A foot-drop case

Dr. Montano: A 42-year-old man was admitted to our department because of migratory arthromyalgias predominantly involving large joints, with painful swelling for the prior 3 weeks. He had used large doses of non-steroid antiinflammatory drugs with limited pain control. The patient was eupneic and apyretic demonstrating pain and swelling of the left hand, and erythema and edema of the right leg and foot. Blood pressure and heart rate were, respectively, 120/80 mmHg and 80 beats/min. The remaining clinical history and physical examination were otherwise negative. The electrocardiogram and the chest X-ray were normal. Compressive ultrasound scan of the legs, looking for a deep venous thrombosis, was normal. Routine laboratory findings were within the normal ranges except for hypertransaminasemia (AST 287, ALT 740); for this reason an abdominal ultrasound scan was performed, but showed only a mild hepatosplenomegaly. Serologic profile revealed previous Epstein–Barr and cytomegalovirus infections, and detected hepatitis B virus (HBV) IgM antibodies, HBsAg and HBeAg, thus showing an acute HBV infection. Autoimmune screening (ANCA and ANA autoantibodies, rheumatoid factor, autoantibodies against gliadin and transglutaminase) were all normal as were the thyroid function tests. The migratory arthralgias were treated with tramadol, with a significant reduction in pain. Intravenous fluids were administered, and a specific diet for hepatic disease was prescribed; the patient was subsequently discharged with the diagnosis of ‘‘migratory arthralgias in an acute hepatitis B infection’’. A month after discharge, the patient was readmitted to our department for dysesthesias and hypoesthesia of both feet (predominantly the right) associated with motor deficits. On neurologic examination, flexion, extension and rotation movements of the right foot were not possible for the patient, and the Achilles tendon reflex was absent. The patient also showed a deficit in right thigh flexion with steppage gait, and a deficit in left foot extension. Laboratory findings showed a leukocytosis (12,000 WBC) and C-reactive protein (CRP) elevation (170 mg/l). A magnetic resonance (MR) examination of the spine was performed to test the hypothesis of spondylo-diskitis or multiple discopathies, but was normal. To evaluate the motor deficit, an electromyography (EMG) was performed. It revealed an acute axonal multineuropathy involving the right common peroneal nerve and the left femoral nerve, associated with chronic axonal damage in some of the studied districts. In particular, This case record was selected for the ‘‘Casi Clinici Gymnasium’’ session at the 2009 SIMI Annual Congress in Rome, and was reviewed by a Committee composed of Maria Domenica Cappellini and Luigi Pagliaro.