Peripheral neuropathy following chronic inhalation

Six months after starting work in a printing factory, a 30 year old male developed numbness and painful paraesthesia in both legs. This was followed by weakness and muscle wasting. His worked involved regular cleaning of a rubber roller blanket with solvents including n-hexane. He did not wear gloves or respiratory protection. One month after the onset of symptoms, his upper limbs also became affected. He gave up work but continued to deteriorate over the next two months. Several of his work colleagues had also become unwell. On examination he had a typical sensorimotor peripheral neuropathy which was more severe in the lower limbs. There was hyporeflexia, severe distal and mild proximal muscle wasting and weakness. Sensory impairment was present in a glove and stocking distribution. Nerve conduction studies showed very small median, ulnar and sural sensory action potential amplitudes. Similarly the median, ulnar, posterior tibial and common peroneal motor action potential amplitudes were small and highly dispersed. Electromyography showed active denervation changes in distal muscles. Somatosensory, visual and brainstem auditory evoked potentials studies were normal. Sural nerve biopsy showed a normal number of myelinated and non-myelinated fibres. There was mild thickening of the perineurium and giant axonal swellings in many myelinated fibres. An electron micrograph showed the swollen axons had attenuated myelin sheaths and contained accumulated neurofilaments in the axoplasm and loss of neurotubules. Some axons had no myelin sheath. In other areas there was no axonal swelling, but paranodal myelin attenuation resulting in a widened nodal gap. He began to recover in the proximal limbs after four months of physiotherapy. At follow up after 12 months there was mild distal weakness in the legs with painful paraesthesia in the feet and poor exercise endurance (Chang et al., 1993).

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