528 - Less is more: The value of leading with conservative management in patients with anti-myelin associated glycoprotein (MAG) polyneuropathy

She initially underwent evaluations by two neurosurgeons and a neurologist. MRI revealed no signs of spinal stenosis and metabolic workup revealed no evidence of inflammatory processes. EMG and nerve conduction studies displayed axonal neuropathy of bilateral lower extremities. During initial physiatry consultation, she displayed focal neurological deficits, such as absent reflexes in bilateral upper and lower extremities, mildly ataxic gait, and bilateral dorsiflexion weakness. Differential diagnoses included limb-girdle muscular dystrophy, amyotrophic lateral sclerosis (ALS), multifocal motor neuropathy, and acquired demyelinating polyneuropathy (AIDP).

During her workup, she worked with a physical therapist and personal trainer five days a week, resulting in significant symptomatic improvement. Following comprehensive workup, including physical examination and diagnostic imaging, positive anti-MAG antibody titers of 1:3200 confirmed the diagnosis of anti-MAG peripheral neuropathy. She maintained a rigorous exercise and physical therapy regimen, adhered to an anti-inflammatory diet, and subsequently started Rituximab monoclonal antibody treatment. 

Discussions: Anti-MAG polyneuropathy is a rare form of acquired demyelinating polyneuropathy that most commonly occurs in men over age 50. Currently, there is no approved treatment for this disease; however, Rituximab is the best available agent and conservative management such as exercise, diet, and balance training is recommended in those with mild symptoms.

Conclusions: This case exemplifies the benefit of lifestyle modifications in motivated patients as an initial treatment approach while undergoing further workup. It is important to distinguish mild from severe cases of neurological conditions while weighing patient goals, motivation, and quality of life. Empowering patients to engage in dietary changes and physical therapy, including balance and strengthening exercises, should be first line treatment in managing patients with complex neurological diseases.