APPROACH TO APPROACH TO PERIPHERAL PERIPHERAL NEUROPATHYNEUROPATHY

PROF.RUCKMANI REDDY’S UNITPROF.RUCKMANI REDDY’S UNIT

M1M1

HUMAN NS-----CNSHUMAN NS-----CNS -----PNS-----PNSEACH NEURON has EACH NEURON has 3 parts3 parts SOMASOMA DENDRITESDENDRITES AXONAXON

What forms peripheral nerve?What forms peripheral nerve?

1.DORSAL NERVE ROOT1.DORSAL NERVE ROOT2.VENTRAL NERVE ROOT2.VENTRAL NERVE ROOT3.DORSAL ROOT GANGLIA3.DORSAL ROOT GANGLIA4.CRANIAL NERVES EXCEPT 1 $ 24.CRANIAL NERVES EXCEPT 1 $ 25.BRACHIAL & LUMBOSACRALPLEXUS5.BRACHIAL & LUMBOSACRALPLEXUS6.OTHER sensory,motor,autonomic 6.OTHER sensory,motor,autonomic

nervesnerves

Role of nerve fibres in Role of nerve fibres in peripheralneuropathyperipheralneuropathy

HISTORYHISTORYOnset –acute/subacute/c/cOnset –acute/subacute/c/cPart of body involvedPart of body involvedSequence of involvementSequence of involvementSymptoms -----sensorySymptoms -----sensory -----motor-----motor -----autonomic-----autonomic

Sensory symptomsSensory symptoms

Pain -pricking,burning typePain -pricking,burning typeAllodyniaAllodyniaHyperalgesiaHyperalgesiaNeuropathic painNeuropathic painAnaesthesiaAnaesthesiaTremors-action tremor-in a phase of PNPTremors-action tremor-in a phase of PNP -slow tremor with clumsiness-slow tremor with clumsiness large fibres affected-large fibres affected-

AI,CIDP,antimyelinasso GP AI,CIDP,antimyelinasso GP polyneuropathypolyneuropathy

Paraesthesia Paraesthesia marked in hands & feetmarked in hands & feet objectory sensoryloss is lackingobjectory sensoryloss is lacking Spontaneous parasthesiaSpontaneous parasthesia -in acquired causes-60%-in acquired causes-60% -in inherited causes-17%-in inherited causes-17% Painful parasthesiaPainful parasthesia –DM –DM --ALCOHOLIC NPY--ALCOHOLIC NPY --AMYLOID--AMYLOID Why pain?loss of large touch pressure fibresWhy pain?loss of large touch pressure fibres ExceptionException – –FREDERICH’S ATAXIAFREDERICH’S ATAXIA --Purely sensory polyNP--Purely sensory polyNP

Motor symptomsMotor symptomsMUSCLE CRAMPSMUSCLE CRAMPS WEAKNESSWEAKNESS

FASCICULATIONSFASCICULATIONS DECREASED MANUAL DECREASED MANUAL DEXTERITYDEXTERITY

MYOKYMIAMYOKYMIA WASTING OF MUSCLEWASTING OF MUSCLE

TREMORTREMOR DIIFFICULTY WITH FOOD DIIFFICULTY WITH FOOD INTAKEINTAKE

SPASMSSPASMS

Autonomic symptomsAutonomic symptoms

ORTHOSTATIC LIGHT HEADEDNESSORTHOSTATIC LIGHT HEADEDNESS

FAINTING SPELLSFAINTING SPELLS

SWEATING-INCREASED/DECREASEDSWEATING-INCREASED/DECREASED

HEAT INTOLERANCEHEAT INTOLERANCE

BLADDER,BOWEL,SEXUAL BLADDER,BOWEL,SEXUAL DYSFUNCTIONDYSFUNCTION

ANOREXIA,NAUSEA,VOMITING-ANOREXIA,NAUSEA,VOMITING-GASTROPARESISGASTROPARESIS

PANDYSAUTONOMIA-PANDYSAUTONOMIA- AmyloidosisAmyloidosis Hereditary smallfibrePNHereditary smallfibrePNDRUG H/O-DRUG H/O-

cisplatin,nitrofurantoin,pyridoxinetoxicitycisplatin,nitrofurantoin,pyridoxinetoxicityFAMILYFAMILY H/O-Repeated injury,c/c H/O-Repeated injury,c/c

subcut&osteomyelitis infectionsubcut&osteomyelitis infectionPAST H/OPAST H/O recent infectionsrecent infections viral diseasesviral diseases

GE-SKIN,HAIR,NAILSGE-SKIN,HAIR,NAILSVASCULITISVASCULITIS PURPURA,LIVEDORETICULPURPURA,LIVEDORETICUL

ARISARIS

CRYOGLOBULINEMIACRYOGLOBULINEMIA PURPURAPURPURA

FABRY’S DISEASEFABRY’S DISEASE ANGIOKERATOMASANGIOKERATOMAS

LEPROSYLEPROSY SKIN SKIN HYPERPIGMENTATIONHYPERPIGMENTATION

OSTEOSCLEROTIC OSTEOSCLEROTIC MYELOMA-POEMSMYELOMA-POEMS

HYPERPIGMENTATIONHYPERPIGMENTATION

VARIEGATE VARIEGATE PORPHYRIAPORPHYRIA

BULLOUS LESIONSBULLOUS LESIONS

REFSUM’S DISEASEREFSUM’S DISEASE ICTHYOSISICTHYOSIS

ARSENIC/THALLIUM ARSENIC/THALLIUM INTOXICATIONINTOXICATION

MEE’S LINESMEE’S LINES

THALLIUM THALLIUM POISONINGPOISONING

ALOPECIAALOPECIA

GIANT AXONAL GIANT AXONAL NEURPATHYNEURPATHY

CURLED HAIRCURLED HAIR

NERVE THICKENING in NPthyNERVE THICKENING in NPthy

LEPROSYLEPROSYDIABETESDIABETESAMYLOIDOSISAMYLOIDOSISNEUROFIBROMATOSISNEUROFIBROMATOSISREFSUM’S DISEASEREFSUM’S DISEASEDEJERINE SOTTAS DISEASEDEJERINE SOTTAS DISEASEROUSSY LEVY SYNDROMEROUSSY LEVY SYNDROME

DEFORMITY in NPthyDEFORMITY in NPthy

Foot,hand,spineFoot,hand,spineTalipes equinusTalipes equinusClaw footClaw footPes cavusPes cavusKyphoscoliosisKyphoscoliosisBurnsBurnsPressure soresPressure sores

Cranial nervesCranial nerves

Neuropathy with facial nerve damageNeuropathy with facial nerve damageGBSGBSC/C inflammatory polyradiculonuropathyC/C inflammatory polyradiculonuropathyLyme diaseaseLyme diaseaseSarcoidosisSarcoidosisHIV-1infectionHIV-1infectionGelsolin familial amyloid neuropathyGelsolin familial amyloid neuropathyTangier’s diseaseTangier’s disease

Look for-muscle wastingLook for-muscle wasting

Strength of muscleStrength of muscle

REFLEXESREFLEXES –decreased/lost –decreased/lost

--sign of PNP except in spinal shock--sign of PNP except in spinal shock

Incoordination of movementsIncoordination of movements

Gait abnormality-flinging/slapping gaitGait abnormality-flinging/slapping gait

ATAXIAATAXIA CAUSE?CAUSE? proprioceptive deafferentiation proprioceptive deafferentiation

spinocerebellar dysfunctionspinocerebellar dysfunction

ATAXIA WITHOUT WEAKNESSATAXIA WITHOUT WEAKNESS -tabesdorsalis -tabesdorsalis

DDs-DM,miller fisher variant,sensoryNPthyDDs-DM,miller fisher variant,sensoryNPthy

Ataxia similar to cerebellar,but no Ataxia similar to cerebellar,but no nystagmus,dysarthrianystagmus,dysarthria

SENSATIONS-SENSATIONS- pin prickpin prick temperaturetemperature vibrationvibration pressurepressure position senseposition senseProprioception assessmentProprioception assessment

Pattern of sensory lossPattern of sensory loss

POLY POLY NEUROPATNEUROPATHYHY

Symmetrical,distal,legs>armsSymmetrical,distal,legs>arms

Can even progress to face Can even progress to face

SEVERE SEVERE AXONAL AXONAL NEUROPATNEUROPATHYHY

ESCUTCHEON pattern of sensory ESCUTCHEON pattern of sensory loss over abdomen and thoraxloss over abdomen and thorax

SENSORY SENSORY GANGLIONGANGLIONOPATHYOPATHY

Sensory loss of trunk,scalp,face d/t Sensory loss of trunk,scalp,face d/t simultaneous damage of simultaneous damage of proximal&distal part of sensory proximal&distal part of sensory nervenerve

NERVE FIBRE AFFECTED?NERVE FIBRE AFFECTED?

SYMPTOMSSYMPTOMS SIGNSSIGNS

numbnessnumbness Decreased vibration senseDecreased vibration sense

Pin & needle sensationPin & needle sensation Decreased joint position Decreased joint position sensesense

tinglingtingling Diminished or absent Diminished or absent reflexesreflexes

Poor balancePoor balance

LARGE FIBRE NEUROPATHYLARGE FIBRE NEUROPATHY

Causes of large fibre/ataxic NPCauses of large fibre/ataxic NP

SJOGREN’S SYNDROMESJOGREN’S SYNDROMEVIT B12 NEUROPATHYVIT B12 NEUROPATHYCISPLATIN CISPLATIN PYRIDOXINE NEUROTOXICITYPYRIDOXINE NEUROTOXICITYFRIEDEREICH’S ATAXIAFRIEDEREICH’S ATAXIA

SMALL FIBRE NEUROPATHYSMALL FIBRE NEUROPATHY

PAIN-PAIN-burning,shock burning,shock like,stabbing,priclike,stabbing,prickling,shooting,lakling,shooting,lancinatingncinating

AllodyniaAllodynia

Decreased Decreased pinprick pinprick sensationsensation

Tight band like Tight band like pressurepressure

Insensitive to Insensitive to heat and coldheat and cold

Diminished Diminished temperature temperature sensationsensation

Causes of small fibre neuropathyCauses of small fibre neuropathy(painful NP&dissociated sensory (painful NP&dissociated sensory

loss)loss)Heriditary sensory neuropathyHeriditary sensory neuropathyLepromatous leprosyLepromatous leprosyDiabetes mellitusDiabetes mellitusAmyloidosis(early familial&primary)Amyloidosis(early familial&primary)Tangier diseaseTangier diseaseFabry’s disease-pain predomonatesFabry’s disease-pain predomonatesDysautonomia-riley-day syndromeDysautonomia-riley-day syndromeHIV & antiretroviral therapy neuropathyHIV & antiretroviral therapy neuropathy

SMALL & LARGE FIBRE SMALL & LARGE FIBRE NEUROPATHYNEUROPATHY

Global sensory lossGlobal sensory lossCarcinomatous sensory neuropathyCarcinomatous sensory neuropathyHereditary sensory neuropathyHereditary sensory neuropathyDiabetic sensory neuropathyDiabetic sensory neuropathyVacor intoxicationVacor intoxicationXanthomatous neuropathy of primary Xanthomatous neuropathy of primary

biliary cirrhosisbiliary cirrhosis

Motor predominant neuropathyMotor predominant neuropathy

Immune neuropathiesImmune neuropathiesHeriditary motor sensory neuropathiesHeriditary motor sensory neuropathiesAcute intermittent porphyriaAcute intermittent porphyriaDiphtheritic neuropathyDiphtheritic neuropathyLead neuropathyLead neuropathyBrachial neuritisBrachial neuritisDiabetic lumbosacralplexus neuropathyDiabetic lumbosacralplexus neuropathy

Autonomic Autonomic

Acute-pandysautonomiaAcute-pandysautonomia -botulism-botulism -porphyria-porphyria -GBS-GBS -Amiodarone-Amiodarone -vincristine-vincristineChronic-amyloid,diabetes,sjogren’s,HSN Chronic-amyloid,diabetes,sjogren’s,HSN

1&3,chagas,paraneoplastic1&3,chagas,paraneoplastic

Distribution of neuropathyDistribution of neuropathy

??MONONEUROPATHMONONEUROPATHYY

Focal involvement of Focal involvement of a single nervea single nerve

Weakness & sensory Weakness & sensory loss in the territory of loss in the territory of a single peripheral a single peripheral nervenerve

Pain along the Pain along the pathway of the nervepathway of the nerve

Direct Direct traumatrauma

compressiocompressionn

entrapmententrapment Vascular Vascular lesionslesions

neoplasmsneoplasms

?MONONEUROPATHY ?MONONEUROPATHY MULTIPEXMULTIPEX

Random pattern of nerve involvementRandom pattern of nerve involvement In distribution of separate nerves,asymmetricIn distribution of separate nerves,asymmetric May/may not be painfulMay/may not be painful Not length dependentNot length dependent Isolated reflex lossIsolated reflex loss CAUSESCAUSES—inflammatory-leprosy,sarcoid—inflammatory-leprosy,sarcoid Vascular-DiabetesVascular-Diabetes Pressure,Trauma,InfiltrationPressure,Trauma,Infiltration Vasculitis-PAN,SLE,RA,sclerodermaVasculitis-PAN,SLE,RA,scleroderma Immune-vaccinationImmune-vaccination

?POLYNEUROPATHY?POLYNEUROPATHY

MC type –Distal symmetric polyneurpathyMC type –Distal symmetric polyneurpathyBurning sensation,tingling,numbnessBurning sensation,tingling,numbnessLength dependent patternLength dependent patternStarts in feet,distal stocking glove patternStarts in feet,distal stocking glove patternFairly symmetricFairly symmetricSymmetrically decreased reflexesSymmetrically decreased reflexesSensory>motorSensory>motor

CAUSESCAUSES

Diabetes mellitusDiabetes mellitusAlcoholAlcoholVit B12 deficiencyVit B12 deficiencyHIVHIVAlthough more than Although more than one nerve involved one nerve involved one will be prominantone will be prominant

DDs of distal symmetricNPDDs of distal symmetricNP

Lumbosacral polyradiculopathy/stenosisLumbosacral polyradiculopathy/stenosisMyelopathy-structuralMyelopathy-structural -nonstructural-nonstructuralVascular insufficiency-exercise related Vascular insufficiency-exercise related

cramps,aching pain>numbnesscramps,aching pain>numbnessOrthopedics –stress #,plantar fascitisOrthopedics –stress #,plantar fascitis

?POLYRADICULOPATHY?POLYRADICULOPATHYDisease of multiple peripheral nerve rootsDisease of multiple peripheral nerve rootsAsymmetric with erratic distribution-proximal in Asymmetric with erratic distribution-proximal in

one,distal in anotherone,distal in anotherPain is a common featurePain is a common feature?MONORADICULOPATHY?MONORADICULOPATHYRoot disease by disease of spinal columnRoot disease by disease of spinal columnChanges in distribution of spinal nerve rootChanges in distribution of spinal nerve root

?SENSORY NEURONOPATHY?SENSORY NEURONOPATHYGanglion cells predominantly affectedGanglion cells predominantly affectedBoth proximal & distal involvementBoth proximal & distal involvementSensory ataxia is commonSensory ataxia is commonNo weaknessNo weaknessBut awkward movement d/t sensory But awkward movement d/t sensory

disturbancesdisturbances?MOTOR NEURONOPATHY?MOTOR NEURONOPATHYDisorder of ant horn cellsDisorder of ant horn cellsWeakness,fasciculation,atrophyWeakness,fasciculation,atrophyNot properly a process of peripheral NPNot properly a process of peripheral NP

?PLEXOPATHY?PLEXOPATHYAsymmetricAsymmetricPainful onsetPainful onsetMultiple nerves in a single limbMultiple nerves in a single limbRapid onset of weakness,atrophyRapid onset of weakness,atrophy Isolated reflex lossIsolated reflex loss

?polyneuritis cranialis?polyneuritis cranialisa/c idiopathic polyneuritisa/c idiopathic polyneuritisPeripheral nerve+cranial nerve Peripheral nerve+cranial nerve

involvementinvolvementSelf limiting painful ophthalmoplegiaSelf limiting painful ophthalmoplegiaCAUSES-TB meningitisCAUSES-TB meningitis osteomyelitis skull osteomyelitis skull otitis mediaotitis media syphilitic meningitissyphilitic meningitis sarcoidosissarcoidosis carcinomatous meningitis carcinomatous meningitis

ANATOMIC PATTERN?ANATOMIC PATTERN?

AXONALAXONAL DEMYELINATINGDEMYELINATING NEURONALNEURONAL

Distal>proximalDistal>proximal

Length Length dependentdependent

Proximal=distalProximal=distal Non length Non length dependentdependent

UE,LE,faceUE,LE,face

Slow evolutionSlow evolution Acute/subacuteAcute/subacute rapidrapid

Dysesthesia&distDysesthesia&distal weaknessal weakness

Paraesthesia&weaParaesthesia&weaknesskness

ataxia,paraesthesataxia,paraesthesiaia

Pain&temp Pain&temp affected>vib,proaffected>vib,proprioceptionprioception

Vibration&propriocVibration&proprioception>pain&tempeption>pain&temp

Vibration&proprioVibration&proprioception>pain&temception>pain&tempp

Distal weaknessDistal weakness Distal & proximal Distal & proximal weaknessweakness

Proprioceptive Proprioceptive weaknessweakness

AXONALAXONAL DEMYELINATINGDEMYELINATING NEURONALNEURONAL

Distal areflexiaDistal areflexia areflexiaareflexia areflexiaareflexia

Amplitude Amplitude affected>velocitaffected>velocityy

Velocity>amplitudVelocity>amplitudee

SensoryamplitudeSensoryamplitudeaffected.affected.

radial>suralradial>sural

Axonal Axonal degeneration&rdegeneration&regenerationegeneration

Demyelination&reDemyelination&remyelinationmyelination

Axonal Axonal degeneration,no degeneration,no regenerationregeneration

Slow recoverySlow recovery Rapid recoveryRapid recovery Poor recoveryPoor recovery

AXONALAXONAL DEMYELINATINGDEMYELINATING NEURONALNEURONAL

ToxicToxic GBSGBS Sjogren’sSjogren’s

metabolicmetabolic diphtheriadiphtheria cisplatincisplatin

HIVHIV CIDPCIDP pyridoxinepyridoxine

Diabetes Diabetes mellitusmellitus

Diabetes mellitusDiabetes mellitus

CMTCMT MMNMMN

COURSE OF DISEASECOURSE OF DISEASE1.syndrome of a/c ascending motor paralysis1.syndrome of a/c ascending motor paralysis

a.acute idiopathic polyneuritisa.acute idiopathic polyneuritis

b.IMN with polyneuritisb.IMN with polyneuritis

c.diphtheriac.diphtheria

d.hepatitis with polyneuritisd.hepatitis with polyneuritis

e.porphyriae.porphyria

f.TOCP poisoningf.TOCP poisoning

g.paraneoplasticg.paraneoplastic

h.post vaccinialh.post vaccinial

2.syndome of subacute sensorymotor NP2.syndome of subacute sensorymotor NPA.Deficiency=alcoholic beriberiA.Deficiency=alcoholic beriberi pellagrapellagra vit B12vit B12B.Toxins=arsenic,lead,Hg,PbB.Toxins=arsenic,lead,Hg,PbC.Drugs=nitrofurantoin,INHC.Drugs=nitrofurantoin,INH dapsone,disulfiramdapsone,disulfiram clioquinolclioquinolD.UremicD.UremicE.DM,PAN,sarcoidosisE.DM,PAN,sarcoidosisA,B,C,D====SYMMETRICA,B,C,D====SYMMETRIC

3.C/C sensorimotor polyneuropathy syndrome3.C/C sensorimotor polyneuropathy syndrome

GENETICGENETIC ACQUIREDACQUIRED

Peronealmuscle atrophy/CMTPeronealmuscle atrophy/CMT leprosyleprosy

Dejerine sottas diseaseDejerine sottas disease Diabetes mellitusDiabetes mellitus

Hereditary sensory NPHereditary sensory NP uremiauremia

Portugeseamyloidosis/Portugeseamyloidosis/

andrade’s diseaseandrade’s disease

carcinomacarcinoma

Refsum’s diseaseRefsum’s disease myelomamyeloma

A beta lipoproteinemiaA beta lipoproteinemia paraproteinemiaparaproteinemia

Tangier’s diseaseTangier’s disease amyloidosisamyloidosis

MetachromaticleucodystrophyMetachromaticleucodystrophy

RECURRENT POLYNEUROPATHYRECURRENT POLYNEUROPATHYRelapsing CIDPRelapsing CIDPPorphyriaPorphyriaRefsum’s diseaseRefsum’s diseaseHNPPHNPPGBSGBSBeriberi Beriberi Toxic neuropathyToxic neuropathy

SENSORY ATAXIC NEUROPATHYSENSORY ATAXIC NEUROPATHYSensory NP(polyganglionopathy)Sensory NP(polyganglionopathy)Paraneoplastic sensory NP=sjogren’s Paraneoplastic sensory NP=sjogren’s =idiopathic=idiopathicToxic=cisplatinToxic=cisplatin =vit B6 excess=vit B6 excessDemyelinating polyradiculopathy=MGUSDemyelinating polyradiculopathy=MGUS =Millerfisher=Millerfisher

HOW TO DISTINGUISH HOW TO DISTINGUISH VARIOUS LMN LESIONS?VARIOUS LMN LESIONS?

AHCAHC NeuropatNeuropathyhy

NMJNMJ MyopatMyopathyhy

Fatigue,diurFatigue,diurnalweaknesnalweakness variations variation

---------- ------------ More in More in eveningevening

----------

Distribution Distribution of weaknessof weakness

distaldistal distaldistal ExtraoccExtraoccular,bulbular,bulbarar

Prox Prox exceptexcept

SMASMA

fasciculationfasciculation markedmarked Maybe+veMaybe+ve absentabsent absentabsent

wastingwasting severesevere Can occurCan occur Usually Usually negneg

absentabsent

SensorylossSensoryloss absentabsent Usually+Usually+ absentabsent ++

DTRDTR dec/Nldec/Nl absentabsent normalnormal Nl/decNl/dec

INVESTIGATIONSINVESTIGATIONS

BLOODBLOODTC,DC,ESRTC,DC,ESRUrea,electrolytes,LFTUrea,electrolytes,LFTRBS,HbA1CRBS,HbA1CSerum protein electrophoresisSerum protein electrophoresisAuto Ab=ANA,Antiganglioside,AntineuronalAuto Ab=ANA,Antiganglioside,AntineuronalVit B 12 levelVit B 12 levelDNA analysis=chr 17 duplication-HMSN1&1ADNA analysis=chr 17 duplication-HMSN1&1A =chr 17 deletion -HLPP=chr 17 deletion -HLPP

URINEURINEBJ proteinBJ proteinPorphyrPorphyriaiaHeavy metalsHeavy metalsCSF ANALYSISCSF ANALYSISNERVE CONDUCTION STUDYNERVE CONDUCTION STUDYVariation in axonal,demyelinating neuropathyVariation in axonal,demyelinating neuropathyConduction block-CIDP,GBS,MMNConduction block-CIDP,GBS,MMNEMGEMG-muscle denervation changes-muscle denervation changesSensory thresholdSensory thresholdThermal & vibration thresholdThermal & vibration threshold

IMAGESIMAGESCXR-sarcoidosis,malignancyCXR-sarcoidosis,malignancySkeletal survey-multiple myelomaSkeletal survey-multiple myelomaScreening for malignancyScreening for malignancy

AUTONOMIC FUNCTION TESTSAUTONOMIC FUNCTION TESTS

Diagnostic tests imp inDiagnostic tests imp in Asymmetric,motor Asymmetric,motor

predominant,rapid onset,demyelinating predominant,rapid onset,demyelinating neuropathyneuropathy

NERVE BIOPSY-indicationsNERVE BIOPSY-indicationssural,sup peroneal&sup radialNsural,sup peroneal&sup radialN

VASCULITISVASCULITIS GIANT AXONAL NPthyGIANT AXONAL NPthy

AMYLOIDOSISAMYLOIDOSIS Infantile neuroaxonal Infantile neuroaxonal dystrophydystrophy

SARCOIDOSISSARCOIDOSIS CMT 1&3CMT 1&3

LEPROSYLEPROSY CIDPolyradiculoneuropathyCIDPolyradiculoneuropathy

KRABBE’SKRABBE’S Paraprotein neuropathyParaprotein neuropathy

METACHROMATIC METACHROMATIC LEUKODYSTROPYLEUKODYSTROPY

ETIOLOGICAL CLASSIFICATIONETIOLOGICAL CLASSIFICATION1.1.metabolicmetabolic-DM,amyloidosis,porphyria-DM,amyloidosis,porphyria2.2.infectionsinfections-leprosy,HIV,CMV,syphilis,-leprosy,HIV,CMV,syphilis, diphtheria,lymediseasediphtheria,lymedisease3.3.immuneimmune- GBS,CIDN,MMN- GBS,CIDN,MMN4.4.hereditaryhereditary-CMT-CMT55.Toxic.Toxic-drugs,alcohol,heavymetals-drugs,alcohol,heavymetals6.6.vasculitisvasculitis-PAN,CSS,cryoglobulinemia-PAN,CSS,cryoglobulinemia7.7.paraneoplasticparaneoplastic-lung-lung8.8.nutritionalnutritional- B1,B6,B12- B1,B6,B12

H/O & EXAMINATION

Mononeuropathy

EDx

Axonal/demyeln?

Any systemic disorder

Entrapment/compression

MNPthy multiplex

axonal Demyeln +focal condcn block

Vasculitis/multifocal

Nerve biopsy

CIDP

Paraprotein,HIV,lyme

polyNPthy

axonal

Sub a/c c/c

Toxins/systemic disease family h/o,genetics

demyelination

Uniform slowing,C/C Nonuniform slowing,condnblock

paraprotein

Family h/o,genetics

c/c or suba/c-CIDP a/c-GBS

THANK YOUTHANK YOU