Montelukast-related Churg-Strauss vasculitis presenting with peripheral neuropathy.

50 Churg-Strauss syndrome is a systemic inflammatory disorder frequently associated with mononeuritis multiplex affecting both sensory and motor components of the peripheral nerves. We report an asthmatic patient treated with montelukast, a leukotriene receptor antagonist, who subsequently developed CSS presenting as peripheral neuropathy. Discontinuation of the medication and treatment with predni-sone resulted in gradual improvement. A 29 year old woman was admitted because of severe pain and a burning sensation in the lower limbs. Her past history included bronchial asthma for 11 years that worsened over the last 3 years. Intermittent eosinophilia was detected on repeated blood tests. She was treated with prednisone for the previous year intermittently, including 2 weeks prior to hospitalization. Medications received by the patient before admission were predni-sone 40 mg/day for the preceding 4 days, montelukast 10 mg/day for the last year, inhalator of terbutaline, and budesonide as needed. More recent history included a burning sensation and pain in the right lateral shin for the last 8 months, followed by the same symptoms in the right foot. Later, severe burning of the left foot and in both calves developed over 3–4 months and low back pain and asymmetric pain in both hands ensued. In addition, a rash over her hands and elbows, and pain in the wrists and ankles were evident 2 weeks prior to admission. Physical examination demonstrated CSS = Churg-Strauss syndrome a maculopapular rash over the hands and elbows. Tenderness without swelling of the wrists and ankles bilaterally was elicited. Cranial nerve and motor examination at admission were normal. There was evidence for bilateral pes cavus. Tendon reflexes were active and symmetric in both arms. Right ankle jerk was absent and decreased on the left side. Plantar responses were flexor bilaterally. There was decreased distal sensation for temperature and vibration in both legs. Vibration was absent below the ankles, and position sense was impaired for toe movements bilaterally. Sensation to touch and pain were decreased in the right leg as compared to the left and affected the dorsal plantar surface of the foot and lateral aspect of the leg. Gait and cerebellar functions were normal. Nerve conduction studies were performed on admission and showed a severe predominantly axonal sensorimo-tor neuropathy affecting the legs with clear electrophysiologic asymmetry. The laboratory workup at admission included: erythrocyte sedimentation rate 50 mm/hour, white blood cells 18,030 cells/dl, hemoglobin 12.4 g/dl, platelets 298,000 cells/dl, eosinophils: 4.2–58%, creatinine 0.9 …