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A 76-year-old man was referred with a diagnosis of ‘motor neuron disease’ or ‘polyneuropathy’. For about eight months he had noticed progressive muscle weakness in his right leg associated with pain, initially more intense than at referral, and a numb feeling around the right knee. Two years previously his left hand had become weak and wasted, associated with loss of sensation of the ring finger, the little finger, and the ulnar part of the palm of his hand. He had lost weight (5 kg) unintentionally over the past six months. He had always been very active, but was now no longer able to walk his dog or do some gardening. He was recently diagnosed with diabetes mellitus (DM) for which oral antidiabetics were prescribed. Family history was unremarkable.
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