One Challenging Case, Many Perspectives: Clinical Collaboration on AANEM Connect

When Pruritus Is More Than Skin Deep: A Complex Case on AANEM Connect

A 70-year-old man with recurrent pruritus prompted an AANEM Connect discussion after his symptoms spread from the periscapular area to the thoracic region and extensor forearms. He had initially responded well to a steroid injection for presumed notalgia paresthetica, but the later widespread itching raised questions about whether another process was involved.

Although his neurologic examination and cervical/thoracic MRI were largely unremarkable, needle electromyography (EMG) showed small-amplitude fibrillation potentials and positive sharp waves in several upper-extremity muscles bilaterally. The patient had also lost 70 pounds over six months while taking Wegovy and described mild generalized weakness.

Members considered whether the presentation reflected notalgia paresthetica, neuropathy, myopathy, medication effects, systemic disease, or multiple coexisting conditions. Several emphasized that spontaneous activity on EMG should not automatically be interpreted as purely neurogenic; careful review of motor-unit morphology and recruitment could help distinguish chronic axonal loss from subtle myopathic change.

The discussion explored a possible relationship between Glucagon-like Peptide-1 (GLP-1) therapy, substantial weight loss, and muscle loss or neuromuscular symptoms. Suggested next steps included creatine kinase testing, quantitative EMG, and lower-extremity nerve conduction study (NCS)/EMG to assess for generalized neuropathy. Given the patient’s age, pruritus, and weight loss, contributors also recommended laboratory and paraneoplastic evaluation.

At follow-up, the paraneoplastic panel was negative, and symptoms had improved somewhat after the patient lowered his GLP-1 dose, stabilized his weight, and increased food intake. He declined repeat electrodiagnostic testing and chose to pursue another steroid injection, which had previously provided significant relief.

Continue the Discussion on AANEM Connect

The summary above captures only part of this thoughtful exchange. Read the full AANEM Connect discussion to review the complete case, the electrodiagnostic findings, suggested evaluations, references shared by participants, and any further clinical follow-up.