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• Chief complaint and duration: hand,foot numbness andpricking pain for 15 days durationHistory of Present illness :- a 65 years old male patientPresened to hospital for hand and foot numbnesss andpricking sensation on the foot for 15 days duration, thecondition started suddenly from about 15 months, whilethe patient walking in the garden he noticed his foot isdropping and attacking the ground .he neglect thecondition and after about 3 days he feels weakness in theleft foot and leg with decrease sensation. .


• the weakness progress gradually to involve the RT.Leg and involvement of fingers of both hands in about1 week, the numbness progress from distal toproximal part of hands and foot which was associatedwith weakness ,drop foot and pricking sensation inboth legs,the pricking pain was so sever that preventhim from sleep and walking and patient was bedridden for few days


This was accompanied by skin rash that occurred suddenlyand coincidentally with the weakness purplish in colorextend from dorsal aspect of the foots to involve both legsand thighs to the lower part of the abdomen which is not painful neither pruritic diffused without involvement of MM orother area , no bleeding from any orifice


• . the rash disappeared soon after warm bathing hiscondition is not associated with headache or loss ofconsciousness or abnormal movement and no visual orhearing disturbance The patient claimed that after 4-5days of starting his condition he develop a severattacks of nausea vomiting on every meal and diarrheawhich was watery in consistency and associated wihdecrease appetite and generalized fatigue and weaknesswithout elevation of body temperature. no incontinenceof urine or feces


• Nerve conduction study was done from about 1 yearwhich revealed a delay in conduction velocity andpatient was diagnosed as chronic peripheralneuropathy.,in 19/2/2013 his condition deteriorate andrelapsed with most sever attacks of pain ,weakness dropof foot with same extension of purplish rash withattacks of vomiting and diarrhea for 5 days and lowerabdominal pain


• . The doctor advice him to take 5 ampule of steroid withcourse of intravenous IG(IVIG) which make patient dramatically better , and now the patient is able to walk and foot drop disappear after 10 minute of start walking with disappearing of the rash after bathing and decrease pain, CRP,ESR,FBS,LFT,FRT, lipid profile us of abdominal and pelvis CX.R hepatitis c +ve on investigation.


Review:Respiratory:no productive cough , no chest pain,, no SOB., no wheeze or stridorG.I.T.:decrease appetite,weight loss about 2kg,no dysphagia ,noodynophayia,lowerabdominal pain,no change in bowel motion ,nausea and vomiting 3 times daily watery,no indigestion or heartburn , no rectal bleeding .genitonurinaring: normal color urine and quantity and no bloodin it,no nocturia,no incontinence,MSK: joint pain no swelling, muscle and bone pain with backache.


Past medical and surgical :the patient is not hypertensive or diabetic with noprevious acutemedical illness and no previous admittionbefore starting hisconditionabdominal herniorrhaply was done at 1985 followed bysepticemia and he have history of acute renalfailure ARFwhich required hemodialysis and then his conditionstabilized . He sustained bullet to the abdomen withemergency laprotomy was done. 5 pints of blood wasgiven from one member of the gang. resection of 50% ofpancreas and 10cm of bowel and complicatd after 1 weekby burst abdomen and mesh was putted


• Drug history: he has allergy to plaster ,no allergy to drugs ,no chronic drug used apart from the above mentioneddrugs.• Personal history: not smoker,not alcoholic,no drug abuse• Family history : no similar condition in the family ,no HTor D.M. in ,no history of bleeding tendency in family• Social history: good S.E status,no animal in the house.


Examination:general examination : an elderly male lying comfortable on bed he is conscious alert not dyspneic with thin body build with a canulla in volar aspect of forarm not anemic or jaundiced ,no lymph node enlargement,no goiter , no abnormal neck pulsation there is purpu-ric lesions distributedon the (feet , ankle proximally till the thigh and lower abdomen redish In color not blanch on pressure, not palpalpable ,no edemanormal hair distributionnormal peripheral pulses


hand: no joint swelling or deformitymuscles (wasted hands)skin color : no pallor of palm , no cyanosis , no palmarerythema .no skin lesionsno clubbed fingers , no koilonychias , no anycholysis.noleukonichiano flapping tremor , just fine tremor on out stretchedhand is present no stigmata of chronic liver disease


Neurological examination :Crainail nerves:olfactory nerve(|) normaloptic nerve(||) :visual acuity : normalvisual field : normalophthalmoscopic examination: was normal no papilledemapupillary reflexes (||,|||) : normaloculomotor ||| , trochlear (I V) , and abducent (VI) nerves : all normalby inspection : pupils are symmetrical and of normal size , no squint , no ptosis , nonystagmus .eyes movements are normal to all directionstrigeminal nerve (V) :facial sensation intact bilaterally .corneal reflex (V ,VII) : normalmotor : no wasting of temporalis and masseter muscles , normal jew jerkfacial nerve (VII) : normalvestibule cochlear nerve (VIII) :normalGlossopharyngeal (IX ) and vagus(X) nerves :gag reflex(afferent IX , efferent X) : normal bilaterally .sensory function : normal (light touch each side of the soft palate ).accessory (XI)hypoglossal (XII) : no atrophy , no fasciculation and no weakness in the tongue


• motor system :• by inspection : no postural abnormality , no involuntarymovements , no fasciculation noticed , but some loss of muscle bulk seen in the lower limbs , and generally the movement of the patient is subnormal , regarding speech the verbal fluency is slow with dysphonia (difficulty with speech volume)• muscles tone : normal (passive dorsiflexion at ankle jointwas limited movement )• Muscles power : in upper limbs (normal) in lower limbsis subnormal in the right lower limb (grade 4+)the left lower limb power is weaker than right (grade 4-)the patient can't do dorsiflexion at ankle joint but can doextention and flexion of toes


• reflexes : deep tendons and superficial reflexes of lowerlimbs markedly decrease , with more affection of theRT side more than the left side the upper limb wasnormal bilaterally .motor coordination :finger to noserapid alternating movement (diadochokinesis )reboundheel to shin,ALL WAS NORMAL


• gait : slow walking , short steps , shuffling , foot drop at early walking and all are decrease after about 10 minute ofwalking .• sensation : Light touch patient not feel the cotton woolfrom 10 cm below the knee and distally in lower limbs ,palmsand palmar aspect of fingers in upper limbs .and similar sensation was seen with pinprick .• joint position sense was normal


Systemic examination• A-cardiovascular:-• on inspection : there is no abnormality of chest shape, no visiblepulsation in the chest, no epigastric pulsation , apex beat is visible.• on palpation: the apex beat at left 5 th intercostal space at midclavicular line, palpable , not sustainted ,no parasernal heave or thrill,trachea is central.• on percussion: just dull .• on auscultation: 1 st and 2 nd heart sound is audible no added sounds.• B-respiratory :-• on inspection: no abnormality of chest shape,abdominal breathingchest move with respiration normal expantion• there is scar of bullet injury in the right side• on palpation: trachea is central, expantion 3cm, symmetrical tactilevocal fremitus percussion, no lymph node enlargement no chest walltenderness.• on percussion: normal symmetrical resonance.• on auscultation: normal vesicular with no added sounds inspiratoryrhonchi


• C-abdominal :• on inspection: flat abdomen move with respirationinverted rounded umbilicus,no dilated veins,normal hairdistribution,scar of laprotomy is present and no pigmentation.• on palpation: superficial palpation:no tenderness, no superficial mass, no organomegally .• on percussion: resonance• on auscultation: normal bowel sound.•• Vital signs:• BP: 140/85 mm/ghPR: 70 B/ minuteRR: 16cycle / minutetemperature : 37 c


investigations


Differential diagnosis


• 1-mixed cryoglobulinemia with hepatitis c• 2- pan artritis nodosa• 3-porphyria


Causes of peripheral neuropathyMulifocal:Acute:1-dephtheria2-DM3-vasculitis4_lyme dis.5-cryglubulinaemia


Chronic:1-leprosy2-paraprotienaemia3-DM4-sarcoidosisGENERALIZEDAcute:1-Guillian-Barre2-Alcohol3-toxins4-porphyrai5-tick paralysis


Input vector fields◮ Fluid simulations◮ Velocity extrapolated to the boundaryPC vector fieldsAndrzej SzymczakPrior workMorsedecompositionMorsedecomposition:computationPC vector fieldsTransition graphMorsedecompositions:PC caseCVPC vector fieldsExperimentalresultsPCMorse ConnectionGraphsStable MorsedecompositionsMorse hierarchy3D case

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