Malik Anas Rabbani, Bushra Ahmad, Syed Mansoor Ahmed Shah, Aasim Ahmad.
Ischemic Monomelic Neuropathy: A complication of vascular access procedure.
J Pak Med Assoc Jan ;55(9):400-1.

A 58 year old female with 20 years history of type-I diabetes, 6 years history of ischemic heart disease and hypertension and known to have chronic renal failure for 2 years, was admitted with loose watery motions, gradually decreasing urine output, nausea, generalized weakness and generalized body swelling for the last ten days. She was on insulin, lisinopril, aspirin and nitrates. On examination her blood pressure was 160/100 mmHg, pulse 90/minute regular, jugular venous pressure 4.5 cm, pedal oedema and coarse bilateral crepitations in the lungs. Her laboratory investigations revealed Hb 12.4 gm/dl with normal white blood cell and platelet counts. Serum creatinine was 11.3 mg/dl, serum sodium 137 mEq/L, potassium 4.5 mEq/L, chloride 101 mEq/L, bicarbonate 18.3 mEq/L, calcium 9.8 mg/dl and phosphorus 4.8 mg/dl. Chest x-ray was consistent with pulmonary edema. She was started on hemodialysis via double lumen right internal jugular catheter. Due to poor peripheral vasculature a left brachio-cephalic arterio-venous bridge graft was placed as a permanent access for dialysis. A week after discharge she presented with numbness and burning sensation of the left arm extending from just above the cubital fossa down to the lateral aspect of the hand. These symptoms worsened after first hemodialysis via PTFE graft. Examination revealed decreased pinprick sensation along lateral aspect of left forearm with absent biceps and triceps reflexes. She also had difficulty in gripping objects with the left hand. Electrophysiological studies revealed sensory and motor axonal loss in the median, ulnar and radial nerve territories distal to the graft on left side. There was also evidence of sensory neuropathy. Unfortunately she refused to undergo any further surgical procedure with regards to her acute neuropathy. On follow up six months later she had wasting of thenar and hypothenar muscles of the left hand along with burning pain and tingling sensation.

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