A 35-year-old carpenter with peripheral neuropathy and skin lesions
A 35-year-old, fair-skinned male is referred to your clinic for evaluation. His symptoms began approximately 3 months ago, with the insidious onset of numbness and tingling in his toes and fingertips, progressing slowly in the ensuing weeks to involve the feet and hands in a symmetric “stocking-glove” fashion. In the past 2 to 3 weeks, the tingling has taken on a progressively painful, burning quality and he has noted weakness in gripping tools. No ataxia, dysphagia, visual symptoms, or bowel or bladder incontinence have been noted, and he has not complained of headaches, back or neck pain, or confusion. Except as noted, the review of systems is otherwise negative.
The patient’s medical history is remarkable for a flu-like illness approximately 4 months ago characterized by 3 to 4 days of fever, cough, diarrhea, and myalgias, which resolved spontaneously. Further questioning reveals the patient has been a carpenter since completing high school 17 years ago. For the last 10 years, he has lived in a rural, wooded area in a home he built. Approximately 10 months ago he was married and moved with his wife, an elementary school teacher, into a newly built home on an adjacent parcel of land. The patient consumes one to two alcoholic drinks a week, and quit smoking 2 years ago after a 15-pack-year history. He takes one multivitamin a day but no prescription medications. Family history is unremarkable; his wife, parents, and two younger brothers are in good health.
Neurologic examination reveals diminished proprioception in the hands and feet, with a hyperesthetic response to pinprick sensation on the soles. Motor bulk and tone are normal, but there is slight bilateral muscular weakness in dorsiflexors of the toes and ankles, wrist extensors, and hand intrinsics. Reflexes are absent at the ankles and 1+ at the biceps and knees. Coordination and cranial nerve function are within normal limits. Dermatologic examination reveals brown patches of hyperpigmentation, with scattered overlying pale spots in and around the axillae, groin, nipples, and neck. The palms and soles show multiple hyperkeratotic corn-like elevations 4 to 10 mm in diameter. Three irregularly shaped, sharply demarcated, erythematous, scaly plaques, measuring 2 to 3 cm, are noted on the patient’s torso. The remainder of the physical examination is normal.
On initial laboratory evaluation, the CBC shows slight macrocytic anemia with hematocrit 35% (normal range 40% to 52%), and MCV 111 fL (normal range 80 to 100 fL). White blood cell count is 4.3×103/mm3 (normal range 3.9 to 11.7×103/mm3); the differential reveals moderate elevation of eosinophils at 9% (normal range 0% to 4%). Occasional basophilic stippling is noted on the peripheral smear. Liver transaminases are slightly elevated. BUN, creatinine, and urinalysis are normal.
(a) What problem list is suggested for this patient?
(b) What further investigations would you undertake at this time?
(c) What treatment options would you consider?
Answers to Pretest questions can be found in Challenge answers (2) through (10) on pages 23–24.