Neurology Q27

A 52-year-old man is evaluated for a 1-year history of progressive weakness that began as right foot drop and bilateral tingling in the feet. Within the past 2 months, the patient has developed progressive weakness, which makes walking difficult; he also notes weakness in the hands and burning below the knees but no autonomic symptoms. He has hypothyroidism treated with levothyroxine.

On physical examination, vital signs are normal. Motor strength is 4/5 in the intrinsic hand and quadriceps muscles and 3/5 in the tibialis anterior and gastrocnemius muscles; bulbar and facial muscle strength is normal. Deep tendon reflexes are absent in the lower extremities. Sensory perception of vibration is severely impaired at the knees. Pinprick testing shows reduced sensation below the ankles. Splenomegaly is present, as are patchy areas of hyperpigmentation and scattered angiomas on the trunk. Gait is broad based and wobbly, and a Romberg test has positive results.

Serum immunofixation reveals a λ light chain monoclonal protein.

Needle electromyography reveals a demyelinating sensorimotor polyneuropathy.

Which of the following is the most likely diagnosis?

POEMS syndrome

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