A Man With a Neuropathy, Weight Loss, and Lung Nodules

A 31-year-old black man was referred from another institution for evaluation of a neuropathy with a nerve biopsy suggestive of vasculitis. He had been healthy until 1 year before when he developed perioral dysesthesias followed by hand and leg weakness, with numbness in the legs and difficulty walking. He had a 60-lb weight loss.

The previous workup revealed a normal erythrocyte sedimentation rate and a spinal fluid protein of 60 mg/dL without cells. FANA was negative. A chest x-ray showed multiple pulmonary nodules.

Past medical history was unremarkable. His father had some type of lung disease, apparently chronic obstructive pulmonary disease, and was a non–insulin-dependent diabetic. The patient drank a six-pack of beer per month but did not smoke.

He appeared cachetic but had no visceromegaly or palpable nodes. Mentation and cranial nerves were normal except for decreased sensation in the right mental area and he had facial asymmetry from mild weakness of the right hemiface. There was weakness of the hand interossei muscles and bilateral foot drop with prominent weakness of the distal muscles in both legs. He had areflexia in the legs and arms, vibration sense was absent in the toes and ankles and decreased in the knees and toes, and there were decreased pinprick and touch sensations up to the midarm and up to the mid-calf. The ulnar nerves were thick.

Complete blood count and metabolic panel were normal. Antineutrophilic cytoplasmic antibody titers were normal. A spinal fluid test showed seven white blood cells, 97% lymphocytes, and three monocytes; cytology was negative for malignant cells, protein was 678 mg/dL. Acid-fast bacilli and fungus cultures were negative. Electrophoresis, human T-lymphotropic virus 1, and HIV tests were negative. Angiotensin-converting enzyme was elevated at 69 μg/L (normal, <52 μg/L).

What is the Differential Diagnosis?

This patient had pulmonary nodules and a peripheral neuropathy. The differential diagnosis includes sarcoidosis, particularly as the angiotensin-converting enzyme was mildly elevated, but there was no evidence of a mediastinal mass. Another possibility is Wegener granulomatosis which presents with peripheral neuropathy and granulomatous lesions in the lungs. A malignant lymphoma and lymphoid granulomatosis could have a similar presentation. Tuberculosis does not cause a neuropathy; leprosy does not present with lung disease.