1SECTION1第一部分

A25-year-oldbanker,anonsmokerandnon-drinker,presentedwithpaininthehandsandfeetfor4weeksthatprogressedtoinvolveshouldersandhips.Painwasassociatedwithconstipation,followedbydiarrhea.Hehadnopriortrauma,vaccinations,orinfectioussymptoms.Medicalhistorywasnoncontributory;hewasonnomedication.Hehadconsultednumerousdoctorsforthepain,whonotedtransienturinaryhesitancy,tachycardia,andhypertensionthatrequiredshortdurationtreatmentwithantihypertensives.Allsymptomsexceptthepainresolvedspontaneously.Onexamination,hewasafebrile,alert,andoriented.Cranialnerveswereintact;therewasnoptosis,diplopia,orfacialplegia.Four-limbpowerwasMedicalResearchCouncil5/5proximallyand4/5distally,limitedbypain.Reflexeswerejustelicitable;analtonewasintact.Cerebellarsignswereabsent.Gaitwasslowfrombilateralsolepain.Nojointdeformitiesorskinabnormalitieswereseen.Heoftenadoptedaposturewithbotharmsabductedandfingersextended,whichalleviatedpain.Sensorytestingrevealedhyperalgesiaandbrushallodyniaoverthehandsandfeet.Temperature,vibration,andproprioceptionwerepreserved.

患者，25岁银行家，双侧手、脚疼痛4周，逐渐进展，累及双肩及臀部。否认吸烟饮酒史。疼痛时伴便秘，后出现腹泻。既往史无殊，否认外伤、感染史，否认疫苗接种史；否认药物应用史。患者因疼痛曾多处就诊，医生注意到其有短暂排尿不畅、心动过速及高血压，并给予其短时间降压治疗。除疼痛外所有症状自行缓解。体检示，患者体温、意识及定向力正常。颅神经正常；无眼睑下垂、复视及面瘫。四肢肌力因疼痛受限，远端4级，近端5级。反射仅可引出；肛门张力正常。无小脑受损体征。因双侧足底疼痛而步态缓慢。无关节畸形及皮肤异常。患者经常采用双臂交叉、手指伸直的姿势以减轻疼痛。感觉检查示双侧手、脚存在痛觉过敏及毛刷刺激诱发性疼痛。温度觉、振动觉及本体感觉正常。

Questionsforconsideration

1.Whatdifferentialdiagnoseswouldyouconsider?

2.Whatinvestigationswouldyouperformtocon-firmthediagnosis?

问题思考

1.如何考虑鉴别诊断？

2.应做何检查以确诊？

2SECTION2第二部分

Hyporeflexiaandglovestockingsensorydisturbancestronglysuggestalength-dependentpolyneuropathy.Allodyniaandpaininthedistalextremitiesintheabsenceofvibration,proprioception,andtouchinvolvementpointtowardinvolvementofthenociceptivesmallsensoryfibers,sparinglargesensoryfibers.

反射减退和手套-袜子样感觉障碍强烈提示长度依赖性多神经病。无触觉、振动觉及本体感觉异常的远端肢体异常性疼痛提示参与疼痛的小感觉纤维受累，大感觉纤维正常。

Questionforconsideration

1.Whatpreliminaryinvestigationswouldyouconsider?

问题思考

1.应做何初步检查？

3SECTION3第三部分

Themostapparentabnormalityinthebloodtestswashyponatremia.Thesyndromeofinappropriateantidiuretichormone(SIADH)isdiagnosedwhenurineosmolalityandsodiumarehighinthepresenceoflowserumosmolalityandhyponatremia.Inviewofthesubacuteonsetofdysesthesiaandpain,hyporeflexia,andSIADH,asensoryvariantofGuillain-Barrésyndrome(GBS)shouldbeconsidered.

患者血液检查最明显的问题是低钠血症。当尿钠、尿渗透压升高而血钠、血清渗透压降低时应考虑抗利尿激素分泌异常综合征（SIADH)的诊断。鉴于患者亚急性发作的触刺激痛、反射减退及SIADH，应考虑吉兰-巴雷综合征（GBS）感觉变异型的诊断。

WorkupforothercausesofsubacutepolyneuropathyincludednormalvaluesforvitaminB12,fastingglucose,andthyroidfunction,makingnutritionalandmetabolicdisordersimprobable.Normalerythrocytesedimentationrate(ESR),normalC-reactiveprotein,andabsenceofspecificautoantibodiesrenderautoimmunecausesfromsystemiclupuserythematosusorSj?grensyndromeunlikely.Thoroughhistoryandanormaltoxicologyscreenexcludedneurotoxinssuchasmetronidazoleandsolvents,whichcancausesmallfiberneuropathy.InfectiouscausesfromHIVandhepatitisBandCwereexcludedwithnegativeserumantibodiesandnegativehepatitisBsurfaceantigen.Additionally,inpartsoftheworldwhereLymediseaseisendemic,serologictestingforBorreliaburgdorferi,aninfectiouscauseofperipheralneuropathy,shouldbeperformed.Asmallproportionofsarcoidosispatientshaveassociatedperipheralneuropathy,andinpopulationswheresarcoidosisis







































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