Shireen Jacob1, Xiangping Li2, Laura Wu2, James McHenry3, Meghana Koleti3, Malvika Ramesh3, Kian Abdul-Baki3
1Neurology, University of Texas Medical Branch at Galveston, 2University of Texas Medical Branch (UTMB), 3UTMB
Background:
Chronic inflammatory axonal polyneuropathy (CIAP), an axonal chronic inflammatory demyelinating polyneuropathy’ (CIDP), has been reported since 1990’s. However, there are many controversies regarding this diagnosis. Here we report an unusual case of lead toxicity presenting with progressive weakness and numbness mimicking CIAP.
Results:
A 33-year-old male with history of mood disorders and methamphetamine use presents with a three-month history of progressive weakness and numbness. He initially developed bilateral foot numbness, followed by weakness in upper and lower extremities. On examination, he was noted to have decreased muscle strength with upper extremities worse than lower extremities. He also had decreased sensation and hyporeflexia involving all extremities. Infectious and autoimmune work up including MRI and CSF studies were unremarkable. EMG/NCV showed large fiber, axonal sensorimotor polyneuropathy. Patient was presumed to have CIAP based on his EMG/NCS. He was started on IVIG, with minimal improvement in symptoms. His blood lead level was found to be > 100 mcg/dl and further work up demonstrated fragmentation of retained bullet in the right knee. Patient underwent knee arthrotomy and started on succimer monotherapy with significant improvement in motor strength.
Conclusions:
This case highlights an uncommon presentation of lead poisoning leading to profound motor and sensory deficits mimicking CIAP. Our patient meets the following 2 criteria for CIAP including acquired chronic progressive or relapsing symmetrical or asymmetrical polyneuropathy with duration of progression >2 months and electrophysiological evidence of axonal neuropathy in at least two nerves. However, he did not improve with the immunotherapy. Lead poisoning could cause peripheral nervous system involvement in the form of peripheral neuropathy, commonly manifesting as wrist drop and distal muscle weakness. This case shows the importance of ruling out heavy metal poisoning in the workup for CIAP.
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