peripheral neuropathy-kabera rene

8/3/2019 Peripheral Neuropathy-Kabera Rene

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National University of Rwanda

Family and Community Medicine

Peripheral neuropathy

KABERA Ren,MD

PGY IV Resident

Family and Community Medicine

National University of Rwanda


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Plan

Definition

Classification

Signs and symptoms

Causes Treatment


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Definition

Peripheral neuropathy is the term for damage to nerves of

the peripheral nervous system, Caused either by diseases of or trauma to the nerve or the

side-effects of systemic illness.

The four cardinal patterns of peripheral neuropathy arepolyneuropathy, mononeuropathy, mononeuritis multiplex and

autonomic neuropathy.

The most common form is (symmetrical) peripheral

polyneuropathy, which mainly affects the feet and legs.


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Classification

Peripheral neuropathy may be classified according to:

The number of nerves affected

The type of nerve cell affected (motor, sensory, autonomic),

The process affecting the nerves (e.g. inflammation in neuritis).


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Mononeuropathy

Single nerve affected

The most common cause :physical compression of the nerve,known as compression neuropathy.

Carpal tunnel syndrome

The "pins-and-needles" sensation of one's "foot falling asleep"(paresthesia) ,temporary.

Direct injury to a nerve, interruption of its blood supply

(ischemia),

Inflammation


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Mononeuritis multiplex

Simultaneous or sequential involvement of individual

noncontiguous nerve trunks Partially or completely

Acute or subacute loss of sensory and motor function of

individual peripheral nerves. The pattern of involvement is asymmetric,


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Mononeuritis multiplex

Disease progress, deficit(s) becomes more confluent

and symmetrical, making it difficult to differentiatefrom polyneuropathy.

Deep pain , aching pain that is worse at night, is

frequently in the lower back, hip, or leg.

Diabetes mellitus: mononeuritis multiplex is acute,

unilateral, severe thigh pain followed by anterior

muscle weakness and loss of knee reflex.


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Polyneuropathy

Many nerve cells in different parts of the body are affected

In distal axonopathy, one common pattern, the cell bodies of

neurons remain intact, but the axons are affected in

proportion to their length.

Diabetic neuropathy is the most common cause of this pattern.

In demyelinating polyneuropathies, the myelin sheath around

axons is damaged, which affects the ability of the axons to

conduct electrical impulses.


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Polyneuropathy

The third and least common pattern affects the cell bodies of

neurones directly. The motor neurones (known as motor neurone disease) or the

sensory neurones (known as sensory neuronopathyor dorsal

root ganglionopathy).

Left and right sides symmetrically.


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PolyneuropathyThe chief symptoms :

1. weakness or clumsiness of movement (motor);2. unusual or unpleasant sensations such as tingling or burning;

3. reduction in the ability to feel texture, temperature, etc.;and

4. Impaired balance when standing or walking (sensory).

These symptoms occur first and most severely in the feet.

Autonomic symptoms may also occur, such as dizziness onstanding up, erectile dysfunction and difficulty controllingurination.


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Polyneuropathies

Diabetes and impaired glucose tolerance are the most

common causes. Inflammatory diseases such as lyme disease, vitamin

deficiencies, blood disorders, and toxins (including alcohol

and certain prescribed drugs).

Such damage is often reversible, particularly in the early

stages, with diet, exercise and weight loss.


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Autonomic neuropathy

Polyneuropathy which affects the non-voluntary, non-sensory

nervous system (i.e., the autonomic nervous system) Affecting mostly the internal organs such as the bladder

muscles, the cardiovascular system, the digestive tract, and the

genital organs.

Autonomic nerve fibers form large collections in the thorax,

abdomen and pelvis outside spinal cord, however they have

connections with the spinal cord and ultimately the brain.


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Most commonly autonomic neuropathy is seen in persons with

long-standing diabetes mellitus type 1 and 2.

Autonomic neuropathy is one cause of malfunction of the

autonomic nervous system, but not the only one;

Multiple system atrophy, and therefore cause similar symptomsto autonomic neuropathy.


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Signs and symptoms

urinary bladder: bladder incontinence or urine retention gastrointestinal tract: dysphagia, abdominal pain, nausea,

vomiting, malabsorption, fecal incontinence, gastroparesis,

diarrhea, constipation Cardiovascular system: disturbances of heart rate

(tachycardia, bradycardia), orthostatic hypotension,

inadequate increase of heart rate on exertion

Other: hypoglycemia unawareness, genital impotence, sweatdisturbances



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Neuritis

Inflammation of a nerve or the general inflammation of the

peripheral nervous system. Symptoms depend on the nerves involved, but may include

pain, paresthesia (pins & needles), paresis (weakness),

hypoesthesia (numbness), anesthesia, paralysis, wasting, and

disappearance of the reflexes.


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Causes include:

Physical injury Inflammation of the nerves to the toes is the wearing of high-

heeled shoes or ill-fitting shoes that bind the toes painfully.

Temporary numbness and pain in the affected toes for severaldays.

Neuritis


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Infection:

Herpes simplex, Shingles, Leprosy, Guillain-Barre syndrome,

Lyme Disease, Chemical injury, Radiation

Underlying conditions causing localized neuritis (affecting a single

nerve):

Diphtheria, Localized injury, Diabetes

Neuritis


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NeuritisUnderlying conditions causing polyneuritis (affecting multiple

nerves): Beriberi, Vitamin B12 deficiency, Vitamin B6 excess,

Metabolic diseases, Diabetes Herpes zoster Hypothyroidism

Porphyria , Infections, bacterial and/or viral,Autoimmune

disease, especially Multiple Sclerosis, Cancer, Alcoholism,

Wartenbergs migratory sensory neuropathy


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Types of neuritis :

Polyneuritis or Multiple neuritis (not to be confused withmultiple sclerosis)

Brachial neuritis

Optic neuritis Vestibular neuritis

Cranial neuritis, -Bell's Palsy-

Arsenic neuritis

Neuritis


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Signs and symptoms

numbness, tremor, and gait abnormality.

tingling, pain, itching, crawling, and pins and needles. Hypersensitive Skin especially the feet


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Motor symptoms

Loss of function (negative) symptoms of weakness, tiredness,heaviness, and gait abnormalities; and

Gain of function (positive) symptoms of cramps, tremor, and

muscle twitch (fasciculations).

Pain in the muscles (myalgia), cramps, etc., and there may

also be autonomic dysfunction.

Generalized peripheral neuropathies :most commonly have

distal sensory or motor and sensory loss, Ankle jerk reflex is classically absent in peripheral

neuropathy

Signs and symptoms


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Causes

Genetic diseases: Friedreich's ataxia, Charcot-Marie-Tooth

syndrome Metabolic/Endocrine: diabetes mellitus, chronic renal failure,

porphyria, amyloidosis, liver failure, hypothyroidism

Toxic causes: Drugs (vincristine, metronidazole, phenytoin,

nitrofurantoin, isoniazid, ethyl alcohol), organic metals, heavy

metals, excess intake of vitamin B6 (pyridoxine)

Fluoroquinolone toxicity: Irreversible neuropathy is a serious

adverse reaction of fluoroquinolone drugs


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Causes

Inflammatory diseases: Guillain-Barr syndrome, systemic

lupus erythematosis, leprosy, Sjgren's syndrome, LymeDisease, sarcoidosis,

Vitamin deficiency states: Vitamin B12 (cyanocobalamin),

vitamin A, vitamin E, vitamin B1 (thiamin)

Physical trauma: compression, pinching, cutting, projectile

injuries (i.e. gunshot wound), strokes including prolonged

occlusion of blood flow, electric discharge, including lightning

strikes Others: shingles, malignant disease, HIV,radiation,

chemotherapy


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Treatment

Tricyclic antidepressant (such as amitriptyline) and antiepileptic

therapies such as gabapentin or sodium valproate. Synthetic cannabinoids and inhaled cannabis are effective

treatments for a range of neuropathic disorders, especially for

people who are resistant, intolerant, or allergic to common

medications


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Treatment Smoked cannabis has been found to provide relief from

HIV-associated sensory neuropathy.

Smoked cannabis was also found to relieve neuropathyassociated with CRPS type I, spinal cord injury, peripheralneuropathy, and nerve injury.

Pregabalin is an anticonvulsant drug used for neuropathicpain. It has also been found effective for generalizedanxiety disorder.

Duloxetine, a serotonin-norepinephrine reuptake inhibitor,

TENS (Transcutaneous Electrical Nerve Stimulation) therapymay be effective and safe in the treatment of diabeticperipheral neuropathy.


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References Harrison's, Principles of Internal Medicine

The Foundation for Peripheral Neuropathy(http://www.foundationforpn.org/)

The Canadian Neuropathy Association

(http://canadianneuropathyassociation.org/)

National Diabetes Information Clearinghouse

(http://diabetes.niddk.nih.gov/) at National Institute of

Diabetes and Digestive and Kidney Diseases

The Neuropathy Association (http://www.neuropathy.org/)


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End

Thank You

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