Faculty Bibliography

Peripheral neuropathy is one of the most prevalent neurologic conditions encountered by neurologists and nonneurologists. Geriatricians and primary care physicians often face the task of screening patients for early neuropathy when they have underlying conditions such as diabetes mellitus and evaluating patients who report new symptoms that suggest neuropathy. An understanding about different forms of neuropathies based on anatomic pattern and type of nerve fiber involvement and ability to perform basic neurologic examination reliably can help determine how to pursue further investigations and identify those patients who are likely to benefit from early specialist referral.

OBJECTIVES/OBJECTIVE:We report a case of immune myopathy with perimysial pathology associated with anti-glycyl-transfer RNA synthetase (anti-EJ) antibody and an excellent treatment response. METHODS:Chart review. RESULTS:A 36-year-old woman presented with 3 months of fatigue, weight loss, progressive weakness in a scapuloperoneal distribution, and dysphagia. Nerve conduction studies, electromyography, and ultrasound suggested an irritable myopathy. She had marked elevations of creatine kinase and positive anti-glycyl-transfer RNA synthetase (anti-EJ) antibodies. A left biceps muscle biopsy revealed inflammation of the perimysium and surrounding perimysial blood vessels with focal fragmentation of the perimysium. Further evaluation revealed interstitial lung disease. Treatment with prednisone and mycophenolate mofetil led to marked clinical improvement of her symptoms. CONCLUSIONS:Our case adds to the growing spectrum of inflammatory myopathies and highlights the importance of performing a comprehensive, multisystem workup.

INTRODUCTION/BACKGROUND:Carpal tunnel syndrome (CTS) is a common clinical syndrome seen in the outpatient setting that is easily confirmed by electrodiagnostic testing. METHODS:We describe the case of a patient who presented with the classic symptoms and neurological examination for CTS, but had a normal nerve conduction study and electromyogram. RESULTS:Neuromuscular ultrasound of the median nerve on the symptomatic side revealed penetration of the nerve by a persistent median artery and vein in the mid-forearm, with a positive sonographic Tinel sign over this spot. This finding is an anatomical variation that has been described sparingly in the literature, mostly in cadavers. It has not been reported previously to be a mimic of CTS. CONCLUSIONS:This case demonstrates the diagnostic utility of neuromuscular ultrasound and the importance of considering an anatomical variation involving the median nerve in the differential diagnosis of CTS.

We studied the clinical features of 85 cases of phenytoin toxicity in 76 patients treated at a general hospital. Serum levels of phenytoin on admission ranged from 30.3 to 95.0 micrograms/mL (median, 46.5). Iatrogenic causes of intoxication were common and included increased daily dosage and intravenous loading in the emergency room for single seizures in patients with subtherapeutic serum phenytoin levels. The most frequent neurologic findings were nystagmus (95%), ataxia (88%), lethargy (22%), and seizures (19%). Outcome was usually good, but three patients had serious complications