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Bilateral dropped hands in a patient with systemic lupus erythematosus

A 61-year-old woman with systemic lupus erythematosus (SLE) developed sudden weakness of the left hand, then weakness of the right hand the next day. She was referred from a clinic with suspected SLE-related acute neuropathy. She presented with bilateral dropped hands without sensory loss. Bilateral biceps, triceps, and brachioradialis reflexes were increased, and Wartenberg reflex was positive on both sides. Brain diffusion-weighted images revealed diffuse, fresh ischemic lesions in the cerebral cortex and subcortex including bilateral precentral knobs (Fig. 1). No embolic sources were detected. Based on positive lupus anticoagulant, anticardiolipin IgG antibody, and anticardiolipin/b2-glycoprotein I complex, antiphospholipid syndrome was suspected. Dropped hands are rarely caused by ischemic stroke, but some reports have described bilateral hand weakness predominantly affecting the extensors due to cerebral ischemia. Increased tendon reflexes or pathologic reflexes may be key to detecting central lesions.