A 48‐year‐old man presented with 2 weeks of ascending numbness and tingling of the right leg and toes. The numbness continued to ascend to the level of the umbilicus. He also noted 1 episode of bladder incontinence and new‐onset constipation. He reported a more acute onset of sensitivity to light touch in the same lower extremity in the same distribution and difficulty ambulating. He denied recent fevers or viral prodromes. Vital signs were normal. The neurological evaluation revealed altered sensation to light touch on his entire right lower extremity. Concurrent allodynia was noted in the same distribution. Sensory level was identified at T10. He had 11 reflexes on the right lower extremity compared with 21 on the left. A positive Babinski's sign was also elicited on the right. Cranial nerves were noted to be intact bilaterally, and no motor deficits were identified. Complete blood count, chemistry, and liver function tests were within normal limits. HIV and hepatitis panel were negative and nonreactive. Erythrocyte sedimentation rate was 3 mm/h and C‐reactive protein < 0.3 mg/dL. MRI of the T‐spine revealed a 2‐cm segment of hyperintensity within the cord in the mid‐ to upper thoracic region confined to the posterior columns. MRI of the brain and C‐spine revealed multiple areas of periventricular white matter changes more prominent on T2 and flair sequences and T2 hyperintensities scattered within the cervical spinal cord. Lumbar puncture was performed and revealed elevated oligoclonal bands. The patient was started on intravenous steroids for a diagnosis of multiple sclerosis (MS), and his symptoms slowly improved. He reported evaluation in the emergency department 1 week prior for the same symptoms, when he received an MRI of the L‐spine with no findings.
Peripheral paresthesia is commonly encountered by the internist. A thorough neurologic and sensory exam can help delineate the anatomical site and possible cause of the lesion. Sensory modalities include touch, proprioception, vibration, temperature, and pain. Limited sensory loss confined to part of an extremity is usually indicative of peripheral or nerve root injury, whereas that affecting an entire limb and extending to the trunk is indicative of spinal cord disease. A sensory level is typically defined. Extensive loss of vibratory sense and proprioception typically occurs with diseases of the dorsal columns of the spinal cord and with demyelinating neuropathies and sensory neuronopathies. MRI of the entire spine should be performed, remembering that when a sensory level is identified, the lesion itself is at or above that level. If indicated and demyelinating disease such as MS is a concern, then MRI of the brain is also recommended, as well as confirmation with cerebrospinal fluid studies.
Evaluating peripheral paresthesias can be perplexing. Physicians should use the neurologic exam to identify a potential level at which spinal cord pathology is likely, and further imaging and laboratory testing should include evaluation of the spinal cord at and above that level.
M. Maylin ‐ none
To cite this abstract:Maylin M. Feeling Your Way Through a Diagnosis. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 336. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/feeling-your-way-through-a-diagnosis/. Accessed September 20, 2019.