A 45-year-old man with long-standing seropositive rheumatoid arthritis presents with progressive quadriparesis and sensory ataxia over 10 days. He has bilateral wrist drop and foot drop. Examination shows BP 80/50 mmHg (supine), which drops to 60/40 on sitting. Heart rate remains 72 bpm in both positions. Which is the most likely cause of his autonomic dysfunction?
- A Amyloid-associated autonomic neuropathy
- B Rheumatoid vasculitis causing autonomic neuropathy ✓
- C Cervical myelopathy from atlantoaxial subluxation
- D Side effect of methotrexate
Correct answer: B. Rheumatoid vasculitis causing autonomic neuropathy
Explanation
Rheumatoid vasculitis in long-standing seropositive RA can cause mononeuritis multiplex (wrist/foot drop) and autonomic neuropathy (neurogenic orthostatic hypotension with fixed heart rate, indicating baroreflex failure). Atlantoaxial subluxation causes cervical myelopathy with upper motor neuron signs, not peripheral neuropathy. Amyloidosis causes autonomic neuropathy but would also show nephrotic syndrome or malabsorption. MTX does not cause this pattern.
Reference: Kelley and Firestein's Textbook of Rheumatology, 11th ed.
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