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989 - Refractory Pain in a Patient with Mononeuritis Multiplex Secondary to SLE Vasculitis: A Case Study

Thursday, February 27, 2025

5:00 PM - 6:30 PM MST

Corresponding Author(s)

RT

Richard Tran, MD

Resident Physician
NewYork-Presbyterian Hospital -- Columbia & Cornell
New York, New York, United States

Presenting Author(s)

MA

Mohamoud Ahmed, BS

Medical Student
University of Colorado School of Medicine
Aurora, Colorado, United States
CK

Caitlyn Ko, MD

Resident Physician
New York Presbyterian Columbia/Cornell
New York, New York, United States

Co-Author(s)

PN

Parker Nguyen, MD

Resident Physician
NewYork-Presbyterian
New York, New York, United States

Case Diagnosis: Mononeuritis multiplex secondary to Systemic Lupus Erythematosus (SLE) vasculitis

Case Description: A 31 year old woman with a history of SLE complicated by end stage renal disease (ESRD) on dialysis and multiple admissions for uncontrolled pain presented with rapidly progressive right foot drop, sharp pain in the distal right lower extremity, and left foot numbness. MRI brain and MRI cervical/thoracic/lumbar spine were unremarkable. After pain management and routine hemodialysis, the patient was discharged with scheduled outpatient EMG study, which ultimately showed evidence of mononeuritis multiplex with significant right peroneal and left tibial nerve involvement. She was readmitted for recurrence in pain, treated with pulse dose steroids, and started on rituximab. Autoimmune labs were obtained, and she was discharged on azathioprine, steroid taper, and pain regimen that included venlafaxine, capsaicin cream, gabapentin, and hydromorphone. She was readmitted two times further, each for inpatient pain control and steroid titration. Symptoms improved progressively following each admission.

Discussions: Mononeuritis multiplex is a rare and late stage complication in SLE. In this patient with severe disease as noted by ESRD with failed renal transplant requiring dialysis, electrodiagnostics was the study that ultimately identified an otherwise unclear source of recurrent and refractory pain. Neuropathy secondary to vasculitic mononeuritis multiplex has variable responsiveness to immunosuppression, and improvements are generally gradual. Thus, medical management aimed toward pain control can help bridge patients through their treatment course.

Conclusions: In a medically complex patient with chronic pain, multiple admissions for acute pain flares, and neurological symptoms, a multidisciplinary diagnostic and therapeutic approach is crucial for guiding management. While this patient had known systemic autoimmune disease, electrodiagnostics were required to identify the root etiology of pain, and treatment required both rheumatologic intervention to address the source of pain as well as inpatient medical management to address the debilitating symptoms of pain.