Diagnosis and Management of Bilateral Hand Burning, Swelling, and Tingling with Negative EMG
Most Likely Diagnosis
This presentation is most consistent with small fiber polyneuropathy, which characteristically presents with burning pain, tingling, and can have normal EMG/nerve conduction studies since these tests only evaluate large myelinated fibers. 1
The key diagnostic clue is that conventional nerve conduction studies are often normal in small fiber neuropathy because 79.6-91.4% of peripheral nerve fibers are small fibers not detected by standard EMG 1. The bilateral, symmetric involvement of hands with burning and tingling in a 48-year-old female with negative EMG studies 2 years ago strongly suggests this diagnosis 1, 2.
Diagnostic Workup
Essential Initial Testing
- Screen for reversible causes: Diabetic screen (fasting glucose, HbA1c), vitamin B12, folate, TSH, HIV, and serum protein electrophoresis 1
- Inflammatory markers: ESR and CRP to evaluate for inflammatory or autoimmune causes 3
- Autoimmune panel: Consider ANA, rheumatoid factor, anti-CCP if symptoms persist or worsen 3
Confirmatory Testing for Small Fiber Neuropathy
- Skin biopsy with intraepidermal nerve fiber density measurement is the validated diagnostic test when conventional nerve conduction studies are normal 1, 2
- Autonomic testing should be considered to document autonomic nervous system dysfunction, particularly if she has symptoms like orthostatic lightheadedness, gastrointestinal issues, or temperature regulation problems 1
When to Avoid Repeat EMG
Do not repeat EMG studies in this patient. The American College of Rheumatology explicitly states that EMG is not recommended for routine serial monitoring of stable peripheral neuropathy, and repeated EMG is only warranted when there is uncertainty about new or worsening neurological processes 1. Since her symptoms have been present for at least 2 years with negative studies, repeating EMG adds cost without changing management 1.
Differential Diagnoses to Consider
Erythromelalgia
- Characterized by episodic burning pain with redness and warmth of extremities, triggered by physical activity and heat exposure 3, 2, 4
- The swelling component in this patient makes erythromelalgia a consideration 3
- Physical examination should specifically evaluate for redness and warmth during symptomatic episodes 2
Early Inflammatory Arthropathy
- Bilateral hand involvement with swelling could suggest inflammatory arthritis, though burning and tingling are less typical 3
- Examination should assess for joint tenderness, synovitis, and range of motion limitations 3
Allergic Contact Dermatitis or Irritant Contact Dermatitis
- Given her history of allergies, occupational or environmental exposures should be explored 3
- However, the prominent neurologic symptoms (burning, tingling) make this less likely as the primary diagnosis 3
Treatment Algorithm
First-Line Pharmacologic Management
Initiate treatment with one of the following neuropathic pain medications 1, 2:
- Pregabalin - First-line option with strong evidence 1, 2
- Duloxetine - First-line option, particularly if comorbid depression or anxiety 1, 2
- Gabapentin - Alternative first-line option 1
Start with low doses and titrate based on efficacy and tolerability, considering safety, cost, and side effect profile 1.
Second-Line Options
If first-line medications are ineffective or not tolerated 1:
- Tramadol
- Selective serotonin reuptake inhibitors
- Tricyclic antidepressants (though these are also considered first-line by some guidelines)
Non-Pharmacologic Management
For symptom relief 2:
- Avoid triggers that worsen symptoms (heat exposure, tight clothing, prolonged standing)
- Elevate extremities during symptom flares
- Use cooling measures safely (avoid excessive cooling like ice water immersion, which can cause tissue damage) 2
If erythromelalgia is confirmed 2:
- Consider aspirin trial, particularly if associated with thrombocythemia 2
- Topical treatments as first-line therapy 2
- Swimming instead of high-impact exercise 2
Addressing Swelling
- Assess for concurrent conditions causing edema (venous insufficiency, cardiac issues, medication side effects) 4
- Consider compression therapy if venous component identified, but avoid if arterial insufficiency present 4
Critical Pitfalls to Avoid
Do not dismiss symptoms because EMG is normal - Small fiber neuropathy requires skin biopsy for diagnosis 1, 2
Do not order repeat EMG - Clinical examination is sufficient for monitoring, and repeat EMG only adds cost without benefit in stable neuropathy 1
Do not allow excessive cooling behaviors - Patients with burning symptoms may use ice water immersion or powerful fans, which increase risk for tissue damage and ulcerations 2
Do not delay treatment while awaiting skin biopsy results - Symptomatic treatment with neuropathic pain medications can be initiated based on clinical diagnosis 1, 2
Do not overlook treatable underlying causes - Diabetes, B12 deficiency, hypothyroidism, and autoimmune conditions require specific treatment 1
Monitoring and Follow-up
- Reassess in 4-6 weeks after initiating pharmacologic therapy to evaluate efficacy and tolerability 1
- Monitor for development of additional symptoms suggesting progression or alternative diagnosis (weakness, autonomic dysfunction, asymmetric involvement) 1
- Screen for complications including sleep disturbance, anxiety, and depression, which commonly accompany chronic burning pain 2
- Serial neurologic examinations are preferred over repeated electrodiagnostic testing for monitoring 1
When to Refer
Consider rheumatology referral if 3:
- Joint swelling or synovitis is present
- Symptoms persist despite initial treatment
- Autoimmune markers are positive
Consider neurology referral if 1:
- Diagnosis remains uncertain after initial workup
- Symptoms progress to include weakness or asymmetric involvement
- Standard neuropathic pain medications are ineffective