Zebra of the Day

Every so often, we run into an unusual condition that comes up for discussion on rounds or at a conference. I thought it might be fun to highlight these for the sake of expanding our store of differential diagnoses and especially for RITE preparation. I’ll provide a few sentences about the clinical presentation, and perhaps a scan, above the jump and then the diagnosis after. These will be brief–not monographs; I will provide links to further reading for those interested.

Case Presentation

A 40 year old man presents with 3 months of bilateral arm pain and numbness. The onset was acute. The pain is in both upper arms and the left forearm and is worse when he moves those limbs. The numbness has a burning quality and is located in the lateral aspects of the both upper arms and the lateral left forearm. A year earlier, he had had burning numbness of the left lateral leg that lasted for a month.

Exam shows loss of pinprick sensation over the areas described above and is otherwise normal.

Nerve conduction studies show low amplitude sensory nerve action potentials in the left lateral antebrachial cutaneous nerve. Sensory and motor nerve conduction studies and needle electromyography were all normal.

Diagnosis

Wartenberg’s migrant sensory neuritis

Acute sensory neuropathies are rare. Wartenberg described this condition in 1958 as a “recurrent, intermittent, remittent neuritis”; there have been several case reports since. The key clinical features are:

  • Acute onset
  • Discrete areas of sensory loss (i.e., individual nerves)
  • Pain, especially upon stretching the involved nerve
  • No motor involvement
  • Relapsing / remitting course

The prognosis is variable, with some patients experiencing good recovery from each relapse but others having persistent symptoms.

Pathologically, perineuritis has been described, prompting the use of immunosuppression. There is no good evidence showing the benefit of such, however.

(By the way, if you search Pub Med for R. Wartenberg, you’ll see that he’s published a bevy of papers on neurologic signs, such as “The Neurology of Bing”, “Winking Jaw Phenomenon”, “Head Dropping Test”, “Knee Dropping Test”, “Some Useful Neurological Tests”, etc.)

About Justin A. Sattin

I'm a vascular neurologist and residency program director. I created this blog in order to share some thoughts with my resident and other colleagues, and to foster my own learning as well.
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