Case report 4

A 50-year-old male patient complained of persistent fatigue, muscle weakness, and tingling sensations in his hands and feet for six months. He had no significant medical history and was not on any medications. The patient reported a sedentary lifestyle, spending long hours at his desk job, and having an unhealthy diet, often relying on fast food and processed meals. His family history was unremarkable for neurological disorders.

On examination, the patient exhibited reduced muscle strength and diminished deep tendon reflexes in the extremities. He also had decreased sensitivity to light touch and pinprick sensations in both hands and feet. Cranial nerve function and cognitive abilities were intact.

Investigations:

1. Vitamin B12 levels: 110 pg/mL (normal range: 200-900 pg/mL)
2. Complete Blood Count (CBC): Within normal limits
3. Blood Glucose: Within normal limits
4. Nerve Conduction Studies (NCS): Mild peripheral neuropathy with reduced nerve conduction velocities in the hands and feet.
5. Electromyography (EMG): Mild neurogenic changes in the muscles of the extremities.
6. Neuroinflammatory markers: C-reactive protein (CRP) and interleukin-6 (IL-6) were elevated, indicating the presence of neuroinflammation.

Based on the clinical presentation and investigations, the patient was diagnosed with peripheral neuropathy. The patient's management plan initially involved lifestyle changes, including exercise and a balanced diet. After three months, some improvement was seen in symptoms, but muscle weakness persisted. As a result, vitamin B supplementation was added to the management plan. The patient reported significant symptom improvement at the second follow-up after three months of supplementation. The tingling sensations had almost completely resolved, and he experienced a notable increase in muscle strength. His overall energy levels had improved significantly, allowing him to engage in more physical activities.