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Endgames Picture Quiz

A woman with a cough and difficulty walking

BMJ 2010; 341 doi: (Published 28 July 2010) Cite this as: BMJ 2010;341:c3674
  1. Peter Foley, registrar,
  2. George Oommen, foundation year 2 trainee,
  3. Jonathan O’Riordan, consultant neurologist
  1. 1Department of Neurology, Ninewells Hospital, Dundee
  1. Correspondence to: P Foley peterfoley{at}

    A 47 year old woman was referred urgently to the out of hours neurology service with severe difficulty walking. Five weeks previously she had developed a “numb, stabbing” persistent pain in her left foot. Three weeks before admission, an identical pain developed in her right foot. One day before referral her right foot “went floppy.” Hours before admission, this weakness spread to affect the left foot, and she could not walk unaided. She had also felt short of breath and had a dry cough. Her only known medical history was asthma.

    On examination, the patient was coughing. Her pulse rate was 115 beats/min (regular), respiratory rate 20 breaths/min, oxygen saturation 89% on air, and temperature 36.8°C. Respiratory examination showed globally reduced breath sounds and bibasal crepitations. Her peak expiratory flow rate was 109 l/min (predicted 400 l/min). She had an erythematous rash over the metacarpophalangeal joints. A chest radiograph was performed.

    Neurologically, cranial nerve and upper limb examinations were unremarkable. Lower limb examination confirmed bilateral foot drop with distal sensory loss. Ankle reflexes were absent, and plantar responses were downgoing.

    Initial investigations showed normal haemoglobin concentration, platelet count, urea concentration, and electrolytes level; however, a leucocytosis of 33.4 (neutrophils 8x109/l, eosinophils 21x109/l) and a C reactive protein concentration of 162 mg/l were observed.


    • 1 What pattern of neurological disturbance best explains this patient’s difficulty in walking?

    • 2 What abnormalities are present on the chest radiograph?

    • 3 What are the differential diagnoses and the most likely unifying diagnosis?

    • 4 What treatment should be started immediately?


    1 What pattern of neurological disturbance best explains this patient’s difficulty in walking?

    Short answer

    Mononeuritis multiplex is the neurological disturbance that best explains this patient’s problems with walking.

    Long answer

    Mononeuritis …

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