Disclosures: Natalie M. Sajkowicz, MD: Nothing to disclose

Case Description: The patient presented with an 18-month history of bilateral lower extremity weakness, numbness, and paresthesias. Initially symptoms were attributed to a L4-L5 herniated disc with spinal stenosis, and the patient underwent lumbar laminectomy and fusion. Post-operatively, lower extremity weakness progressed. Initial exam at inpatient rehabilitation revealed 1-2/5 motor strength, decreased light touch sensation, decreased proprioception, and hyporeflexia in the lower extremities. Patient denied bowel or bladder incontinence. Upper extremity exam was unremarkable. No preceding infection or systemic symptoms were noted. Cerebrospinal fluid analysis revealed elevated protein. Viral panel and limited heavy metal panel were unremarkable. Patient received intravenous immunoglobulin for suspected chronic inflammatory demyelinating polyneuropathy without improvement.

Setting: Acute inpatient rehabilitation unit.

Patient: A 60-year-old male with type 2 diabetes mellitus and no family history of polyneuropathy, who worked as an electroplater.

Assessment/Results: Nerve conduction studies (NCS) performed 18 months after onset of weakness revealed severe axonal sensorimotor neuropathy affecting the legs, with electromyography suggesting acute denervation in all left leg muscles (right leg was not tested). Repeat NCS 1 month later re-demonstrated chronic axonal sensorimotor neuropathy with recovery of motor units in the left leg, but not the right leg. Though minimal strength was regained while in rehabilitation, therapists provided training in wheelchair mobility and use of knee-ankle-foot orthoses.

Discussion: This case illustrates an unusual presentation of diabetic radiculoplexus neuropathy (DRPN) in which weakness was not preceded by acute, focal onset of pain. In literature, uncertainty exists about whether painless DRPN is a variant of painful DRPN or a separate entity. In this case, possibility of a co-existing heavy metal toxicity cannot be excluded given limited heavy metal screening.

Conclusion: It is important to maintain a broad differential diagnosis in patients with findings inconsistent with typical diabetic neuropathy. A comprehensive workup may avoid delays in diagnosis and subsequent appropriate medical management and rehabilitation.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/revisiting-diabetic-painless-motor-neuropathy-a-case-report/