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RA Peripheral Neuropathy — SCE Rheumatology MCQ

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ModerateRheumatoid ArthritisRA Peripheral NeuropathySCE Rheumatology

A 60-year-old woman with a 15-year history of seropositive rheumatoid arthritis develops slowly progressive numbness and mild distal weakness in both feet, followed by involvement of the fingertips, over 12 months. Examination shows symmetrical distal sensory loss and reduced ankle reflexes, without focal nerve deficits, foot drop or wrist drop. Her rheumatoid arthritis is in remission, and she has no nodules, purpura, ulcers or systemic symptoms. HbA1c, vitamin B12, folate, thyroid and renal function, and serum protein electrophoresis are normal. She does not drink excess alcohol and has not received leflunomide or another potentially neurotoxic drug. Nerve conduction studies demonstrate a length-dependent, predominantly axonal sensorimotor polyneuropathy without demyelination or conduction block. What is the most likely diagnosis?

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Correct answer: A — Non-vasculitic RA-associated distal symmetric axonal polyneuropathy

This is **non-vasculitic RA-associated distal symmetric axonal polyneuropathy**. The slow, length-dependent, symmetrical glove-and-stocking syndrome and axonal nerve-conduction pattern match a recognised neuropathy phenotype in RA. Common metabolic, paraproteinaemic, toxic and drug-related causes have been excluded. Rheumatoid vasculitic neuropathy more characteristically presents acutely or subacutely with painful, asymmetric or multifocal nerve involvement, often producing discrete deficits such as foot or wrist drop; remission alone would not exclude vasculitis, but the complete phenotype here argues strongly against it. Guillain–Barré syndrome is acute and usually demyelinating, with rapidly evolving weakness and generalised areflexia. Diabetes and vitamin B12 deficiency are not supported by the investigations. Attribution to RA should only be made after excluding alternative causes.

Reference: Bayrak AO et al. Electrophysiological assessment of polyneuropathic involvement in rheumatoid arthritis: relationships among demographic, clinical and laboratory findings. Neurological Research. 2010;32:711–714. https://pubmed.ncbi.nlm.nih.gov/20307377/