Introduction
Neuralgic amyotrophy (NA), also known as Parsonage-Turner syndrome is a peripheral nervous system disorder with core features; episodes of extreme pain at symptom onset, rapid multifocal paresis and atrophy of the affected muscles, and slow recovery requiring months to years. NA would be diagnosed clinically first and needs to exclude other cause of plexopathy or neurological conditions. We experienced a meaningful case and would report.
Case report
A 42-year-old woman visited an emergency room with right shoulder pain and weakness for 3 weeks. The character of pain was stabbing and visual analogue score (VAS) was 8. She complained of chill and decreased mentality for several days before. She had received hemodialysis for end stage renal disease (ESRD). She was diagnosed as type 1 diabetes mellitus (T1DM) and prescribed insulin. Laboratory test showed WBC 5870/uL, segment neutrophil 72.0% and CRP 3.11mg/dL. A magnetic resonance imaging showed focal effusion with enhancement at right glenohumeral joint, subacromial subdeltoid bursa and right biceps tendon sheath. The orthopedic surgeon performed an arthroscopic incision and drainage, but operative finding was clear. Also, systemic inflammation and fever were continued. Finally, she was diagnosed as infective endocarditis and had aortic valve replacement surgery.
She was referred to department of rehabilitation medicine for cardiac rehabilitation but she still complained of right shoulder weakness. On physical examination, muscle strength was as follow: right shoulder abduction P- grade, shoulder flexion P grade, elbow flexion & extension F grade, wrist flexion & extension G grade. On electrodiagnostic (EMG) test, there was diffuse motor and sensory peripheral polyneuropathy which showed mixed severe axonal injury and demyelinating pattern. The needle EMG of right shoulder muscles implied mixed myopathic and axonal degenerative pattern. These findings were also showed on the opposite side. Therefore, electrodiagnostic confirm was not decisive (table 1, 2 and fig 1).
She was prescribed NSAIDs for pain control and applied physiotherapy of electrical stimulation and strengthening exercise for shoulder weakness and limited range of motion. It is hard to start systemic steroid pulse therapy because of the medical history of ESRD on HD, osteoporosis and T1DM. The shoulder pain was decreased from VAS 8 to 5 at discharge and changed to dull ache. Muscle strength of shoulder was improved but still weak: right shoulder abduction P- grade, shoulder flexion P grade, elbow flexion & extension F+ grade.
Conclusion
In this case, we reminded that patient’s chief complain is the most important key to find diagnosis and determine treatment. Considering the clinical course, NA would be considered. Early intervention of physiatrist and appropriate management could prevent unnecessary procedure or surgery. |
