peripheral nerve diseases (1)

8/20/2019 Peripheral Nerve Diseases (1)

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DISE SES

OF PERIPHER L NERVE

ALTHEA PURZUELO-TAMPOS, M.D.


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Peripheral nerve


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•PERIPHERAL NEUROPATHY• Abnormalities that affect the peripheral nervous

system

• Site: nerve cell bodies, nerve roots, nerve trunks, or

terminal branches• Pathology: axon, myelin sheath, connective tissues,

vascular tissues


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Pathologic reactions of Peripheral Nerves

•Wallerian degeneration – destruction of myelinsheath and axon distal to the site of disruption ofan axon

•Segmental demyelination• Focal degeneration of myelin sheath with sparing of the

axon• Axonal degeneration

• Degeneration of myelin sheath secondary to axonaldamage from distal to proximal

• “dying-back” phenomenon

•Chromatolysis / axonal reaction – changes in nervecell body that are due to axonal reaction


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•Three main types of nerve fibers:

1.Group A fibers – Largest fibers, 1-2 µm – Conduction rate: 5 – 100 m/sec

– Myelinated, has both sensory and motor functions

– Found in somatic nerves

2.Group B fibers – 1-3 µm diameter

– Conduction velocities – 3 – 14 m/sec

– Found solely in preganglionic autonomic nerves

3.Group C fibers

– Smallest fibers,


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• Degeneration of peripheral nerves:

•

Early phase – 1st

3 – 5 days after damage• Axons swell, myelin sheath begins to form bead-like structures, and series of

enlargements (round, fatty fragments) appear

• Late phase – 8 – 32nd day

• gradual disappearance of myelin, increase in Schwann cells and macrophages


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• Regeneration of peripheral nerves:

• Formation of outgrowths or sprouts of axon near the cut tip

• Rapid proliferation of Schwann cells• Neuroma / Pseudoneuroma – tumor-like swelling in larger gaps (>3mm)

• Doctrine of neurotropism – ability of the axon to grow into peripheral stumpand form a new axon

• Rate of growth of regenerating nerve – 1 to 4 mm/day


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• Terms:

• Neuronopathy

• Radiculopathy

• Polyradiculopathy

• Polyradiculoneuropathy

• Plexopathy/plexitis

• Mononeuropathy• Polyneuropathy

• Mononeuritis multiplex

• Axonal neuropathy

•

Demyelinating neuropathy• Entrapment neuropathy


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Symptomatology of Peripheral Nerve Disease

• Impairment of motor function• Axonal polyneuropathy – GBS, nutritional, metabolic

• Generalized paralysis – GBS, diphtheria, toxic

• Bibrachial – motor neuron diseases, inflammatory-demyelinatingpolyneuropathies, paraneoplastic

• Paraparesis – inflam of cauda equina, cytomegalovirus, herpessimplex infecions

• Bifacial – GBS, connective tissue diseases

• Atrophy – 90 to 120 days; reduces volume by 75 to 80%

• Tendon reflexes:• Generally lost or diminished but lesser in small fiber neuropathy


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• Sensory loss

• Escutcheon pattern of sensory loss

• Sensory ganglionopathy• Universal sensory loss

• Paresthesias, Pain and Dysesthesias• Allodynia

• Hyperpathia vs Hyperesthesia

• Causalgia

• Sensory Ataxia and Tremor

•

Pseudoataxia


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• Deformity and trophic changes• Talipes equinus

• Claw foot / le pied en griffe

• Charcot joint

• Autonomic dysfunction

• Anhidrosis• Orthostatic hypotension

• Fasciculations, Cramps and Spasms

• myokimia


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Peripheral Neuropathies

• Negative signs:

1. Muscle wasting

2. Muscle weakness

3. Sensory loss

4. Sensory ataxia5. Areflexia

6. Autonomic dysfunction

• Positive signs:

1. Fasciculations

2. Muscle cramps / pain on

exercise3. Paresthesia

4. Dysesthesia

5. Hyperalgesia/Hyperesthe

sia


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Approach to patient with PN

1. Establish the existence of PNS disease

2. Determine its nature and possibilities of treatment

3. Laboratories:1. EMG 5. Nerve and muscle biopsy

2. NCV 6. Measure Ig and anti-neural3. Biochemical tests antibodies

4. CSF examination 7. Genetic testing

4. Determine the course1. Acute

2. Subacute

3. Chronic


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• Goals of management of Peripheral Neuropathy

I. manage underlying condition or cause- imunosuppressants, plasmapheresis, lifestyle modification

II. repair damage- mechanical aids

- Braces, orthopedic shoes, mechanical ventilator

III. provide symptom relief A. Medications that may help provide pain relief:

1. Pain relievers – acetaminophen, NSAIDS

2. Antiepileptic – gabapentin, carbamazepine, phenytoin

3. Lidocaine patch

4. Tricyclic antidepressants – amitriptyline, desipramine,imipramine

5. Opioid analgesics - Oxycodone or codeine6. Capsaicin

B. Surgery


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Syndrome of Acute MotorParalysis with variable

disturbance of sensory and autonomic function


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Guillain-Barre Syndrome

• Most common acute neuropathy

• 1-2 / 100,000 population / year

• Most patients are healthy and active prior to onset

• Usually sporadic although epidemics do occur

• Age of onset:

• Any age

• Average: 40 yrs old (50-74 y/o)

• Rare over 80 yrs or less than 2 yrs of age


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•Course of the disease:• Progresses over a period less than 4 wks

(3-4 wks)

• Chronic form (CIDP) - > 8 wks

• Most patients reaches maximal deficit within 2 weeks of onset

• Recovery occurs over the ensuing weeks to months


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• About 2/3 of all GBS patients describe an infectious syndrome within 4 weeksprior to the onset of neuropathic symptoms

• Common infectious syndrome reported:

• Upper respiratory tract infections (40%)

• Diarrhea (15-20%)

• Most common enteric organism – C. jejuni


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• Symptoms:• Symmetric ascending weakness involving proximal and distal muscles

• Paresthesias and muscle pain may be presenting complaints

• Sensory impairment is usually minimal


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• Signs:• Deep tendon reflexes are lost early

• Cranial nerves, particularly facial nerves are commonly affected

• Respiratory failure (30%)

• Autonomic nerve involvement:

• Fluctuations of BP

• Cardiac arrhythmias

• Bowel and bladder dysfunctions


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Diagnostic Criteria for Guillain-Barre Syndrome(Asbury, et al)

• Features required for diagnosis:• Progressive muscle weakness with areflexia

• Features that are supportive of the diagnosis:

1. Symmetric progression less than 4 wks

2. Autonomic features

3. Cranial nerve involvement4. Absence of fever


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Diagnostic Criteria for Guillain-Barre Syndrome

•CSF findings• Elevated protein without cells (albuminocytological

dissociation)

•

CSF protein peaks within 4 – 6 weeks but may be normalearly

•Electrodiagnostic findings•

Suggestive of demyelination: prolonged distal latenciesand abnormalities in F-wave responses or mild slowing ofconduction velocities


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•Variants of GBS:• Functional:

• Generalized ataxia without dysarthria or nystagmus

• Pure sensory

• Pandysautonomia

• Pure motor / Acute Motor Axonal Neuropathy (AMAN)

• Acute Motor-Sensory Axonal Neuropathy (AMSAN)


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• Recent Classification:

1. Acute inflammatory demyelinatingpolyradiculoneuropathy (AIDP)

2. Acute motor and sensory axonal neuropathy(AMSAN)

3. Acute motor axonal neuropathy (AMAN)

4. Chronic Inflammatory DemyeinativePolyneuropathy (CIDP)


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•Acute Axonal Form:• Characterized by widespread and severe axonal

degeneration

•

Muscle atrophy appears early – within weeks• Numerous electrically inexcitable motor and signs of

extensive denervation

• Antibodies to GM1

• Recovery is prolonged but incomplete


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• Laboratory findings:• CSF Examination

• Normal pressure

• Few lymphocytes

• Protein is normal in few weeks but peaks in 4 – 6 weeks

•

Presence of Ig M antimyelin antiboies

• EMG / NCV• Decrease in amplitude of muscle action potentials

• Slowed conduction velocity

•

Conduction block in motor nerves


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• Pathologic findings:

•

Increased lymphocytic infiltrates along endoneuralperivascular area

• Segmental demyelination

• Wallerian degeneration

• Pathogenesis and etiology

• Cell-mediated immunologic reaction directed atperipheral nerves


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Treatment

•General Medical care:• Admitted to monitor respiratory, autonomic and motor

functions

•

Respiratory assistance• If FVC < 15 ml/kg

• High dose corticosteroid therapy - controversial


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Treatment

• Human immunoglobulin• 0.4 g/kg iv qd x 5 days (total dose: 2 g); start with slow infusion rate,

increase rate of infusion as tolerated

• Side effects:

• Headache, renal failure

• Plasmapheresis

• 4-6 exchanges over 8 to 10 days = total of 200-250 ml/kg plasma isremoved

• Heparin

• 5000 U sq, q 12

• Deep vein thrombosis prophylaxis


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• Prognosis:

• 3 – 5% do not survive• Majority recover with mild motor / sensory deficit

• 10% have pronounced residual deficits

• If axons are damaged – recovery is 6-18 mos or longer

•

5-10 % will have recurrences


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• CIDP (Chronic Inflammatory DemyelinatingPolyradiculoneuropathy) and CRIP (Chronic RelapsingInflammatory Polyradiculoneuropathy) Syndromes

• Autoimmune disorder Similarities between GBS and CIDP

Widespread polyradiculoneuropathies

Cytoalbuminologic dissociation of CSF – increased

protein concentrations with few or no cells Decreased conduction velocity and partial

conduction block in motor nerves

Multifocal perivenous inflammatory infiltrates


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• Differentiated from GBS by:

1. Prolonged and relapsing course

2. Enlargement of nerves

3. Responsiveness to corticosteroids

• Laboratory features: Increased CSF protein – 75 to 250 mg/dl

Rarely papilledema and pseudotumor cerebri syndrome in very high CSF protein

Increased CSF gamma globulin fraction Mild lymphocytic pleocytosis

Nerve biopsy – demyelination with interstitial and perivascular infiltrates of inflammatorycells


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Treatment ;

steroids – prednisone 60 to 80 mg/day

Immunosuppressants

IV Ig - 2 g/kg x 4 to 5 days


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• Herpes Zoster• affects individual nerve roots / trunks producing pain and sensory

loss, motor functions are usually spared

• Vesicles erupt 4-5 days after onset of severe localized pain

• Postherpetic neuralgia

• Treatment – anti-viral agents, pain relievers

•

Diphtheritic neuropathy• Corynebacterium diphtheriae inhibits myelin synthesis of

Schwann cells

• Neuropathy (20%) occurs 4 –8 wks after infection; fatal due torespiratory involvement

• Blurred vision, nasal speech (1st 2 wks)

• Cause of death – diphtheritic myocarditis


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I. HMSN (PERONEAL MUSCULAR ATROPHY, CHARCOT-

MARIE-TOOTH DISEASE TYPE I & TYPE II) Autosomal dominant w/ almost complete

penetrance / recessive gene on chromosome 1 or17 / x-linked dominant or recessive

• Duplication of gene for peripheral myelin protein(PMP22) on chromosome 17

• Age of onset: any age but obvious signs andsymptoms usually occur at 10 – 20 yrs of age

• Prevalence: 1 / 2500 – 1 / 4000


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HMSN I HMSN II

Mean Conduction

velocity

decreased - less than 38

m/sec

Normal / near normal

Amplitudes of

sensory and action

potentials

Reduced Reduced

Genetics

Age of onset

Duplication of PMP 22

gene – autosomal

dominant

First decade

Mutation forconnexin -32

gene = X-linked

transmission

Second decade


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Hallmark

Genetic transmission

Complete symmetry

Very slow progression

Loss of myelin disproportionate to axons

Other features:

Slowed nerve conduction velocity (10 – 20 m/s)

Pathology – peripheral segmental demyelination and dorsal column degeneration


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• Clinical features:

• Difficulty in running, frequent weakness, sprainsof ankles, stumbling and slapping of feet

• Kyphoscoliosis

• Weakness of extensor hallucis, digitorum longus,peronei and intrinsic feet muscles lead to:

• pied en griffe – high arches and hammertoes

• Pes cavus

• Foot drop – atrophy of calf muscles

• Champagne glass or stork-like legs


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• Clinical features (cont):

• Impaired motor, vibration and joint position sense

• Tremors (occasional)

• Paresthesias, cramps, sensory loss

• Atrophy of muscles - Claw foot and hand

Differential diagnosis:

Distal muscular dystrophies

Friedrich’s ataxias

Roussy-Levy syndrome

Adult onset – CIDP


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Pathologic findings:

Depletion of axons, myelin sheaths, sensory and

motor fibersNerves may be enlarged with onion bulb

formations of Schwann cells and fibroblasts

Prognosis: good

Treatment:

No specific treatment

Regular exerciseLight braces or shoes with springs

Arthrodoses to stabilize ankles


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II. HEREDITARY NEUROPATHY WITH PRESSURE PALSIES

Multiple recurrent focal neuropathies and plexopathies oftenprovoked by compression

Dominant trait

Deletion of PMP22 gene at half normal level

Usually non-painful

often with underlying chronic but slowly progressive milddemyelinating sensorimotor neuropathy

Nerve biopsy – (+) localized nerve sheath thickening withduplication of myelin lamellae (tomaculae)

EMG – mild slowing of conduction of distal sensory and motornerves


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• Other Manifestations:

1.Kyphoscoliosis2.Deformities of hands and feet

3.Miotic, unreactive pupils

4.Nystagmus

5.Deafness

6.Hypertrophy of nerves7.Severe motor deficit

7. Severe sensory deficit (pseudoataxia / pseudoathetosis)


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• NCV – markedly reduced (10 m/s)

•

Pathology – segmental demyelination• Thickening of nerves – onion bulb• Mononeuritis multiplex

• CSF protein – persistently increased

• Prognosis:

•

Poor ; wheelchair bound at early age• Treatment:

• Symptomatic


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PREDOMINANTLY SENSORYNEUROPATHIES


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• Hereditary Sensory and Autonomic Neuropathy Type I(HSAN I) / Mutilating Hereditary (Dominant)Polyneuropathy in Adults

• Rare; autosomal dominant• Begins with subtle loss of pain and temperature

sensation in the feet later of the fingers

• Calluses, later blistering, ulceration of feet

•Osteomyelitis and osteolysis

• Shooting pain and sensory loss

• Mild muscle weakness

• Hypo/areflexia

•

Loss of sweating


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• Pathology – slowly progressive sensory distal axonaldegeneration and segmental demyelination affecting non-myelinated and small myelinated fibers

• Loss of function of enzyme serine palmitoyltransferease –

rate limiting step in biosynthesis of sphingolipids

• Sensory nerve conduction – absent or slowed

• Prognosis - good


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• Recessive Mutilating Sensory Polyneuropathy ofChildhood

• Autosomal recessive• Onset: infancy and early childhood

• Walking is delayed

• Ataxia

•Ulceration of tips of toes and fingers

• Areflexia

• Impaired sensory modalities

• Disruption of nerve growth factors


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• HSN II (Morvan’s syndrome, Infantile Syringomyelia,Congenital SN)

• Rare; autosomal recessive

• Distal sensory deficit

•

Onset: infancy


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HSN IV (Congenital SN w/ anhydrosis / CongenitalInsensitivity to Pain)

- Rare; autosomal recessive- Onset – infancy

- High fever due to absence of sweating mechanisms

- mental retardation

- short stature- insensitivity to pain

- Absence of neurons in dorsal root ganglia, Lissauer’stract and decreased size of descending tract of CN V

- Prognosis - poor


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HSN with Familial Dysautonomia(Riley-Day Synd)

Rare; autosomal recessive

Jewish families

Congenital absence of autonomic and dorsal root ganglia sensory neurons

Autonomic neuropathy (fluctuating body temperature, no tears, postural hypotension, drymouth, impaired taste sensation w/ strikingly smooth tongue, poor suck, failure to thriveepisodes of pneumonia)

Loss of pain and temperature sense with preservation of pressure and tactile sense

Absent reflexes


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Motor functions slightly affected

Corneal ulceration, fixed pupils, blotchiness of skin,excessive sweating, difficulty in swallowing,esophageal and intestinal dilatation, emotionalinstability, recurrent vomiting, stunted growth

Histopath: diminished myelinated and unmyelinated

fibers, and sympathetic and parasympathetic ganglioncells

• Prognosis – poor (die at age 15) due to autonomicdysfunction


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• Hereditary Areflexic Dystasia (Rousy-Levy Syndrome)

• CMT3

• Autosomal dominant• Mutation of myelin protein gene

• Onset: infancy / from birth

• Sensory ataxia

•

Pes cavus and areflexia• Some degree of sensory loss: vibratory and position

• Atrophy of muscles of legs and postural tremors

• Relatively benign


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• Inherited (Familial Amyloidosis, FA) AmyloidNeuropathies• Pathology: deposition of amyloid around nerve fibers or

covering of nerves & microvascular deposition ofamyloid leading to vasculitic neuropathy

• Small diameter fiber damage producing pain and

temperature loss and autonomic neuropathy• 2 main types:

1. Familial amyloidosis (FA)

2. Primary (non-familial) systemic amyloidosis (AL)


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• Non-familial systemic amyloidosis

• Generalized symmetrical sensorimotor neuropathy w/ serious autonomic involvement

• Multiple myeloma

• Diagnosis - biopsy of sural nerve, rectum / gum

• Death – cardiac or renal involvement by amyloid

• Familial amyloid polyneuropathy


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• Familial amyloid polyneuropathy• Autosomal dominant

• Males = females

• 4 types:

1. Portuguese (Andrade) type - Unpleasant, progressive and fatal neuropathy;starts from legs in the 3rd decade and runs its course for 10 or more years

• Numbness, paresthesias, pain in lower extremities

• Mild weakness and areflexia

• Sensory loss (pseudosyringomyelic pattern)

• Autonomic involvement – loss of pupillary light reflexes and miosis, anhydrosis,

vasomotor paralysis with orthostatic hypotension, alternating diarrhea and

constipation, impotence


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• Difficulty in walking

• Cranial nerve involvement (facial weakness andnumbness, loss of taste) may occur late

• Cardiac enlargement and irregular cardiacrhythm

• Anemia

• Behavior abnormalities, cerebellar ataxia,bilateral corticospinal signs, nephrotic

syndrome, uremia• CSF – normal or increased protein

• Africa, France, Brazil, Japan, Sweden


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3. Iowa type – onset – 30 yrs – Amyloid deposits in testes, adrenal glands, kidneys

– Fairly severe sensorymotor neuropathy – Mutated apolipoprotein A1

4. Cranial neuropathy with corneal lattice dystrophyand facial palsies

– Finnish type

– Onset – 3rd decade

– 5th decade – facial nerves are affected

– Excessive skin folds in face, facial diparesis, dysarthria,spasticity, loss of posterior column function, amyloiddeposits from gelsolin protein


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Lipoprotein Disorders and Peripheral

Neuropathy


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• Cerebral Lipoidosis – deposition of abnormal lipids inthe brain

•

Diagnosis: NCV & nerve biopsy• 2 types:

1. Metachromatic Leukodystrophy – deficiency of arysulfatase A

- widespread demyelination of brain

- Intrellectual impairment

- Prognosis – poor

2. Krabbe’s Disease – deficiency of galactosylceramide beta-galactosidase- accumulation of galactocerebroside in brain and PN

- Fatal w/in 1-2 years of onset


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- Cerebellar signs (progressive ataxia, titubation ofhead, dysarthtria

- Peripheral neuropathy (impaired posture sense, lossof pain and temperature sense)

- Ophthalmoparesis

- Retinitis pigmentosa

- Muscle weakness

- Babinski sign


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- Laboratory – extremely low serum cholesterol,

acanthocytosis

- Complications: cardiac enlargement and congestivefailure

- Neuropathologic findings: demyelination of peripheral

nerves and degeneration of nerve cells in spinal graymatter and cerebellar cortex

- Management – high doses of fat-soluble vitamins. &dietary fat restrictions

- Prognosis – may live to middle age


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2. Tangier Disease (High-Density Lipoprotein Deficiency)

- autosomal recessive

- Gene mutation – inhibits function of ATP cassettetransporter protein

- Cholesterol deposition in tonsils

- Swollen yellow-orange tonsils producing difficulty of

breathing and swallowing- Impaired pain and temperature sense sometimes

limited to face and upper extremities(pseudosyringomyelia)


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- Laboratory – absent serum high-density lipoproteins& low cholesterol and high triglyceride serum levels

- Fat-laden macrophages in bone marrow

- Neuropathy progresses slowly

- Treatment: dietary restrictions of fats


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• Diagnosis: increased phytanic acid in blood(normal – 0.3) of patients with chronic peripheralneuropathy

• Treatment – low phytol diet

•

Cause of death – cardiac involvement


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4. Fabry’s Disease (Anderson-Fabry dse., AngiokeratomaCorporis Diffusum,)

• β-Galactosidase A Deficiency• X-linked recessive

• Lipid deposition in all tissues and body fluids

• Deposition of glycolipid (ceramide trihexodase) in

nerves and cells of spinal ganglia and anterior andintermediolateral horns of spinal cord

• Heterozygous women (10%) have later onset andmilder neuropathic symptoms than men

• Initial Symptom: pain-severe burning type, followed

by paresthesias of palms and soles


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• Telangiectasia of lower trunk and upper legs

• Impairment of renal function and cerebral and cardiac

infarction• Dark red macules and papules over trunk and limbs,

some cluster around thigh and lower limbs and aroundumbilicus

•

Treatment: anticonvulsants for pain, enzymereplacement therapy

• Cause of death – renal failure


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•Acute Intermittent Porphyria•

Defect in uroporhyrinogen-1 synthetase• Autosomal dominant

• Incidence – 1.5/100,000

• severe colicky abdominal pain w/ vomiting, abnormalbehavior, severe ascending neuropathy, rapidly

ascending flaccid paralysis, cranial nerve palsies,autonomic involvement, deep red color of urine

• Diagnosis – determination of erythrocyteurobilinogen-1 synthetase


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• Other metabolic dysfunctions• Evidence of SIADH, salt-losing nephropathy

• Liver damage

• Treatment – IV glucose @ 10 –20 g/h, haematin 4

mg/kg/12 h, Chlorpromazines• Prognosis – poor; 25-50% mortality

• Recovery at 6-8 wks; slow & incomplete


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SYNDROME OF CHRONIC SENSORY

MOTOR POLYNEUROPATHY


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•Alcoholic Peripheral Neuropathy• Severe pain in the feet w/ marked hypersensitivity to

light touch / other stimuli• Painless motor neuropathy

• Treatment – alcohol withdrawal, Vit B

•Neuro of Chronic Renal Failure• Due to uremia

• Generalized mild painful sensorimotor neuro

• “Restless leg” syndrome


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• Leprosy (Hansen’s Dse)

• generalized skin involvement and nerve damage dueto Schwann cell involvement by Mycobacterium

leprae

• India, Central Africa, South America, Florida, Texas,Louisiana, Gulf of Mexico

• Stages:1. Indeterminate leprosy - patchy skin lesions affecting cutaneous nerves

(depigmented and anesthetic patches)

2. Tuberculoid leprosy – circumscribed epithelioid granuloma involving cutaneousand subcutaneous nerves resulting to hypopigmented patch with superficialnumbness and sensory loss


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• Underlying subcutaneous sensory nerves mayenlarge

• Ulnar, median, peroneal, posterior auricular,facial nerves

• May lead to sensorimotor deficit3. Lepromatous leprosy – diffuse infiltration of bacilli to skin, ciliary bodies, testes,

lymph nodes, nerves

•

Symmetrical pattern of pain and temperatureloss, involving pinnae of ears, nose, dorsalsurfaces of hands, elbows, forearms, andfeet, anterolateral aspects of legs =temperature-dependent pattern


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- Impaired motor function and loss of sweating

- Preserved tendon reflexes

- Infections, trophic changes and loss of tissue

4. Dimorphous leprosy – has both tuberculoid andlepromatous characteristics

- diagnosis – nerve biopsy

- Treatment – Dapsone, Rifampicin and Clofazimine

Thalidomide


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VASCULITIC Neuropathies


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• Sarcoidosis• Chronic generalized granulomatous disorder

• Pulmonary problems w/ peripheral nerve lesions in 5 % (bilateralor recurrent attacks of Bell’s palsy; sensorimotor neuropathy)

• May affect CNS usually pituitary stalk –diabetes insipidus , ormyelopathy

• Painful small fiber sensory neuropathy

• Rheumatoid Arthritis• 1 – 5 % of patients with RA have vasculitic involvement of one or

more nerves

• Small-vessel fibrinoid type with immunoglobulins on vessel walls


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• Systemic lupus erythematosus• 10% of patients with SLE have peripheral neuropathy

• Symmetrical, progressive sensorimotor paralysis beginning at feetand legs and extending to arms

• Weakness and areflexia are prominent in some

• Sensory deficit usually vibratory and position senses

• Mechanisms of nerve damage;

• Axonal degeneration• Chronic demyelinating pathology

• Vasculitic injury from deposition of immune complexes


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•SYNDROME OF SUBACUTESENSORIMOTOR PARALYSIS FROM

PERIPHERAL NEUROPATHY


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Toxic Neuropathies


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•Arsenic• Pathology: axonal degeneration

•

Chronic: GI symptoms, anemia, polyneuropathy, jaundice, brownish cutaneous pigmentation,hyperkeratosis of palms and soles, Mees lines

• Acute: severe GI symptoms, renal & hepatic failure,encephalopathy, neuropathy

• Treatment: gastric lavage, BAL

•Thallium• Rapidly progressive painful sensory neuropathy, optic

atrophy, ophthalmoplegia, alopecia (15-30 days)

• Treatment: potassium chloride

• Lead


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Lead• Colic, anemia, predominantly motor peripheral

neuropathy, encephalopathy basophilic stippling of

red cell precursors in bone marrow• Laboratory: copoporphyrin in urine, blood lead level

>70 μg/dl

• Treatment: penicillamine

•

Other metals1. N-hexane

2. Methyl n-butyl ketone

3. Methyl bromide

4. Ethylene oxide

Drugs that could cause neuropathies


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Drugs that could cause neuropathies

I. Antibiotics1. Metronidazole

2. Nitrofurantoin

3. Dapsone

4. Isoniazid

5. ChloramphenicolII. Antineoplastic

1. Vinka alkaloids

2. cisplatin

III. Other drugs1. Phenytoin

2. Disulfiram

3. Hydrallazine

4. Penicillin

5. Cliquinol6. Sodium cyanate

7. pyridoxine


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•Diabetic Peripheral Neuropathy• 50% of diabetics who have the disease for 20 yrs have neuropathy

• Presenting symptom in maturity onset diabetes• Pathology: 1º axonal degeneration w/ 2º demyelination; proximal

vascular lesions; compression palsies

• Forms:

• Mild peripheral sensory neuropathy – slight numbness of feet

and loss of ankle reflexes• Sensorimotor neuropathy – distal sensory loss, generalized

areflexia, pain• Treatment – amitriptyline, phenytoin, carbamazepine


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• Diabetic Peripheral Neuropathy• Forms (cont)

• Autonomic neuropathy – impotence, diarrhea, posturalhypotension, tachycardia, gastrointestinal stasis, pupillaryconstriction, impaired autonomic response tohypoglycemia; bad prognostic feature

•

Nerve compression palsies – carpal tunnel synd, ulnar nerveand peroneal nerve compression

• Vascular nerve lesions – recurrent and multiple extraoccularnerve palsies and intercostal nerve vascular lesions

Di b i P i h l N h


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• Diabetic Peripheral Neuropathy• Forms (cont)

• Diabetic amyotrophy• Maturity onset diabetes; male

• Onset – sudden dramatic weight loss without obvious deterioration in diabeticstate

• Excruciating pain from anterior thigh to medial maleolus in distribution offemoral nerve; severe for

5-10 days

• Rapidly progressive weakness of quadriceps; disappearance of knee jerk;

atrophy of thigh muscles• Recovery – 6 – 18 mos


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•Neuro associated Carcinoma (Oat cell CA)

• Mild general sensory w/ minor motor• Due to chemotherapy or damage to dorsal root

ganglion

Ischemic Peripheral Neuropathy- tingling paresthesias in the feet w/ blunted cutaneous

sensation of foot

- Cyanosis, loss of pulsations of peripheral vessels

- Onset – 70-80 yrs


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Mononeuropathy,mononeuropathy

multiplex and plexopathy


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• Motor, reflex and sensory changes confined to• the territory of a single nerve (mononeuropathy)

• several individual nerves affected in a random manner( mononeuropathy multiplex)

•

a plexus of nerves or part of a plexus, ( plexopathy)• Pain overlying site of infarction or distally


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• Brachial Plexus Neuropathies• Sensorimotor derangements

• Etiology = compression e.g tumors

infections, usually viral

trauma – arm is hyperabducted or shoulder isviolently separated from the neck

delayed results of radiotherapy

direct compression by adjacent skeletal anomalies

subcutaneous or intramuscular injections

ischemic lesion from subclavian artery /veinthrombosis

inflammatory diseases related to lymphoma orgranulomas

idiopathic


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• Lesions of entire brachial plexus• Paralysis of entire arm, complete sensory loss from shoulder

to medial side of middle third of upper arm

•Loss of biceps, triceps, radial reflexes

• Usual cause = vehicular trauma


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• Upper brachial plexus paralysis•

Distal 5th

and 6th

cervical root injury• Usual causes = forceful separation of head and shoulder during

difficult delivery (Erb-Duchenne palsy), pressure onsupraclavicular region, immune reactions to injections of foreignserum, pressure on supraclavicular region during anesthesia,idiopathic brachial plexitis

• Muscles affected = biceps, deltoid, supinator longus,supraspinatus and infraspinatus, and rhomboids

• Arm hangs at the side, internally rotated and extended at theelbow, movements are unaffected

• Good prognosis but Erb-Duchenne palsy is usually permanent


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• Lower brachial plexus paralysis• C7, C8, T1

• Result from traction of abducted arm in a fall or during operation onthe axilla, compression of tumor from apex of lung (PancoastSyndrome), compression by cervical ribs, breech delivery (Dejerine-Klumpke paralysis)

• Weakness and wasting of small muscles of the hand, clawhanddeformity

• Sensory loss over ulnar border of hand and inner forearm

• Horner syndrome


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• Intraclavicular lesions involving cords of Brachial Plexus

• Common causes = iatrogenic (damage to subclavian or axillaryvessels, anesthesia block of brachial plexus), dislocation of head ofhumerus, direct axillary trauma, supraclavicular compression duringawkward positioning of the arm

• Lesion of lateral cord

• Musculocutaneous nerve and lateral root of median nerve

• Weakness of flexion and pronation of forearm

• Lesion of medial cord

• Medial root of median nerve and ulnar nerve

• Combined median and ulnar nerve palsy

• Lesion of posterior cord

• Weakness of deltoid muscle, extensors of the elbow, wrist and

fingers, sensory loss on outer surface of upper arm


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• Thoracic Outlet Syndrome• Shoulder and arm pain, aching in character, felt over posterior

hemithorax, pectoral region and upper arm• Compression or spontaneous thrombosis of subclavian vein = dusky

discoloration, venous distention, edema of arm

• Paget-Schotter Syndrome – vein may become thrombosed afterprolonged exercise

•

Compression of subclavian artery• Ischemia of limb, digital gangrene and retrograde embilization

• Unilateral Raynaud phenomenon, brittle nails, ulceration offinger tips

• Supraclavicular bruit

• Neurologic symptoms in thoracic outlet syndrome


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• Neurologic symptoms in thoracic outlet syndrome

• Slight wasting and weakness of hypothenar, interosseous,adductor pollicis, and deep flexor muscles of 4th and 5th fingers

• Weakness of flexor muscles of forearm• Preserved tendon reflexes

• Intermittent aching pain and/or numbness or tingling sensation ofulnar side of forearm and hand

• Sensory symptoms may be reproduced with firm pressure above

clavicle or traction of arm• Conventional tests for vascular compression

• Adson test – patient is seated with arm extended takes and holdsfull breath, tilts head back and turns it to affected side

• Wright maneuver – abducts and externally rotates the arm, braces

shoulders and turns head to either side

• Diagnosis


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g

• Reduced amplitude of ulnar sensory potential on NCV

• Large amplitude motor units on EMG

•Brachial artery MR angiography – arterial occlusion, aneurysm

• Differential diagnosis

• Carpal tunnel syndrome

• Ulnar neuropathy or entrapment at the elbow

• Cervical radiculopathy due to arthritis or disc disease

• Brachial neuritis

• Treatment

• Local heat

• Analgesics and muscle relaxants

• Physical therapy / exercises

• Surgery

BRACHIAL MONONEUROPATHIES


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• BRACHIAL MONONEUROPATHIES• LONG THORACIC NERVE OF BELL

• C5,6,7

• Supplies seratus anterior

• Inability to raise arm over the head, winging of medial borderof scapula when outstretched arm is pushed against resistance

• SUPRASCAPULAR NERVE

• C5,6

• Supraspinatus and infraspinatus muscles

• Weakness of abduction and external rotation of arm


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• RADIAL NERVE• Posterior cord, C5-8

•

Triceps, brachioradialis, supinator muscles, extensor muscles of wrist and fingers,abductor of thumb

• Paralysis of extension of elbow, wrist and fingers, and supination of forearm

• Impaired sensation over posterior aspect of forearm radial aspect of dorsum of hand

• Crutch palsy, lead intoxication

•


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• ..

• MEDIAN NERVE• C5-T1

• Pronator of the forearm, long finger flexors, abductor and opponens muscles of thumband sensory to palmar aspect of hand

• Inability to pronate the forearm or flex the hand in radial direction, paralysis of flexionof index finger and terminal phalanx of thumb, weakness of flexion of other fingers,weakness of opposition and abduction of thumb



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• Compression of median nerve at the wrist (transversecarpal ligament)

• Impairment of superficial sensation over palmar aspectof thumb, index finger and middle finger, paresthesias

• Phalen maneuver

• Tinel sign

• Treatment:• Splinting of wrist

• Injection of hydrocortisone

• surgical division of carpal ligament


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• Pronator syndrome

• Compression of the nerve at the elbow where the nervepasses between two heads of pronator teres or justbehind bicipital aponeurosis

• Forceful pronation of the arm produces aching pain,weakness of abductor pollicis brevis and opponensmuscles, numbness of first 3 digits and palm

• ULNAR NERVE


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ULNAR NERVE• C8 – T1

• Ulnar flexor of wrist, ulnar half of deep finger flexorsabductors and adductors offingers, adductor of thumb, and 3rd and 4th lumbricals, muscles of hypothenar

eminence

• Claw hand deformity – wasting of small hand muscles, hyperextension of fingers atmetacarpophalangeal joints and flexion at interphalangeal joints

• Sensory loss over 5th finger, ulnar aspect of 4th finger and ulnar border of palm

• Delayed (tardive) ulnar palsy


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• ..


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• FEMORAL NERVE• L2-L4

• Iliacus and psoas muscles

• Anterior division – pectineus and sartorius muscles, anteromedial surface of thigh

• Posterior division – quadriceps muscles, medial side of leg

• Weakness of extension at knee, wasting of quadriceps muscles, failure of fixation ofknee, absent knee jerk

• If more proximal – weakness of hip flexion

• SCIATIC NERVEL4 L5 S1 S2


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• L4, L5, S1, S2

• Motor to hamstring muscles and all muscles below knee, sensory to posterior thigh,posterior and lateral of leg, entire sole

• Cannot flex knee, paralysis of all muscles below knee, weakness of gluteal muscles,pain in buttock and posterior thigh

• Sciatica – disc compression L4-L5: pain in posterolateral thigh and leg, numbness overinner foot, weakness of dorsi flexion of foot and toes

• L5-S1: pain in posterior thigh and leg, numbness oflateral foot, weakness of foot plantar flexion, loss

of ankle jerk


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Problems in Diagnosis ofChronic Polyneuropathies

Diagnosis of Early Chronic Polyneuropathy


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Diagnosis of Early Chronic Polyneuropathy

• Sensorimotor paralysis involving legs more than arms anddistal more than proximal• Diabetes - occult neoplasia

• HIV infection - paraproteinemia

•

Connective tissue diseases - CIDP• Toxic neuropathies - Vit. B deficiency / malnutrition

• Purely or predominantly sensory polyneuropathy not causedby diabetes• Carcinoma - paraprotinemia• Sjogren syndrome

• Primary and familial amyloidosis


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Diagnosis of Late Chronic Polyneuropathy

• Usually heredofamilial or sporadic mutations of genes

• DNA testing is very helpful

• Slowly progressive polyneuropathy with CNS degenerationparticularly cerebellar ataxia is most often hereditary


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Laboratory tests for the investigation of subacute and


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chronic polyneuropathies (in addition to EMG/NCV)

• Serum glucose, glucose tolerance test, glycosylatedhemoglobin A1C – diabetes

• Anti Hu antibody – paraneoplastic neuropathies

• Immunoelectrophoresis or immunofixation of serum and

urine – paraproteinemic and amyloid polyneuropathies• Antimyelin-associated glycoprotein and antisulatide

antibodies – chronic immune sensory neuropathies

• Anti GM1 antibody – multifocal motor conduction block


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• Human immune deficiency virus antibody

• Lyme antibody• Heavy metal concentrations in blood and tissue – toxic

neuropathies

• Blood urea nitrogen

• Thyroid hormone• Sedimanetation rate, ANA, cryoglobulins, c-ANCA,

rheumatoid factor, and SSA-SSB Sjogren antibodies,eosinophil count – vasculitides

• antiglandin antibodies – sprue


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•

Vit B 12 and methyl malonic acid levels – B12deficiencies or nitrous oxide exposure

• Serum carotene, Vit E, pyridoxine levels – nutritionaldeficiencies and vitamin excess

• Genetic testing for Charcot-Marie-Tooth disease andfor hereditary liability to pressure palsy and brachialplexopathy – inherited neuropathies

• Spinal fluid protein determination and cell content –chronic inflammatory demyelinating polyneuropathy,

neoplastic and granulomatous meningitis

peripheral nerve diseases (1)

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