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Hi all,

I am hoping for some input on the following case.

The patient is a 70F with no known medical history.

Left lower extremity weakness and pain for ~ 8 months. Progressed slowly; ~4 months ago the left lower extremity symptoms started to improve but patient developed weakness of the right lower extremity. Has had multiple falls. Some burning pain and numbness of right leg (not well characterized). No back pain. No upper extremity complaints.

Exam

LLE strength 2-3/5

RLE strength 1-2/5 proximally; 0/5 dorsiflexion, toe extension; trace plantarflexion

Sensation intact to pinprick and light touch, decreased to vibration on the right

Achilles/patellar reflexes absent

Patient has been seen by neurology. There was concern for CIDP.

Has not had extensive labs; ESR/CRP, CMP, CBC normal.

MRI lumbar spine and LP with CSF studies unremarkable

Electrodiagnostic results:(technically limited by lower extremity edema and obese body habitus)

NCS

Absent sural sensory responses bilaterally (there was moderate edema)

Left fibular CMAP: normal latency and CV; decreased amplitude 0.5 mV at EDB, 1.1 mV at TA

Right fibular CMAP: absent at EDB and TA

Left tibial CMAP: normal latency and CV; decreased amplitude (3.0mV)

Right tibial CMAP: normal latency; dec CV (28m/s); decreased amplitude (0.4mV)

Normal right radial SNAP and normal ulnar/median CMAPs

F waves-normal right median, normal left fibular, prolonged left tibial, absent right tibial

H reflex-borderline left tibial, absent right tibial

EMG: TA, FL, gastroc, VM, RF bilaterally: fibs/psws in all muscles; unable to activate the right TA or FL; there were mild-moderate neuropathic changes in all other muscles.

I'd like to call it an axonal polyneuropathy but am thrown by the relatively rapid onset, waxing/waning left lower extremity symptoms, and extent of proximal muscle involvement without any upper extremity involvement.

From reviewing Preston and Shapiro, the relapsing/remitting nature, stepwise progression, and asymmetry suggest mononeuritis multiplex or a CIDP variant. But would these present with findings isolated to the lower extremities and abnormal findings in all muscles tested?

Thank you and I appreciate any input!