An unusual case of neuralgic amyotrophy presenting with bilateral phrenic nerve and vocal cord paresis

Abstract

Background: Neuralgic amyotrophy (brachial plexus neuropathy, brachial plexus neuritis, or Parsonage-Turner syndrome) is an uncommon inflammatory condition typically characterized by acute and severe shoulder pain followed by paresis with muscle weakness and atrophy of the upper limb or shoulder girdle. We report an unusual clinical manifestation of neuralgic amyotrophy, namely bilateral phrenic nerve palsy with concomitant laryngeal paresis.

Case report: A 55-year-old male presented with orthopnea and aphonia after an episode of bilateral shoulder pain preceded by an upper respiratory tract infection. Spirometry, chest X-ray and videolaryngoscopy revealed bilateral and simultaneous paresis of the diaphragm and the vocal cords. Clinical examination at admission and at the 2-month follow-up did not show upper limb weakness or atrophy, except for a mild atrophy of the right supraspinatus muscle. An electromyography of the upper limb muscles and nerve conduction studies did not reveal signs of denervation. Analysis of the cerebrospinal fluid and an MRI of the neuraxis were unremarkable. After treatment with prednisolone, vocal cord function markedly improved within 8 weeks, whereas paresis of the diaphragm persisted.

Conclusion: Shoulder pain followed by diaphragmatic paralysis with dyspnea and hoarseness may be a manifestation of neuralgic amyotrophy even if upper limb or shoulder girdle palsies are absent.

Keywords: Diaphragmatic palsy; Laryngeal palsy; Neuralgic amyotrophy; Neuropathy; Parsonage-Turner syndrome.

Fig. 1

Chest X-ray at initial visit in maximum expiration (a) and maximum inspiration (b), showing paresis of the diaphragm and partial atelectasis of the right lung.

Fig. 2

Videolaryngoscopy during phonation after the initial visit (a) and at the 2-month follow-up (b), demonstrating an improvement of the vocal cord mobility and a normalization of the ventricular fold tension.