peripheral nerve disrders
DESCRIPTION
Peripheral nerve disrdersTRANSCRIPT
Diseases of peripheral nerve
• Inflammatory, traumatic, metabolic, toxic, genetic, neoplastic
Inflammatory neuropathies• Inflammatory cell infiltrates into peripheral
nerves, roots & autonomic ganglia
Immune mediated neuropathies
G. B. syndrome ( acute inflammatory demyelinating polyradiculoneuropathy )
• Most common, life threatening
• Weakness in distal limbs, rapidly advancing to proximal muscle ( asc paralysis)
• Inflammation & demyelination of peripheral nerves & spinal nerve roots
Pathogenesis • Preceded by acute infleunza like illness,
viral• Immunologically mediated disease
Morphology • Inflammation of peripheral nerve• Perivenular & endoneurial infiltration by
lymphocytes, macrophages & few plasma cells
• Segmental demyelination affecting peripheral nerve is pri.lesion
Clinical course• Dominated by asc paralysis• Deep tendon reflexes disappear early• Nerve conduction velocity slowed bcoz of
multifocal destruction of myelin segments involving axons within nerve, increase in CSF protein due to inflammation
Infectious polyneuropathies
Leprosy • Lepromatous leprosy – schwann cells
invaded by M.leprae which proliferates & infects other cells
• Evidence of segmental demyelination & remyelination & loss of both myelinated & unmyelinated axons
• Endoneurial fibrosis & multilayered thickening of perineural sheaths
• Symmetric polyneuropathy involves pain fibres, leads to loss of sensation, trophic ulcers
• Tuberculoid leprosy – active CMI with nodular granulomatous inflammation
• Inflammation injures cutaneous nerves in the vicinity, axons, schwann cells & myelin are lost
• Fibrosis of perineurium & endoneurium
Varicella zoster virus• Common viral infection • Latent infection of neuron in sensory
ganglia of spinal cord & brain stem follows chickenpox
• Painful vesicular skin eruptions in distribution of sensory dermatomes ( thoracic/trigeminal )
• Ganglia show neuronal destruction, mononuclear inflammatory infiltrate
• Regional necrosis & h’ge may be seen
Hereditary neuropathies• Grp of heterogenous, typically
progressive, often disabling syndrome
Hereditary motor & sensory neuropathies • Common• Caused by mutations in genes whose
products are involved in formation & maintainence of myelin
Type I ( HMSN I )• Childhood • Progressive muscular atrophy of calf • Duplication of large region of chromosome
17p11 – p12 -> segmental trisomy, which includes gene for peripheral myelin protein 22 (PMP22 )
Morphology • Histology shows consequences of
repetitive demyelination & remyelination with multiple onion bulbs more in distal nerves
• Schwann cell hyperplasia surrounding individual axons -> enlargement of individual p.nerves -> hypertrophic neuropathy
• AD , slowly progressive, sensorimotor deficits
Hereditary sensory & autonomic neuropathies
• Numbness, pain, orthostatic HTN
Familial amyloid polyneuropathies• Deposition of amyloid within p.nerves
Acquired metabolic & toxic neuropathies
Peripheral neuropathy in adult onset DM• Depends on duration of disease
1. Distal symmetric sensory/sensory motor neuropathy
2. Autonomic neuropathy
3. Focal/multifocal asymmetric neuropathy
Morphology • Axonal neuropathy in distal symmetric
sensorimotor neuropathy • Other types there is some segmental
demyelination• Endoneurial arterioles show thickening,
hyalinization
Clinical course• Decreased sensation in distal extremities• ulcers
Metabolic & nutritional peripheral neuropathies
• In renal failure – distal symmetric neuropathy, muscle cramps, decreased deep tendon reflexes, axonal degeneration
• Chr liver disease, chr resp insufficiency, thyroid dysfunction
• Thiamine deficiency -> axonal degeneration – Beri Beri
• Excessive consumption of alcohol -> axonal neuropathy
Neuropathies ass with malignancy• Direct infiltration/ compression of p nerves
by tumor -> mononeuropathy• Eg brachial plexopathy – lung tumor• Diffuse symmetric neuropathy in distant
CA due to paraneoplastic syndromes
• Numbness, paraesthesia
Toxic neuropathies• After exposure to industrial/environmental
chemicals, toxins, drugs – lead, arsenic
Traumatic neuropathies• Nerves injured during course of trauma• Lacerations from cutting injuries, avulsions
– tension applied to peripheral nerve
• Regeneration slow, regrowth complicated by discontinuity between proximal & distal portions of nerve sheath/ misalignment of individual fascicles
• Axons in absence of distal segment continue to grow resulting in mass of tangled axonal process -> traumatic neuroma
Compression neuropathy - occurs when p nerve is compressed
Carpal tunnel syndrome • Compression of median nerve at the level
of wrist within compartment limited by transverse carpal ligament
• Women, bilateral• Pregnancy, inflammatory arthritis,
hypothyroidism, acromegaly, DM
• Numbness, paraesthesia of tips of thumb & 1st two digits
Other• Involvement of ulnar nerve at the level of
elbow• Peroneal nerve – level of knee• Radial nerve in the underarm – sleeping
with arm improperly positioned – sat night palsy