Case 97 – the beginning

Welcome to another #TeamHaem case

You are in the Haematology new patient clinic and receive a letter from the local Neurology team asking you to assess a 54 year old male who has an Ig M kappa paraprotein of 6g/dl and presented to their clinic with distal sensory loss and a broad based gait which has been slowly progressing over the past 9 months. The neurologist feels he may have a neuropathy secondary to a plasma cell dyscrasia and asks for your review.

On arrival in the clinic you note he has indeed got a broad based gait. His systemic enquiry apart from the neurological findings outlined above is unremarkable. He denies any weight loss or other B symptoms. He has no bone pains and hasn’t noted any lumps or bumps. His only past medical history is an underactive thyroid for which he takes levothyroxine. He is an accountant by profession and is a lifelong non-smoker and drinks around 10 units of alcohol a week.

Examination is unremarkable apart from you note he has loss of proprioception, temperature and fine touch symmetrically to around ankle level. He also has got bilateral reduced ankle jerks with preserved knee reflexes (However eliciting ankle jerks was never your strong point so you are not sure if this is a genuine finding! )There is no sign of muscle wasting and he appears to have power MRC grade 5/5 in all lower limb groups. His upper limb neurological exam and cranial nerves are all intact. You specifically also check for lymphadenopathy, organomegaly, retinal haemorrhages and papiloedema these are not present.

What are the possible haematological causes of a peripheral sensory neuropathy?

Considering the differential diagnosis what investigations may help you elicit the cause of his sensory neuropathy?

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