Peripheral Neuropathy. Dr James Stevens Consultant Neurologist Southmead Hospital, Bristol
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1 Dr James Stevens Consultant Neurologist Southmead Hospital, Bristol
2 Declaration of interests
3 Aims and objectives
4 A 57 year old textile worker reports pins and needles in her hands, following a fall at work what is the most appropriate investigation? Fasting glucose Serum protein electrophoresis Nerve conduction studies X ray of hands MRI cervical spine
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6 Acknowledgement: Dr Luke Bennetto History
7 What is it Not a diagnosis Any nerve Syndrome Differential diagnosis Management
8 Motor, sensory, autonomic Patchy / uniform Focal / length dependent Painful / painless PNS, CNS, systemic Tempo Cranial nerves
9 39 year old man PMH Panic attacks Otherwise well
10 One month history Tingling hands and feet Progressed to waist No pain Bladder, Bowel, Sexual function normal Unsteady walking since one week
11 O/E Apyrexial BP 120/72, Pulse 72rr CVS, Abdo, RS normal Cranial nerve examination unremarkable
12 O/E (cont) Tone and bulk normal Power reduced at wrists, hips and ankles Absent left biceps and supinator jerks Brisk knee jerks, ankle jerks with reinf. Plantars downgoing
13 O/E (cont) PP impaired to knees and MCPs Cold sensation normal Vibration normal in DIPs, decreased to sternum JPS errors in toes and DIPs
14 O/E Athetoid movements of hands Steppage gait foot drop
15 Syndrome Tests U&E, LFT, Ca/Mg/PO 4 Fasting glucose FBC Normal 4.7mmol/l Normal
16 Neurophysiological studies Peroneal and tibial motor studies absent or significantly attenuated. Normal CVs EMG of tibialis anterior and gastrocnemius large amount of spontaneous activity Broadly normal sensory studies
17 Further tests Plasma viscosity low ANA, ANCA Negative TSH 1.2 mu/l Copper 14.5µmol/l Serum electrophoresis Negative
18 Even more tests Serum folate 10.8µg/l Vitamin B12 120pg/ml ( ) Ferritin Normal Methylmalonic acid 6757nmol/l (<280) Homocysteine 63.8µmol/l ( )
19 Diagnosis Vitamin B12 deficiency myeloneuropathy What next?
20 Red flags Syndrome Tests
21 It is () unwise to demand any but the simplest introspection from patients, to whatever class they may belong But.
22 Neurological examination Guided by history
23 Sensory function Pinprick (temperature) Vibration sense Joint position sense (Romberg) Light touch Other tests Gait, vestibular, L+S BP, rating scales
24 History Exam / NCS to confirm Syndrome
25 76 year old man Symptoms in feet since 5 years Not right Pebbles in shoes Limited tingling Can t walk as far
26 Carotid endarterectomy after amaurosis Hypertension Perindopril Clopidogrel Stopped statin
27 Retired policeman 6-8 pints beer per week Ex smoker
28 O/E Tone / bulk All tendon jerks present Co-ordination normal Power normal
29 O/E (cont) General Examination unremarkable Light touch altered to knees Pinprick decreased to mid shins Vibration decreased to knees Joint position sense normal Romberg negative, gait normal
30 FBC, U&E, LFT, Bone, CRP, PV/ESR Fasting glucose* B12/Folate/Ferritin Serum electrophoresis
31 Neurophysiological results Conduction velocities within normal limits Amplitudes reduced, more distally, more in sensory nerves EMG within normal limits
32 History Exam / Neurophysiology Tests
33 Diagnosis: Idiopathic axonal neuropathy Issues: Progression Pain Statin Genetics
34 Idiopathic axonal neuropathy Diagnosis of exclusion Pain Age Rapid progression Early hand involvement Early motor involvement (power, reflex) Asymmetry Potential cause systemic disease, drugs
35 Causes Inherited Primarily Neuropathy Multisystem Acquired Tempo
36 Inherited CMT SMA HNPP HSAN SCA, FA, AIP
37 Acquired Toxins/ drugs Alcohol Chemotherapy Metronidazole Nitrofurantion Phenytoin Pyridoxine Colchicine Lead Dapsone Anti-TNF Statins HAART Isoniazid Lithium
38 Acquired Guillain Barre syndrome CIDP / MMN MND Diabetes / Impaired glucose metabolism Copper Deficiency B 12 Deficiency (?)
39 Acquired Renal failure Nutritional states Compression Sarcoidosis
40 Acquired HIV, Polio, West Nile, (Hepatitis) Lyme, Leprosy Botulism Paraneoplastic Paraproteinaemic Sjogren s Vasculitides
41 27 year old lady Dr Claire Rice R-handed Brazilian, In UK for 14 months 7 months 4 months L upper limb tingling Increasing discomfort and weakness Difficulty straightening the fingers Weak grip Subsequent pain around L shoulder Few days Electric shock sensations down to L foot
42 Congenital campytodactyly 5th fingers - bilateral OCP Ibuprofen Cleaner Non-smoker, no alcohol Lives with husband and children
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44 Fixed flexion deformities at proximal and distal interphalangeal joints of both 5th fingers Weakness of all left sided intrinsic hand movements, particularly thumb opposition and finger adduction L-sided sensory abnormalities Decreased pinprick approx C6-8 Decreased temperature sensation Decreased proprioception and vibration sensation
45 Neurophysiological studies: Multifocal sensory and motor neuropathy with axonal degeneration Some features of segmental demyelination.
46 Red Flags: Young Upper limb onset Rapid progression / disability Asymmetric Painful Weakness Demyelination
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49 Diagnosis: Paucibacillary Leprosy Hansen s disease - neuropathy and neuronopathy caused by Mycobacterium leprae and the host immunological response to the organism Small skin lesions on philtrum, nostril and L sole Ganglionitis and myelitis in association with skin lesions, thickened peripheral nerves and a claw hand characteristic of lepromatous infection
50 Treatment Corticosteroids Rifampicin Dapsone
51 Peripheral Neuropathy
52 Standard blood screen Assumptions FBC, U&E, LFT, Bone, CRP, PV/ESR Fasting glucose* B12/Folate/Ferritin Serum electrophoresis
53 Atypical CK, LDH Homocysteine, Methylmalonic acid Igs, BJP, anti-mag, Anti-ganglioside, VEGF ANA, ENA, ANCA, Cryoglobulin, Complement ACE HIV, VDRL, Hepatitis Weil, Lyme
54 Even more atypical Lipids Lead, other toxins WCE, VLCFA, Phytanate Genetics*
55 Take home points: History and assessment Red flags Classify syndrome Basic tests - mostly blood If in doubt, do ask
56 Questions Peripheral Neuropathy
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105 Appearance Tone Power Muscle stretch reflexes Co-ordination
106 What else to ask and why Distribution Autonomic Tempo Other medical
107 Cases: IAN DM CIDP Vasculitis B12 defic DRG CMT
108 Title RGB 0,0,30 Text 250,250,150
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