A 52-year-old man was referred to the office for evaluation with a chief concern of numbness involving the distal portions and plantar surfaces of both feet. The sensation of numbness had been noted by the patient for over 1 year. Although not painful, he regarded the inability to feel the plantar surfaces of his feet troublesome and related what he believed to be evolving instability in his gait to his decreased sensation. He had previously purchased magnetic insoles, which he wore for 5 months without resolution of his concerns. He regarded the depth of his anesthetic sensation to have remained unchanged for the prior year. His complaint of profound numbness was unaffected by weight bearing or non-weight bearing.
Examination revealed a moderately obese man, 5’ 6”, 340 lb. His occupation as a cook required him to stand on a hard, unyielding floor 8 to 10 hours daily.
His medical history was significant for the diagnosis of diabetes 5 months prior to his presentation for evaluation of the numbness. At the time of his initial evaluation, he was being treated for diabetes, hypertension, elevated serum cholesterol, osteoarthritis of the lumbar spine and knees, gout, and erectile dysfunction.
His medications were Toprol, allopurinol, nifedipine, Glucophage, Avandia, Lipitor, Celebrex, Viagra as needed, and a daily aspirin.
Vascular evaluation revealed bilateral grade 1/4 non-pitting edema with early venous stasis associated hyperpigmentation of the distal legs. He demonstrated no evidence of arterial disease by history or physical examination. His pedal pulses were easily appreciated as 4/4. He had no history of claudication or rest pain. No subungual infection was noted. He demonstrated a sluggish capillary return to his toes suggestive of vasomotor instability possibly associated with autonomic neuropathy.
Neurologic evaluation was significant for absence of pedal sweating and associated dry, fissured skin suggestive of sudomotor dysfunction with autonomic neuropathy. There was no observed muscle atrophy of the legs or feet. Manual muscle testing revealed normal muscle tone and power. Cerebellar testing demonstrated no abnormalities. He demonstrated an absent Achilles tendon reflex bilaterally. Patellar reflexes were 2/3. He demonstrated a level 2/5 loss of 10 g filament perception, vibratory perception, and temperature sensibility. Joint position and 2-point discrimination were intact to testing. Cranial nerve evaluation was unremarkable. No evidence of focal nerve entrapment was identified.
No significant or contributory additional observations were made.
A presumptive diagnosis of small fiber and large fiber neuropathy was made.
Noninvasive arterial Doppler studies were performed. These studies revealed patent arterial flow to the legs and feet with elevated ankle and metatarsal pressures recorded. The elevated pressures recorded were attributed to either hypertension or vessel noncompressability. Digital waveforms were reduced in amplitude and interpreted as being consistent with vasospasm.
Electrodiagnostic studies demonstrated bilateral findings of a mixed sensorimotor peripheral neuropathy.
Laboratory studies revealed a normal complete blood count and normal electrolytes. His hemoglobin A1c was 10.8. Blood urea nitrogen and serum creatinine were normal. Serum homocysteine was 12.8.
He was placed on Metanx 1 tablet daily for 120 days and scheduled for a re-evaluation at the completion of his 4-month trial.
At the time of his re-evaluation, he reported, “feeling my feet again.” Re-examination with a 10 g filament, 126 c tuning fork, 2-point discriminator, and testing for cold and pain perception did not demonstrate any quantifiable difference from his previous examination. Nevertheless, he related a sense of restored feeling to his feet and a feeling of greater stability while ambulating.
He was evaluated again 90 days later. He continued to express a restored sensation of improved stability and feeling to his feet while ambulating.
Commentary
David E. Allie, MD
This patient has exhibited an excellent response to once daily Metanx even at 340 lbs. I have found patients to tolerate a twice daily Metanx dosage very well. The patient also fits the criteria of morbid obesity. This significantly increases his risks for many health problems including cardiovascular risks, orthopedic risks, and diabetes. He should be counseled aggressively and placed on an appropriate diet and exercise program.
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