NeuroSim Case #01: 60 year-old man with lower limb weakness, pain, and numbness

Clinical History:

60-year old right handed man without significant medical history.
He developed generalized aching in his legs and numbness of his right leg and foot about two years ago. Numbness of his left foot developed a few months later. His symptoms intensify and developed right finger numbness and pain that radiated to his elbow. His symptoms in the lower extremities also deteriorated he had difficulties in walking upstairs and running.
He also complained of difficulties in getting an erection but denied urinary symptoms.

Neurologic examination:

Cortical function: Normal cortical function; normal cranial nerve function.
Strength: Arm and leg strength was normal except for mild weakness; no evidence of wasting or reduced muscle tone.
Pinprick and temperature: Reduced in distal portion of upper and lower extremities.
Vibration and position sensation: Reduced below ankle.
Reflex: Absent, except for 1+ reflex on biceps.
Others: Positive Rhomberg's sign, normal gait, difficulty in tendum walking.

Laboratory studies: No significant findings. Serum creatine kinase level was not available.

Nerve conduction studies: Moderate subacute and chronic sensory-motor polyneuropathy, with demyelinating features.

A biopsy was performed. The cross section (formalin fixed-paraffin embedded) of the muscle biopsy is shown here.

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