An Elderly Man With a Peripheral Neuropathy Like His Sister

A 70-year-old diabetic man was referred for weakness and numbness in the hand and feet. The patient limped due to quadricep muscle injury years before, while he was in the Armed Forces.

Past medical history includes successful lumbar laminectomy for back pain in the past; otherwise, the history was unremarkable.

The patient did not smoke or drink.

Family history revealed that his mother had macroglobulinemia and a sister has a peripheral neuropathy.

His previous EMG showed evidence of a peripheral neuropathy, “suggestive of a familial neuropathy.”

On physical examination, vital signs are normal. Mentation and cranial nerves are normal. There is atrophy of the right quadriceps muscles with a surgical scar. Strength testing showed mild weakness in the interossei muscles of the hands and dorsiflexor weakness. Reflexes were 1+ in the arms, and absent in the legs. There is a glove/stocking sensory deficit and decreased pinprick in the right ulnar nerve distribution. The pinprick deficit was up to the mid-calf, whereas vibration sense deficit included the knees.

An EMG Test was Performed

Nerve conduction Peroneal R.

Ankle	NR ms	NR mV	RI–ankle	m/s
Fibular head	NR ms	NR mV	Ankle–fibular head	m/s

Peroneal R.

Fibula (head)	12.0 ms	0.5 mV	Fibula (head) Popliteal fossa	24.1 m/s
Popliteal fossa	15.1 ms	0.5 mV		m/s

Tibial L.

Ankle	NR ms	NR mV	Ankle–popliteal fossa	m/s
Popliteal fossa	NR ms	NR mV		m/s

Median R. ^a

Wrist	19.1 ms	3.8 mV	APB–wrist	m/s
Elbow	32.5 ms	1.3 mV	Wrist–elbow	16.4 m/s

a T<1=0.22.

Ulnar R. ^a

Wrist	13.6 ms	1.3 mV	ADM–wrist	m/s
Below elbow	34.7 ms	1.6 mV	Wrist–below elbow	10.6 m/s
Above elbow	45.3 ms	1.1 mV	Below elbow–above elbow	11.3 m/s

a T<1=0.44.

Median L. ^a

Wrist	19.1 ms	1.2 mV	APB–wrist	m/s
Elbow	37.1 ms	1.1 mV	Wrist–below	12.5 m/s

a T<1=0.29.

Ulnar L. ^a

Wrist	12.4 ms	1.3 mV	ADM–wrist	m/s
Below elbow	30.3 ms	0.4 mV	Wrist–below elbow	11.7 m/s
Above elbow	56.9 ms	0.3 mV	Below elbow–above elbow	11.3 m/s

a T<1=0.46.

F-Wave Studies

Nerve	M-Latency	F-Latency
Median R.	19.8	39.5
Ulnar R.	13.7
Median L.	32.7	64.7
Ulnar L.	19.0

Sensory Nerve Conduction

Nerve and Site	Peak Latency (ms)	Amplitude (µV)	Segment	Latency Difference	Distance	Conduction Velocity
Median R.: Wrist	NR	NR	Index–wrist	ms	mm	m/s
Ulnar R.: Wrist	NR	NR		ms	mm	m/s
Median L.: Wrist	NR	NR	Index–wrist	ms	mm	m/s
Ulnar L.: Wrist	NR	NR		ms	mm	m/s

Needle EMG Examination

	Insertional	Spontaneous Activity			Volitional MUAPs					Max Volitional Activity
Muscle	Insertional	Fibs	+Wave	Fasc	Duration	Amplitude	Poly	Config	Recruitment	Amplitude	Pattern	Effort
Tibialis anterior R.	Increased	None	+1	None	SI. Incr.	SI. Incr.	None	Normal	Normal	Normal	Full	Max.
Gatrocnemius R.	Normal	None	None	None	Normal	Normal	None	Normal	Normal	Normal	Full	Max.
First dorsal interosseous R.	Normal	None	None	None	SI. Incr.	SI. Incr.	None	Normal	Normal	Normal	Full	Max.
Vastus medialis L.	Normal	None	None	None	SI. Incr.	SI. Incr.	None	Normal	Normal	Normal	Full	Max.
Tibialis anterior L.	Normal	None	None	None	SI. Incr.	SI. Incr.	None	Normal	Normal	Normal	Full	Max.
Gastrocnemius L.	Increased	+2	+2	None	Normal	Normal	None	Normal	Normal	Normal	Full	Max.