Medical Mystery: Weakness, numbness, tingling in man

A 70-year-old Philadelphia man came to the hospital complaining of muscle weakness and other mysterious symptoms.

He had been spending the winter in Florida, but was concerned enough about his health that he came home to see his personal physician. Two weeks earlier, he started developing severe nausea and diarrhea. He thought maybe he had food poisoning, although his wife, who was eating the same foods, was fine.

He mentioned that his wife didn't like the cold weather and chose to stay behind in Florida. He, on the other hand, was happy to come home and wasn't looking forward to going back to the hot weather.

Soon after the gastric problems, he experienced painful burning sensations in his hands and feet. Even walking had become difficult for him, although he had always been generally healthy before this episode.

As part of his examination, we administered tiny pinpricks to his toes and calves, but he had trouble feeling them. A firm tap to each knee with a reflex hammer produced no response. His ankle muscles were also weak.

Nerve conduction studies showed the kind of peripheral neuropathy - weakness, numbness, and tingling in the arms and legs - we see in patients who've suffered a traumatic injury or an infection, or who have diabetes. In this case, we suspected our patient had Guillain-Barré syndrome, a potentially serious neuropathy that often presents several weeks after a viral infection. We thought the infection might have been the stomach bug that he contracted in Florida.

But further lab tests pointed the investigation in an entirely different direction.

Multiple laboratory studies were performed to look for what was causing our patient's neuropathy. Everything came back normal - except for a urine test that showed very large concentrations of arsenic.

We told our patient that he was suffering from arsenic intoxication. His response, unprintable in a family newspaper, told us that he suspected his wife.

We notified the Philadelphia police and provided a statement on the cause of his illness, but we had no way to know the source of the arsenic.

Arsenic intoxication may occur by accidental or deliberate exposure. This case occurred in the mid-1980s, before insecticidal uses of lead arsenate in the U.S. were banned. Today, it is used only in industrial applications, so exposure is less likely.

Still, arsenic lingers for a long time, such as at hazardous-waste sites.

The symptoms of arsenic exposure usually include severe gastrointestinal distress, hair and skin changes, and signs of neuropathy. One may also see lines across the fingernails, which migrate outward as the nails grow. We initially overlooked these lines on our patient, but they were clearly apparent when he was reexamined after his high levels of arsenic were detected.

He was treated with a chelating agent to remove the arsenic, and recovered.

Joseph S. Lubeck, D.O., is a board-certified neurologist in Bala Cynwyd.

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