Case of neuropathy when lying down

[AttackNME]

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Hello folks, I'm a 3rd year podiatry student (no jokes please!), and I had a patient today with a puzzling form of neuropathy and I hope this is an appropriate place to ask; if not, my apologies in advance.

70 year old AA M hx of prostate cancer, LBP, Hep B/C, DVTs, meningioma in brain, presents with tingling/numbness and sometimes painful paresthesia to dorsal foot b/l but worse on R only when lying down at night since a year ago. In addition he has several "knots" to RLE, including a 0.5cmx0.5cm mass to L dorsolateral midfoot which was surgically removed and microscopy reports dense fibrous tissue with focal myxoid degeneration consistent with ganglion cyst. However, this cyst kept returning and despite multiple aspirations, was still palpable today.

Previously, he saw ortho who did not think the paresthesias were related to the back, and suggested d/c Lupron for his CA thinking that the peripheral neuropathy was drug-induced. Despite d/c of Lupron and trying Neurontin for some time, paresthesia persists.

EMG report found decreased amplitude to sural sensory and motor nerves, and concluded with chronic bilateral L5-S1 radiculopathy with mild axonal loss.

Looking back through the charts, this man consistently reported that his paresthesias are only when lying down at night and gets relief on dependent position and knee bending. Despite conflicting reports with the lower back pain's contribution, he is to receive physical therapy for his back later this week.

TL;DR:
What is your ddx of a possible mononeuritis multiplex with axonal degeneration symptomatic on lying down, relief on knee-bending/dependent-position that manifests as paresthesia to dorsum of foot extending into distal leg, multiple "knots" to R lower extremity (i don't have biopsy report on that), and recurrent ganglion cyst to L foot.

 

[dyeguy21]

The only thing I can think of due to the "knots", Hep B/C history is the possibility of polyarteritis nodosa.

 

[michaelrack]

you may want to try the neurology forum

 

[dr zaius]

If it's strictly positional it makes me think compression. Is he a very thin man?

 

[Beta Cell]

Lol, don't say things like "I'm a podiatry student (no jokes please!)." Don't be ashamed of what you've been doing for three years. Even if you're not, that statement makes it sound like you are.

 

[AttackNME]

@dyeguy21 - The description fits very well, the subcutaneous nodules were distinctly palpable with dark pigmentation on the skin (is that how PAN nodules appear?). i'll update if we ever decide to work him up for PAN

@drzaius - He was slightly overweight

@BetaCell - Only added that because I didn't want foot jokes in this thread, trying to keep it professional :] (or as much as possible being this an internet forum)

 

[sineapse]

Hello folks, I'm a 3rd year podiatry student (no jokes please!), and I had a patient today with a puzzling form of neuropathy and I hope this is an appropriate place to ask; if not, my apologies in advance.

70 year old AA M hx of prostate cancer, LBP, Hep B/C, DVTs, meningioma in brain, presents with tingling/numbness and sometimes painful paresthesia to dorsal foot b/l but worse on R only when lying down at night since a year ago. In addition he has several "knots" to RLE, including a 0.5cmx0.5cm mass to L dorsolateral midfoot which was surgically removed and microscopy reports dense fibrous tissue with focal myxoid degeneration consistent with ganglion cyst. However, this cyst kept returning and despite multiple aspirations, was still palpable today.

Previously, he saw ortho who did not think the paresthesias were related to the back, and suggested d/c Lupron for his CA thinking that the peripheral neuropathy was drug-induced. Despite d/c of Lupron and trying Neurontin for some time, paresthesia persists.

EMG report found decreased amplitude to sural sensory and motor nerves, and concluded with chronic bilateral L5-S1 radiculopathy with mild axonal loss.

Looking back through the charts, this man consistently reported that his paresthesias are only when lying down at night and gets relief on dependent position and knee bending. Despite conflicting reports with the lower back pain's contribution, he is to receive physical therapy for his back later this week.

TL;DR:
What is your ddx of a possible mononeuritis multiplex with axonal degeneration symptomatic on lying down, relief on knee-bending/dependent-position that manifests as paresthesia to dorsum of foot extending into distal leg, multiple "knots" to R lower extremity (i don't have biopsy report on that), and recurrent ganglion cyst to L foot.

My gut feeling is you are getting distracted by the knots on the foot and the ganglion.

EMG report found decreased amplitude to sural sensory and motor nerves, and concluded with chronic bilateral L5-S1 radiculopathy with mild axonal loss.

Isn't the diagnosis pretty much given there? Prostatic mets? Maybe a bit of spinal stenosis? Nerve root impingment from degenerative
changes?

Done an MRI of the lower back?

 

[loveoforganic]

I'm only a first year, so this is frankly a wild guess, but it seems like severe lower extremity peripheral vascular disease could lead to something like that, i.e. ischemic pain due to decreased perfusion when removing the increased flow due to hydrostatic pressure?

 

[RafaTech]

I'm only a first year, so this is frankly a wild guess, but it seems like severe lower extremity peripheral vascular disease could lead to something like that, i.e. ischemic pain due to decreased perfusion when removing the increased flow due to hydrostatic pressure?

That does not make much sense. PVD presents during exertion (ie walking) due to the vasculature not adequately meeting the oxygen demand of the active lower extremity muscles. Its called claudication, kind of like angina of the legs.

 

[loveoforganic]

I agree that if what I said were the case he should also have exertion-induced pain, and in rereading, it doesn't account for the changing positions while in bed relieving pain, but there can be positional pain in peripheral vascular disease, can there not?

 

[Valadi]

ganglion cysts are are a red herring. they do tend to keep recurring fwiw

radiculopathy fits best. next, this man may have bilateral tarsal tunnel syndrome, although the history isn't classic for it. i thought emg/ncs could differentiate between these two, though? then all the stuff you mentioned. i feel like anything is far higher on the list than any hepatitis associated paresthesia/neuralgia.

The great thing about neuro is that it is highly logical. You can isolate it to a specific area of injury based on history, and then proceed with diagnostic workup to determine cause. All the VITAMINs of your differential are on the table.

@loveoforganic, yes severe pvd can be position dependent. you'll find your serious vasculopaths sleeping in a chair so their legs can dangle down

 

[SpecterGT260]

Ganglion cysts will return with only aspiration.... that's kinda their thing - its what they do. And unless directly compressing another nerve I am not aware of them causing neurological symptoms. Id stop considering them all together. Diagnostically they are about as relevant as freckles

 

[SpecterGT260]

When is the last time he had his prostate checked?

 

[SpecterGT260]

Missed the hx. Recumbent nocturnal pain in lower limb can be a result of venous congestion associated w cancers particularly of the prostate in older men

 

[Instatewaiter]

- unilateral Tingling numbness when laying down
- Better when dependent
- knots on the dorsum of foot
- prostate cancer, hep B/C, meningioma
- EMG shows low amplitude of sural AND motor nerves with L5-S1 radiculopathy

@dyeguy21 - The description fits very well, the subcutaneous nodules were distinctly palpable with dark pigmentation on the skin (is that how PAN nodules appear?). i'll update if we ever decide to work him up for PAN

@drzaius - He was slightly overweight

@BetaCell - Only added that because I didn't want foot jokes in this thread, trying to keep it professional :] (or as much as possible being this an internet forum)

My thoughts
- has hep B and C so cryoglobulinemia is high on the differential
- Has prostate cancer: taxols (a type of chemo) cause peripheral neuropathies and radiation can cause lumbosacral plexopathies both of which could present like this
- More dependent position makes me think of rest pain (as in ischemia)- do a ABI and TBI
- Has Hep B and C, I'm assuming he was an IVDU so could be HIV
- Laying down only- ask about clothes at bedtime- could be a meralgia paresthetica

 

[nd15]

Hello folks, I'm a 3rd year podiatry student (no jokes please!), and I had a patient today with a puzzling form of neuropathy and I hope this is an appropriate place to ask; if not, my apologies in advance.

70 year old AA M hx of prostate cancer, LBP, Hep B/C, DVTs, meningioma in brain, presents with tingling/numbness and sometimes painful paresthesia to dorsal foot b/l but worse on R only when lying down at night since a year ago. In addition he has several "knots" to RLE, including a 0.5cmx0.5cm mass to L dorsolateral midfoot which was surgically removed and microscopy reports dense fibrous tissue with focal myxoid degeneration consistent with ganglion cyst. However, this cyst kept returning and despite multiple aspirations, was still palpable today.

Previously, he saw ortho who did not think the paresthesias were related to the back, and suggested d/c Lupron for his CA thinking that the peripheral neuropathy was drug-induced. Despite d/c of Lupron and trying Neurontin for some time, paresthesia persists.

EMG report found decreased amplitude to sural sensory and motor nerves, and concluded with chronic bilateral L5-S1 radiculopathy with mild axonal loss.

Looking back through the charts, this man consistently reported that his paresthesias are only when lying down at night and gets relief on dependent position and knee bending. Despite conflicting reports with the lower back pain's contribution, he is to receive physical therapy for his back later this week.

TL;DR:
What is your ddx of a possible mononeuritis multiplex with axonal degeneration symptomatic on lying down, relief on knee-bending/dependent-position that manifests as paresthesia to dorsum of foot extending into distal leg, multiple "knots" to R lower extremity (i don't have biopsy report on that), and recurrent ganglion cyst to L foot.

Skimmed it, seems interesting. Any verdict reached on it?

 

[AttackNME]

My gut feeling is you are getting distracted by the knots on the foot and the ganglion.



Isn't the diagnosis pretty much given there? Prostatic mets? Maybe a bit of spinal stenosis? Nerve root impingment from degenerative
changes?

Done an MRI of the lower back?

Sorry folks but i failed to mention that the ortho doc already did an MRI and was inconclusive, here is his report verbatem:

"Lumbar MRI shows noncompressive degenerative disk disease. He has a very small right L3-L4 prolapse which has no correlation whatsoever with the symptoms. The feet are tingling and burning. Again there is no directional preference. He has weakness in the legs, but they have not given way. He denies change in weight or pertinent GU or GI review of systems. Active and passive straight leg raising maneuvers are negative. Of note is the fact he has been treated for a brain tumor and prostate carcinoma. He is on Lupron.

This likely is a peripheral neuropathy. I think it may be due to the Lupron. This is not coming from his spine."

If it was prostatic mets, I believe the symptoms should be progressively worse, but it has not changed for the past year.

@SpecterGT - not sure when was his last prostate check, and like a few others suggested, I'm starting to think that the ganglion cyst is unrelated as well.

@Instatewaiter - I don't remember seeing livedo reticularis, and I have asked if he had paresthesia to UE/LE/face in cold weather; he said no. ABI/TBI/HIV tests I would definitely try to do if I get a chance to see this patient again. Asking about bedsheets/clothes bothering him at bedtime is a great idea, I'll try that if I see him, however i thought meralgia paresthetica is just lateral thigh pain, it affects dorsal foot too?

@nd15 - I'd love to reach the bottom of this too, but it's gonna be like a TV series, this may take awhile since our clinic don't have students follow up on their own patients, so I won't be able to implement the suggests of the SDN forum members, but I'll try!

Nevertheless I think this is a good exercise to strengthen my differential, thanks for the comments guys!

 

[Dr Hurly MD]

Hello folks, I'm a 3rd year podiatry student (no jokes please!), and I had a patient today with a puzzling form of neuropathy and I hope this is an appropriate place to ask; if not, my apologies in advance.

70 year old AA M hx of prostate cancer, LBP, Hep B/C, DVTs, meningioma in brain, presents with tingling/numbness and sometimes painful paresthesia to dorsal foot b/l but worse on R only when lying down at night since a year ago. In addition he has several "knots" to RLE, including a 0.5cmx0.5cm mass to L dorsolateral midfoot which was surgically removed and microscopy reports dense fibrous tissue with focal myxoid degeneration consistent with ganglion cyst. However, this cyst kept returning and despite multiple aspirations, was still palpable today.

Previously, he saw ortho who did not think the paresthesias were related to the back, and suggested d/c Lupron for his CA thinking that the peripheral neuropathy was drug-induced. Despite d/c of Lupron and trying Neurontin for some time, paresthesia persists.

EMG report found decreased amplitude to sural sensory and motor nerves, and concluded with chronic bilateral L5-S1 radiculopathy with mild axonal loss.

Looking back through the charts, this man consistently reported that his paresthesias are only when lying down at night and gets relief on dependent position and knee bending. Despite conflicting reports with the lower back pain's contribution, he is to receive physical therapy for his back later this week.

TL;DR:
What is your ddx of a possible mononeuritis multiplex with axonal degeneration symptomatic on lying down, relief on knee-bending/dependent-position that manifests as paresthesia to dorsum of foot extending into distal leg, multiple "knots" to R lower extremity (i don't have biopsy report on that), and recurrent ganglion cyst to L foot.

1) Large fiber and small fiber peripheral neuropathy of the legs and feet secondary to either:

a) HepB/C infection

b) Peripheral Vascular Disease (i.e. the vasa nervorum has poor blood flow of oxygenated nutrient rich blood to the peripheral nerves innervating the legs and feet),

c) chemotherapy medications used to treat his cancers

d) paraneoplastic syndrome from his cancers

2) Radiculopathy

Podiatry student, you have an EMG/NCV report that suggests the diagnosis. Big hint.

I also suggest Epidermal Nerve Fiber Density analysis should be done (gold standard for SMALL FIBER peripheral neuropathy)

 

[modsar]

Is it only at night/laying down or is it that he only notices it when he is laying down?? Does it EVER occur during the day? Is he diabetic?

Ddx- RLS?