Document resource
Background The 2021 guidelines from the European Academy of Neurology/Peripheral Nerve Society on CIDP introduced four variants: distal, multifocal/focal, motor, and sensory. This case describes a patient with multifocal CIDP.Case A 55-year-old forklift driver with a history of bariatric surgery and hypertension experienced progressive, painless left arm distal weakness affecting multiple nerves. Examination revealed moderate to severe wrist drop, moderate finger flexion/extension, and moderate thumb abduction weakness. Lab tests were unremarkable. CSF showed elevated protein (0.7 g/L) with no cells. Initial NCS in 2023 indicated absent ulnar sensory response, reduced radial sensory amplitudes, impersistent median and ulnar F waves, with EMG indicating chronic neurogenic abnormalities of multiple myotomes in the left arm, supportive of a possible brachial plexopathy. MRI of the brain and spine was normal. Subsequent MRI of the plexus and upper limb showed thickening and nodularity in the left brachial plexus. Repeat NCS revealed asymmetrical, multifocal, primarily demyelinating sensorimotor polyradiculoneuropathy in the left median and bilateral ulnar nerves. Treatment with IVIG led to improvement of finger extension weakness at last review.Discussion Multifocal CIDP involves weakness and sensory disturbances in two or more limbs, with electrodiagnostic criteria met in two or more nerves. This case meets the criteria for definite multifocal CIDP.Conclusion Multifocal CIDP is an uncommon cause of asymmetrical weakness sensory abnormalities. Patients often present with asymmetrical motor and sensory symptoms, predominantly in the upper limbs. Other diagnoses, such as brachial plexopathy, mononeuritis multiplex, peripheral nerve sheath tumours and entrapment neuropathy should be excluded.