Vagal hypertrophy in immune-mediated neuropathy visualised with high-resolution ultrasound (HR-US)

A middle-aged patient, without a medical history, presented with asymmetric sensory and flaccid motor tetraparesis developing over 8 weeks, with reduced deep tendon reflexes, severe hoarseness and dysphagia due to left-sided vagal nerve palsy. Extensive laboratory tests including antiganglioside antibodies were unremarkable, except for slight cerebrospinal fluid (CSF) pleocytosis and increased intrathecal immunoglobulin G protein. CSF-cell analysis revealed no hints of lymphoma or other malignancy. Familial history was unremarkable for neuropathic symptoms or hereditary neuropathy. The positron emission tomography/CT revealed no signs of any malignancy. Electrodiagnostic studies showed multifocal motor conduction blocks, temporal dispersion, reduced motor conduction velocity of median and ulnar nerves, and the left tibial nerve. Sensory nerve action potentials were absent in median and ulnar nerves. High-resolution ultrasound (HR-US) of the peripheral nervous system revealed multifocal enlargements of several peripheral nerves in the upper and lower extremities; MRI findings of the right upper limb were in accordance with HR-US …