
6
HD
8
HD
9
HD
10
Given IVIg
Deficits fluctuated
(+) fever, pruritus

44. Course in the Wards
HD
1
D
Guillain-Barre
Syndrome
HD
11
HD
5
HD
3
HD
2
HD
4
HD
7
HD
6
HD
8
HD
9
HD
10
Given IVIg
Deficits fluctuated
(+) fever, pruritus
Rheuma: autoimmune workup
(+) Hematuria
Started on HCQ,
prednisone

45. Course in the Wards
HD
1
D
Guillain-Barre
Syndrome
HD
11
HD
5
HD
3
HD
2
HD
4
HD
7
HD
6
HD
8
HD
9
HD
10
Given IVIg
Deficits fluctuated
(+) fever, pruritus
Rheuma: autoimmune workup
(+) Hematuria
Started on HCQ,
prednisone
Cyclo-
phosphamide

46. QUIZ TIME!

47. A patient comes to your clinic complaining of
hematuria. He also admits to joint pains, reduced
appetite, fever and itchy arms. On PE, you note
reddish cheeks and a mouth sore. Your
impression is SLE.
1. What is the first immunologic test to confirm
your impression?
2. The autoantibody above turns out positive. How
will you manage your patient?

48. SLE is managed according to the
severity of the disease

49. Enumerate the following autoantibodies:
2. Correlates with disease activity
3. Associated with drug-induced SLE
4. Associated with lupus depression or
psychosis

50. Various autoantibodies are useful
in the SLE workup
Harrison's Principles of Internal Medicine, 19th
Ed.

51. 5. What is the most common presentation of
NPSLE?
6. Give 4 SLICC criteria that permit the
diagnosis of SLE.

52. Headaches are the most common
presentation of NPSLE
62%
18%
8%
5%
5%1%
Headache
Seizures
CVD
Psychosis
Neuropathy
Movement
Muscal and Brey. Neurol. Clin. 28(1) 2010

53. SLE is diagnosed using a set of
clinical and laboratory criteria

54. Today's Learning Points

55. Questions?