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Peripheral Neuropathy
By: Amr Mohammed Abdullah11110053
Internal Medicine: Neurology
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Definition
• It is an inflammation or degeneration of the peripheral nerves with motor, sensoryand autonomic manifestations.
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Pathological classification
• a. Demyelinating neuropathy:• Rapid onset, CSF is affected because of root damage, there is degeneration of
the myelin sheath due to immunological or infectious insult. • e.g. Guillian - Barré $ Myelinopathy.
• b. Axonal neuropathy:• Characterized by degeneration of the distal ends of long axons.• It starts with distal sensory manifestations & spread proximally.• It usually occur in diabetic neuropathy, and toxic neuropathy.
• c. Wallerian degeneration after nerve injury.
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Terms of neuropathy
• Mononeuropathy: • affection of a single nerve trunk.• e.g. ulnar or median nerve.
• Mononeuropathy multiplex: (multi focal neuropathy or multiple mononeuropathy):• affection of more than one nerve trunk usually in one limb. • e.g. ulnar nerve + median nerve.
• Polyneuropathy: • diffuse symmetrical affection of peripheral nerves of all limbs.
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causes
• Causes of mononeuropathy:• Trauma, DM, entrapment neuropathy (e.g. carpal tunnel
$).
• Causes of mononeuritis multiplex:• DM, Polyarteritis nodosa, sarcoidosis, leprosy,
amyloidosis.
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Mononeuropathy
• Mononeuropathy: only affects a single nerve.• Causes:• Trauma• Infection H. Z. – leprosy• Vascular polyarteritis nodosa.• Compression Intrapment neuropathy• DM.
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Mononeuropathy (Carpal tunnel $)
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Polyneuropathy
INH: isonicotinylhydrazide (Isoniazid)
SCD: Specific Carbohydrate Diet
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Clinical picture of polyneuropathy• Motor:
• LMNL• Bilateral symmetrical• LL > UL• Distal > proximal, & extensor > flexor• Foot & wrist drop• Lost ankle jerk, but knee jerk is preserved.• Cranial nerve affection• Gait, high steppage due to foot drop
• Sensory:• Superficial sensory loss:
• Glove stock (paresthesia) then hypothesia.• Deep sensory loss (sensory ataxia)
• Vibration normal at ASIS & decreased on malleoli.
• Autonomic:• coldness, cyanosis, loss of hair, orthostatic hypotension, impotence, nocturnal diarrhea,
constipation.
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Specific types of polyneuropathy(Peroneal muscle atrophy (Charcot - Marie tooth disease))• This neuropathy is mainly motor also there is glove and stocking
hypothesia.• It is a heredofamilial autosomal dominant in 1st & 2nd decade, the wasting
starts in L.L in peronii then anterior tibial group then ascends to involve the muscles of lower 1/3 of thigh (inverted champagne bottle appearance).• It is Characterized by:
• marked wasting• minimal weakness• foot deformity e.g pes cavus and hammer toes.
• Treatment:• Bracing of the ankle for foot drop, genetic counselling.
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Specific types of polyneuropathy(diabetic neuropathy)
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Specific types of polyneuropathy(diabetic neuropathy)• C/P: mainly sensory
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Specific types of polyneuropathy(diabetic neuropathy)Treatment• Control blood sugar.• Vit. B. complex, capillary modulators e.g Ca dobesilate (Doxium).• Carbamazepine (tegretol) 200-600mg/D for epilepsy, or Gabapentin (Neurontin) 400 mg/8 hrs for severe parathesia or neuropathic pain.
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Specific types of polyneuropathy(Refsum disease)• It is a lipid storage disease presented at first and second
decades characterized by hypertrophic neuropathy.• It is presented by night blindness, cerebella ataxia and
retinitispigmentosa.
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Acute infective polyneuropathy (Guilain Barre $)• It is an inflammation of the peripheral nerve & roots
with demyelination due to immune or viral insult. (1-4 wks after viral infection).• It is mainly motor (Acute paralytic neuropathy).• Cranial nerves are usually affected specially bilateral facial nerves.
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Acute infective polyneuropathy (Guilain Barre $)• C/P:
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Acute infective polyneuropathy (Guilain Barre $)• Investigations:• CSF examination showing cytoalbuminous dissociation
due to root affection (excess protein with either normal cell count or a moderate increase in cells).• Impaired nerve conduction velocity.
• S. Lead urinary porphyrin (to exclude porphyria).
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Acute infective polyneuropathy (Guilain Barre $)• Treatment:
• Prognosis
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Diphtheritic neuropathy
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Leprotic neuropathy
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Cranial polyneuropathy
• This means multiple cranial nerve Lesions. • This occurs with malignant infiltration e.g Lymphomas,
also it may occur with Sarcoidosis.
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Exercise
? diabetic neuropathy Guilain Barre $S/M Mainly sensory Mainly motorAM Positive autonomic manifestations Positive autonomic
manifestationsCN Cranial nerves are 3,4,6 Cranial nerves are
3,7,10D/P D>P Bilateral, P>DCoarse Progressive acuteTTT • Control blood sugar.
• Vit. B. complex.• Carbamazepine or Gabapentin for
paresthesia.
• IV Immunoglobulins• Steroids (20mg
prednisolone TDS)• Plasmapheresis
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References
• Churchill’s Pocketbook of Differential Diagnosis.4th.• Current Essentials Of Medicine• Davidson's Essentials of Medicine• Oxford Handbook of Clinical Medicine 9th Ed
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Thank U