Solution: Migrant sensory neuritis of Wartenberg

A woman in her late forties experienced severe pain and numbness in left anterior knee while kneeling and stretching to tend a fireplace. She had no swelling, but the numbness persisted and the area is now devoid of sensation to pinprick and vibration. Six months later she had acute pain and subsequent numbness of the lateral aspect of right leg. There are no vasomotor changes or discoloration of the skin; the area is devoid of sensation to pinprick and vibration. A similar area of numbness developed overlying the left Achilles tendon, subsequent to stretching. Watch the video at http://practicalneurology.com/videos.

The most likely diagnosis is:

a.) Polyarteritis nodosa

b.) Wartenberg's migratory sensory neuropathy

c.) Systemic vasculitis

d.) Isolated peripheral nervous system vasculitis

e.) Psychogenic sensory loss

• Wartenberg's migratory sensory neuropathy is characterized by recurrent episodes of burning pain and subsequent patchy loss of sensation in the distribution of one cutaneous nerve at a time.
• It mostly affects the skin of the extremities, chest, and face.
• These sensory changes are usually induced by movement of a limb or pressure on the skin by kneeling, for example, leading to stretching of a cutaneous nerve.
• It usually affects people in their fourth or fifth decade.
• It is described as a pure sensory mononeuritis multiplex
• Electrodiagnostic features are that of Multifocal axonal sensory loss
• Biopsy of affected nerves shows findings suggestive of an autoimmune vascular process including:
  1. Perineurial scarring
  2. Chronic inflammation
  3. Axonal loss & regeneration
  4. Differential fascicular involvement
  5. Endoneurial edema
  6. Immunoglobulin deposition
• The effect of immunomudulation on the course of the disease is ill defined, especially; the disorder is purely sensory and does not cause functional impairment other than pain.
• No association is reported between this condition and DM or autoimmune disorders.