A 60-year-old retired woman presented with upper and lower limb paresthesias since age 40 and chronic diarrhea and weakness. She worked as a teacher. Her deceased mother had experienced similar symptoms. Neurological examination disclosed dysautonomic features ([Figure 1]), severe sensory loss of vibration and proprioceptive senses and a moderate decrease of pain and temperature sensation with stocking-glove distribution, and perforating palmar disease ([Figure 2]). Neurophysiological studies disclosed severe axonal sensorimotor polyneuropathy. Laboratory tests were unremarkable. The pathogenic heterozygous variant Val50Met in the TTR gene defined TTR-related familial amyloid polyneuropathy[1]. This finding highlights perforating palmar disease as a rare complication of familial amyloid polyneuropathy[2],[3]. Neurogenic perforating palmar ulcers may occur in neuropathies due to: (i) severe distal sensory loss and high risk of multiple local microtrauma; (ii) vasomotor disturbances to peripheral dysautonomia and sympathetic dysfunction with chronic hypoperfusion[4].
Figure 1 Dysautonomic and sensory and motor findings in TTR-related familial amyloid polyneuropathy. Clinical examination showing skin color changes, mild edema (A), and bilateral foot drop (B), which initiated a neuropathic steppage gait. Plantar surfaces of both feet were spared from ulcerations.
Figure 2 Perforating palmar disease and neuropathic ulceration in a patient with familial amyloid polyneuropathy. Examination showing the presence of neurogenic ulcer in the right hand, marked distal amyotrophy of thenar and hypothenar region of both hands, and skin color changes. Perforating palmar disease is more commonly associated with chronic sensory polyneuropathy, such as diabetes, leprosy and vasculitis[1],[2],[3].
