Recumbent position5/31/2023 Systemic steroid was prescribed with no improvement at present. After a neurological consult, in consideration of asymmetrical weakness and atrophy of the arms and shoulder pain, a diagnosis of neuralgic amyotrophy with an unusual phrenic involvement was done. Infectious, neoplastic, inflammatory or autoimmune conditions were excluded by rachicentesis and autoimmunity tests. No lesions were found at neck-chest CT scan and spine MRI. NIV with B-PAP was started, with resolution of nocturnal respiratory failure confirmed by polygraphy. EMG detected a severe deficit of both phrenic nerves (right more affected). Chest US revealed a reduced muscle thickness of the right hemi-diaphragm apposition zone (1.9 mm at the end of expiration) with paradoxical thinning in inspiration, compatible with diaphragm deficit. A repeated chest X-ray showed a mild super-elevation of both emidiaphragms, not present earlier. An upper airway obstruction was excluded by bronchoscopy and PFT, which resulted in a moderate restrictive syndrome with a normal TLCO. At our examination he was eupnoic in seated position with SpO2 97% on room air, dropping to 89% in supine position. Besides he had an history of 6-month shoulder pain and algoparesthesias at both arms. A 56 years old man referred dyspnea only in supine position during the last 2 months, already investigated with chest X-ray, echocardiography and ECG resulting normal.
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