peripheral neuropathy - rochester, ny of neuropathy • sensory –large fiber loss (vibration,...
TRANSCRIPT
Peripheral Neuropathy
Ralph F. Józefowicz, MD
PN: Definition
• A general term for any disorder affecting
the peripheral nerves.
Symptoms of Neuropathy
• Sensory:
– Dysesthesias in distal extremities
– Pain
– Numbness (stocking-glove)
• Motor:
– Distal>proximal weakness
• Autonomic:
– Orthostatic hypotension
– Impotence
Signs of Neuropathy
• Sensory– Large fiber loss (vibration, proprioception)
– Small fiber loss (pain, temperature)
• Motor– Weakness (distal>proximal, extensor>flexor)
– Muscle atrophy
– Flaccid tone
• Reflexes: absent or reduced
• Autonomic: orthostatic hypotension
Classification of Neuropathy
• Etiology
• Distribution
• Pathology
• Modality
Etiology of Neuropathy
• Hereditary
• Toxic/metabolic
– Drugs
– Toxins
• 2° to systemic disease
• Autoimmune
Hereditary
• Charcot-Marie-Tooth disease (HSMN I&II)
• Dejerine-Sottas disease (HSMN III)
• Refsum’s disease (HSMN IV)
Drugs
• Amiodarone
• cis-platinum
• Dapsone
• INH
• Phenytoin
• Pyridoxine
• Vincristine
• Nitrofurantoin
• ddI
• ddC
Toxins
• Heavy metals
– Hg, Pb, Zn, As
• Ethanol
• Organophosphates
Systemic Diseases
• Diabetes mellitus
• Uremia
• Porphyria
• Pernicious anemia
• Amyloidosis
• Hypothyroidism
• Carcinoma
• Lymphoma
• Multiple myeloma
• Cryoglobulinemia
• Monoclonal gammopathy
• Vasculitis (SLE, RA, PAN)
• Sarcoidosis
• Infection
Diabetes Mellitus
• Symmetric neuropathies
– Sensory>motor polyneuropathy
– Autonomic neuropathy
• Asymmetric neuropathies
– Mononeuropathy multiplex
– Cranial neuropathy
– Truncal radiculopathy
– Amyotrophy
– Entrapment neuropathy
Infections
• Leprosy
• Syphilis
• HIV
• Diphtheria
Autoimmune
• Guillain-Barré syndrome (AIDP)
• Chronic inflammatory demyelinating
polyneuropathy (CIDP)
Distribution
• Symmetrical generalized
– Polyneuropathy
(stocking-glove, dying back neuropathy)
• Multifocal
– Mononeuropathy multiplex
• Focal
– Entrapment neuropathy
Pathology
• Axonopathy: most polyneuropathies
• Myelinopathy: GBS, CIDP
• Neuronopathy
– Somatic motor: ALS
– Somatic sensory: carcinoma, Sjögren's
– Autonomic: hereditary dysautonomia
Modality
• Motor
• Sensory
• Autonomic
• Mixed
Etiology of Peripheral NeuropathiesDANG THERAPIST
• Diabetes
• Alcohol
• Nutritional
• Guillain-Barré
• Toxic
• Hematologic
• Endocrine
• Rheumatologic
• Amyloid
• Porphyria
• Infectious
• Sarcoid
• Tumor
Diagnostic Studies
• Nerve conduction study
• Electromyography
• Serum studies
• Urine studies
• Nerve biopsy
Nerve Conduction Study
• Demyelinating lesions:
– Slowed conduction velocities
– Prolonged terminal latencies
– Dispersion of evoked CMAP
– Conduction block
• Axonal lesions:
– Reduced amplitudes of CMAP and SNAP
Electromyography
• Axonal lesions:
– Acute denervation: fibrillation potentials
positive waves
– Chronic denervation: large, prolonged CMAP
reduced recruitment
• Demyelinating lesions:
– Reduced recruitment
Serum Studies
• CBC
• Chemistry profile
• T4, TSH
• Vitamin B12 assay
• ESR
• ANA
• Rheumatoid factor
• SPEP
• SIEP
• RPR
• HIV
Urine Studies
• Heavy metal screen
• Porphobilinogen
Nerve Biopsy
(Sural Nerve)
• Only helpful in screening for
– Vasculitis
– Amyloid
– Sarcoid
– Leprosy
Normal Sural NerveTrichrome Stain
Chronic Axonal NeuropathyTrichrome Stain
VasculitisH&E Stain
CIDPToluidine Blue Stain
Demyelinating NeuropathyTeased Nerve Fiber Preparation
Treatment of Neuropathies
• Specific treatment
• Treatment of immune-mediated neuropathies
• Symptomatic treatment
Treatment of Immune Mediated
Neuropathies
• Corticosteroids
• Immunosuppressive drugs
– Azathioprine
– Cyclophosphamide
– Mycophenolate
• Plasmapheresis
• IVIg
Symptomatic Treatment
• Tricyclic compounds– Amitriptyline
– Nortriptyline
– Duloxetine
• Anticonvulsants
– Gabapentin
– Pregabilin
• Topicals
– Capsaicin
– Lidocaine patch
Case 1
A 23-year-old, right-handed college student and summer waitress was well until one month ago when she developed tingling in both hands, primarily in the thumb, second and third digits, and worse on the right. It frequently awoke her from sleep. She occasionally noted pain in her right forearm. She denied any hand weakness. No history of neck pain.
She started to work as a waitress 2 months ago. She had no tingling when waiting on tables or when mowing the lawn but developed the tingling afterwards.
Case 1 – PMH
Past Medical History: Herniated lumbar disk following a fall; s/p right L5 laminectomy
Medications: Oral contraceptives
Family History: Unremarkable
Case 1 – Examination
Physical Examination:
• P=108/min; BP=110/80 mm Hg
• Neck ROM full
• Tinel sign negative bilaterally
• Phalen sign positive bilaterally
Neurologic Examination:
• Motor exam: Slight weakness of the right APB muscle
• Sensory exam: normal, including hands and feet
• MSR: 3+ bilaterally, including ankle jerks
• Romberg: negative
Case 1 – Nerve Conductions
Nerve Terminal
latency
Amplitude Conduction
Velocity
R median
motor
7.0 msec 3.9 mV 59 m/sec
L median motor 6.2 msec 6.6 mV 55 m/sec
Normal <4.2 msec >10 mV >50 m/sec
R median
sensory
5.0 msec 8.4 μV
L median
sensory
5.3 msec 7.2 μV
Normal <3.6 msec >20 μV
Case 1 – Laboratory
• T4 23.5 μg/dl
• Free T4 9.68 units
• TSH <0.1 mIU/L
Diagnosis?
Carpal Tunnel Syndrome
• Median nerve compression at the wrist
• Motor: APB muscle weakness
• Sensory: digits 1, 2, 3, lateral digit 4
• Pain: wrist, median hand, forearm
• Tinel and Phalen signs
• EMG and nerve conduction study
• Treatment: wrist splints and surgery
The Carpal Tunnel
Case 2
A 56-year-old mechanical engineer was referred for evaluation of numb toes that came on gradually and painlessly 12 years ago. The numbness is most pronounced when he is trying to fall asleep and is made worse by cold weather; warm weather improves the sensation in his feet. He has decreased sensation on the soles of his feet when he is stepping on the pedals in his car. Walking barefoot produces intense pain. The numbness has progressed to involve the distal feet.
He denies weakness in his feet, walking difficulty, bowel or bladder difficulty, sexual dysfunction, or back or neck pain.
Case 2 – PMH
Past Medical History: Hypertension, meralgia
paresthetica, s/p appendectomy
Medications: captopril, potassium, aspirin
Habits: occasional EtOH, no tobacco
Family History: unremarkable
Case 2 – ExaminationPhysical examination:
• P=60/min, BP=160/100 mm Hg
• Moderately obese, lipoma over right lateral hip
• Neck and back ROM intact; SLR negative
Neurologic examination:
• Motor: atrophy of EDB muscles in both feet; unable
to fully cock up his toes
• Sensory: reduced pin sensation in toes; absent
vibration and position sense in feet
• Reflexes: absent ankle jerks
Case 2 – Laboratory
• NCS demyelinating neuropathy
• ANA ≥1:640, speckled
• Anti DS-DNA <10
• RF Negative
• SPEP Normal pattern
• Immunofixation Monoclonal IgM lambda protein
Diagnosis?
Distal Polyneuropathy
• Symmetric, distal sensory>motor
• “Stocking – glove” neuropathy
• “Dying back” neuropathy
• Pathology: usually mixed axonal and
demyelinating features
• Various etiologies, including DM,
nutritional deficiency, toxins, metabolic
Case 3
A 70-year-old woman developed numbness in her feet and upper back pain. The following month she developed a left Bell's palsy that was treated with a seven day course of prednisone. She then developed progressive numbness and pain in her feet and hands in a stocking-glove distribution. Distal weakness developed after this. She was treated with amitriptyline which helped the pain but not the numbness or weakness. Over the past two weeks her weakness worsened to the point that she had difficulty walking because of bilateral foot drop. She was therefore admitted for further evaluation.
Case 3 – PMH
Past Medical History: Hypertension
Medications: HCTZ, nifedipine, ranitidine, ASA
Case 3 – Examination
Physical Examination:
• P=84/min; BP=140/82 mm Hg; T=37°C
• Grade 2/6 SEM present
Neurologic Examination:
• Motor: unable to stand on heels or toes; grade 4 weakness in biceps, wrist extensors and flexors, finger flexors and psoas muscles; grade 2 weakness in interossei and dorsi and plantar flexor muscles
• Sensory: light touch, temperature and pin reduced in a stocking-glove distribution; vibration and position sense absent at the toes;
• Reflexes: UE 2+; knees 1+; ankles absent
• Gait: bilateral steppage
Case 3 – Laboratory
• CBC WBC=11.0/mm3; Hct=37%
• ESR 90 mm/hr
• ClCr 42 ml/min
• ANA 1:160, homogeneous
• RF Negative
• Anti DS-DNA Negative
• Anti RNP Negative
• Anti SM Negative
• Anti SSA Negative
• Anti SSB Negative
Case 3 – Additional Labs
• NCS Demyelinating neuropathy
• Sural nerve biopsy Vasculitis
Diagnosis?
Vasculitic Neuropathy
• Due to infarction of vasa nervorum
• Usually asymmetric
• Involves peripheral nerves, roots, plexi
• Typically painful
• Etiology: vasculitis, DM
Case 4
A 63-year-old school bus driver noted tingling and
numbness in her limbs two months ago. The tingling
first began in her left arm and leg. Her gait is unsteady
and she fell 3 times. She has exquisite pain in her feet
when she steps on a sharp object. She also feels that
her lower limbs are weak.
Case 4 - PMH
Past Medical History:
• s/p cervical laminectomy in 1994 for severe spinal stenosis
• s/p left 6th nerve palsy one year ago with resolution
• Stage 2 endometrial cancer in 2001, s/p surgery, pelvic irradiation and chemotherapy (carboplatin / paclitaxel)
• Hypothyroidism
Medications: diltiazem, l-thyroxine, ASA
Case 4 - Examination
Physical Examination:
• P=76/min, BP=142/80 mm Hg
• Neck ROM reduced in all directions
Neurologic Examination:
• Motor: Essentially normal
• Sensory: Absent vibration in hands and feet, position sense in toes, pin and temperature reduced distal to mid forearms and calves and at umbilicus
• Coordination: ataxia with heel-to-shin testing
• Reflexes: MSR absent, plantar responses flexor
• Romberg unsteady, wide based gait
Case 4 – Laboratory
• NCS: Large fiber sensory demyelinating neuropathy
• CSF: 4 WBC, glucose 56 mg/dL, protein 116 mg/dL
Diagnosis?
Guillain-Barré Syndrome
• Large-fiber demyelinating neuropathy
• Motor, sensory and autonomic nerves
• Post-infectious and monophasic
• Etiology: molecular mimicry
• CSF: elevated protein, no cells
• Treatment: plasmapheresis or IVIg
• NO STEROIDS!