A 46-Year-Old Man with Fever and Numbness of Limbs

WHAT IS YOUR DIAGNOSIS? A 46 year-old man was referred to this center with low grade fever and gradual progressive numbness of lower extremities since 4 months ago. He reported loss of superficial sensation of the distal aspect of the left foot started 4 months ago; it then extended to the right side and also both hands. He had no other symptoms or abnormal findings in recent months. Primary evaluations including laboratory analysis and imaging studies were unremarkable. He was a dentist, married, with three children, non-smoker and with no habitual history. His past medical history was insignificant with no history of recent travelling, exposure or transfusion. On admission, he looked well. Physical examination revealed low grade fever, pallor and loss of superficial sensation in feet and hands with no other significant findings. Laboratory analysis showed 11,000/mm3 white blood cells, 10 gr/dl hemoglobin and 300,000/mm3 platelet count, 80 mm/hr erythrocyte sedimentation rate with normal liver function tests, coagulation profile, serum lactate dehydrogenase, urinalysis, blood urea and creatinine concentrations. Angiotensin converting enzyme (ACE), antinuclear antibody (ANA), antineutrophil cytoplasmic antibodies (ANCA), serum protein electrophoresis and cerebrospinal fluid analysis were all normal. Brain and neck magnetic resonance imaging (MRI) were unremarkable. Electromyography and NCV study (EMG-NCV) were repeated because of gradual development of motor dysfunction when grasping and standing during admission and revealed severe motor nerve dysfunction. Chest x-ray showed reticular pattern in upper and lower lobes of the right lung. Chest computed tomography of the patient is shown in Figure 1. Scan of paranasal sinuses showed right maxillary sinusitis. Bronchoscopy was performed to evaluate lung lesions. A nodular endobronchial lesion was seen in right main bronchus. Histopathologic examination was non-specific and non-diagnostic. Following admission, multiple macular reddish lesions appeared on legs. Dermal biopsy showed perivascular infiltration. Finally a diagnostic procedure was performed. (Tanaffos 2011; 10(2): 75-78)