CASE REPORT   

Gazzetta Medica Italiana - Archivio per le Scienze Mediche 2020 October;179(10):594-8

DOI: 10.23736/S0393-3660.19.04221-9

Copyright © 2019 EDIZIONI MINERVA MEDICA

lingua: Inglese

Late-onset mononeuritis multiplex: the importance of differential diagnosis

Sofia F. TAVARES ✉, Vanessa M. CHAVES, Verónica B. GUIOMAR, Pedro M. RODRIGUES, Ana O. MONTEIRO, Inês S. FERREIRA, Teresa ANTUNES

Department of Internal Medicine, Centro Hospitalar de S. João, Porto, Portugal

Mononeuritis multiplex is a peripheral neuropathy most frequently associated with primary systemic vasculitis, but also associated with neoplastic and infectious disorders. We report a case of a 62-year-old woman with leukopenia and a lower extremity neuropathy with motor and sensitive deficits, for 6 months. She had no other symptoms. Except for the neurologic deficits, her physical exam was unremarkable. Previous hematologic study had revealed multiple cervical, thoracic and abdominal pericentimetric adenopathies and immunoelectrophoresis, myelography and bone biopsy were performed with no significant abnormality. Needle electromyography revealed subacute multiple mononeuropathy. Imaging re-evaluation showed stable adenopathies. Axilar node biopsy was performed with nonspecific histological results. An extensive study of primary systemic vasculitis and infectious disorders was performed and a high titre of antinuclear and anti-dsDNA antibodies stood out. A diagnosis of systemic lupus erythematosus was established and treatment was started with methylprednisolone pulse therapy for 3 days followed by prednisolone 0.5 mg/kg/day and hydroxychloroquine 400mg/day. Clinical improvement was observed. Maintenance therapy was accomplished with azathioprine allowing progressive reduction of prednisolone and analgesics. Later on, the immunohistochemistry results of the biopsied lymph node were suggestive (but not confirmative) of a follicular lymphoma. A lymph node excision to confirm the diagnosis was attempted but unsuccessful. Given the asymptomatic state of the patient and the indolent natural course of follicular lymphoma, no further interventions were pursued and observational approach was maintained.

KEY WORDS: Lupus erythematosus, systemic; Mononeuropathies; Leukopenia; Lymphoma