Approach to Peripheral Neuropathy
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Transcript of Approach to Peripheral Neuropathy
APPROACH TO APPROACH TO PERIPHERAL PERIPHERAL NEUROPATHYNEUROPATHY
PROF.RUCKMANI REDDY’S UNITPROF.RUCKMANI REDDY’S UNIT
M1M1
HUMAN NS-----CNSHUMAN NS-----CNS -----PNS-----PNSEACH NEURON has EACH NEURON has 3 parts3 parts SOMASOMA DENDRITESDENDRITES AXONAXON
What forms peripheral nerve?What forms peripheral nerve?
1.DORSAL NERVE ROOT1.DORSAL NERVE ROOT2.VENTRAL NERVE ROOT2.VENTRAL NERVE ROOT3.DORSAL ROOT GANGLIA3.DORSAL ROOT GANGLIA4.CRANIAL NERVES EXCEPT 1 $ 24.CRANIAL NERVES EXCEPT 1 $ 25.BRACHIAL & LUMBOSACRALPLEXUS5.BRACHIAL & LUMBOSACRALPLEXUS6.OTHER sensory,motor,autonomic 6.OTHER sensory,motor,autonomic
nervesnerves
Role of nerve fibres in Role of nerve fibres in peripheralneuropathyperipheralneuropathy
HISTORYHISTORYOnset –acute/subacute/c/cOnset –acute/subacute/c/cPart of body involvedPart of body involvedSequence of involvementSequence of involvementSymptoms -----sensorySymptoms -----sensory -----motor-----motor -----autonomic-----autonomic
Sensory symptomsSensory symptoms
Pain -pricking,burning typePain -pricking,burning typeAllodyniaAllodyniaHyperalgesiaHyperalgesiaNeuropathic painNeuropathic painAnaesthesiaAnaesthesiaTremors-action tremor-in a phase of PNPTremors-action tremor-in a phase of PNP -slow tremor with clumsiness-slow tremor with clumsiness large fibres affected-large fibres affected-
AI,CIDP,antimyelinasso GP AI,CIDP,antimyelinasso GP polyneuropathypolyneuropathy
Paraesthesia Paraesthesia marked in hands & feetmarked in hands & feet objectory sensoryloss is lackingobjectory sensoryloss is lacking Spontaneous parasthesiaSpontaneous parasthesia -in acquired causes-60%-in acquired causes-60% -in inherited causes-17%-in inherited causes-17% Painful parasthesiaPainful parasthesia –DM –DM --ALCOHOLIC NPY--ALCOHOLIC NPY --AMYLOID--AMYLOID Why pain?loss of large touch pressure fibresWhy pain?loss of large touch pressure fibres ExceptionException – –FREDERICH’S ATAXIAFREDERICH’S ATAXIA --Purely sensory polyNP--Purely sensory polyNP
Motor symptomsMotor symptomsMUSCLE CRAMPSMUSCLE CRAMPS WEAKNESSWEAKNESS
FASCICULATIONSFASCICULATIONS DECREASED MANUAL DECREASED MANUAL DEXTERITYDEXTERITY
MYOKYMIAMYOKYMIA WASTING OF MUSCLEWASTING OF MUSCLE
TREMORTREMOR DIIFFICULTY WITH FOOD DIIFFICULTY WITH FOOD INTAKEINTAKE
SPASMSSPASMS
Autonomic symptomsAutonomic symptoms
ORTHOSTATIC LIGHT HEADEDNESSORTHOSTATIC LIGHT HEADEDNESS
FAINTING SPELLSFAINTING SPELLS
SWEATING-INCREASED/DECREASEDSWEATING-INCREASED/DECREASED
HEAT INTOLERANCEHEAT INTOLERANCE
BLADDER,BOWEL,SEXUAL BLADDER,BOWEL,SEXUAL DYSFUNCTIONDYSFUNCTION
ANOREXIA,NAUSEA,VOMITING-ANOREXIA,NAUSEA,VOMITING-GASTROPARESISGASTROPARESIS
PANDYSAUTONOMIA-PANDYSAUTONOMIA- AmyloidosisAmyloidosis Hereditary smallfibrePNHereditary smallfibrePNDRUG H/O-DRUG H/O-
cisplatin,nitrofurantoin,pyridoxinetoxicitycisplatin,nitrofurantoin,pyridoxinetoxicityFAMILYFAMILY H/O-Repeated injury,c/c H/O-Repeated injury,c/c
subcut&osteomyelitis infectionsubcut&osteomyelitis infectionPAST H/OPAST H/O recent infectionsrecent infections viral diseasesviral diseases
GE-SKIN,HAIR,NAILSGE-SKIN,HAIR,NAILSVASCULITISVASCULITIS PURPURA,LIVEDORETICULPURPURA,LIVEDORETICUL
ARISARIS
CRYOGLOBULINEMIACRYOGLOBULINEMIA PURPURAPURPURA
FABRY’S DISEASEFABRY’S DISEASE ANGIOKERATOMASANGIOKERATOMAS
LEPROSYLEPROSY SKIN SKIN HYPERPIGMENTATIONHYPERPIGMENTATION
OSTEOSCLEROTIC OSTEOSCLEROTIC MYELOMA-POEMSMYELOMA-POEMS
HYPERPIGMENTATIONHYPERPIGMENTATION
VARIEGATE VARIEGATE PORPHYRIAPORPHYRIA
BULLOUS LESIONSBULLOUS LESIONS
REFSUM’S DISEASEREFSUM’S DISEASE ICTHYOSISICTHYOSIS
ARSENIC/THALLIUM ARSENIC/THALLIUM INTOXICATIONINTOXICATION
MEE’S LINESMEE’S LINES
THALLIUM THALLIUM POISONINGPOISONING
ALOPECIAALOPECIA
GIANT AXONAL GIANT AXONAL NEURPATHYNEURPATHY
CURLED HAIRCURLED HAIR
NERVE THICKENING in NPthyNERVE THICKENING in NPthy
LEPROSYLEPROSYDIABETESDIABETESAMYLOIDOSISAMYLOIDOSISNEUROFIBROMATOSISNEUROFIBROMATOSISREFSUM’S DISEASEREFSUM’S DISEASEDEJERINE SOTTAS DISEASEDEJERINE SOTTAS DISEASEROUSSY LEVY SYNDROMEROUSSY LEVY SYNDROME
DEFORMITY in NPthyDEFORMITY in NPthy
Foot,hand,spineFoot,hand,spineTalipes equinusTalipes equinusClaw footClaw footPes cavusPes cavusKyphoscoliosisKyphoscoliosisBurnsBurnsPressure soresPressure sores
Cranial nervesCranial nerves
Neuropathy with facial nerve damageNeuropathy with facial nerve damageGBSGBSC/C inflammatory polyradiculonuropathyC/C inflammatory polyradiculonuropathyLyme diaseaseLyme diaseaseSarcoidosisSarcoidosisHIV-1infectionHIV-1infectionGelsolin familial amyloid neuropathyGelsolin familial amyloid neuropathyTangier’s diseaseTangier’s disease
Look for-muscle wastingLook for-muscle wasting
Strength of muscleStrength of muscle
REFLEXESREFLEXES –decreased/lost –decreased/lost
--sign of PNP except in spinal shock--sign of PNP except in spinal shock
Incoordination of movementsIncoordination of movements
Gait abnormality-flinging/slapping gaitGait abnormality-flinging/slapping gait
ATAXIAATAXIA CAUSE?CAUSE? proprioceptive deafferentiation proprioceptive deafferentiation
spinocerebellar dysfunctionspinocerebellar dysfunction
ATAXIA WITHOUT WEAKNESSATAXIA WITHOUT WEAKNESS -tabesdorsalis -tabesdorsalis
DDs-DM,miller fisher variant,sensoryNPthyDDs-DM,miller fisher variant,sensoryNPthy
Ataxia similar to cerebellar,but no Ataxia similar to cerebellar,but no nystagmus,dysarthrianystagmus,dysarthria
SENSATIONS-SENSATIONS- pin prickpin prick temperaturetemperature vibrationvibration pressurepressure position senseposition senseProprioception assessmentProprioception assessment
Pattern of sensory lossPattern of sensory loss
POLY POLY NEUROPATNEUROPATHYHY
Symmetrical,distal,legs>armsSymmetrical,distal,legs>arms
Can even progress to face Can even progress to face
SEVERE SEVERE AXONAL AXONAL NEUROPATNEUROPATHYHY
ESCUTCHEON pattern of sensory ESCUTCHEON pattern of sensory loss over abdomen and thoraxloss over abdomen and thorax
SENSORY SENSORY GANGLIONGANGLIONOPATHYOPATHY
Sensory loss of trunk,scalp,face d/t Sensory loss of trunk,scalp,face d/t simultaneous damage of simultaneous damage of proximal&distal part of sensory proximal&distal part of sensory nervenerve
NERVE FIBRE AFFECTED?NERVE FIBRE AFFECTED?
SYMPTOMSSYMPTOMS SIGNSSIGNS
numbnessnumbness Decreased vibration senseDecreased vibration sense
Pin & needle sensationPin & needle sensation Decreased joint position Decreased joint position sensesense
tinglingtingling Diminished or absent Diminished or absent reflexesreflexes
Poor balancePoor balance
LARGE FIBRE NEUROPATHYLARGE FIBRE NEUROPATHY
Causes of large fibre/ataxic NPCauses of large fibre/ataxic NP
SJOGREN’S SYNDROMESJOGREN’S SYNDROMEVIT B12 NEUROPATHYVIT B12 NEUROPATHYCISPLATIN CISPLATIN PYRIDOXINE NEUROTOXICITYPYRIDOXINE NEUROTOXICITYFRIEDEREICH’S ATAXIAFRIEDEREICH’S ATAXIA
SMALL FIBRE NEUROPATHYSMALL FIBRE NEUROPATHY
PAIN-PAIN-burning,shock burning,shock like,stabbing,priclike,stabbing,prickling,shooting,lakling,shooting,lancinatingncinating
AllodyniaAllodynia
Decreased Decreased pinprick pinprick sensationsensation
Tight band like Tight band like pressurepressure
Insensitive to Insensitive to heat and coldheat and cold
Diminished Diminished temperature temperature sensationsensation
Causes of small fibre neuropathyCauses of small fibre neuropathy(painful NP&dissociated sensory (painful NP&dissociated sensory
loss)loss)Heriditary sensory neuropathyHeriditary sensory neuropathyLepromatous leprosyLepromatous leprosyDiabetes mellitusDiabetes mellitusAmyloidosis(early familial&primary)Amyloidosis(early familial&primary)Tangier diseaseTangier diseaseFabry’s disease-pain predomonatesFabry’s disease-pain predomonatesDysautonomia-riley-day syndromeDysautonomia-riley-day syndromeHIV & antiretroviral therapy neuropathyHIV & antiretroviral therapy neuropathy
SMALL & LARGE FIBRE SMALL & LARGE FIBRE NEUROPATHYNEUROPATHY
Global sensory lossGlobal sensory lossCarcinomatous sensory neuropathyCarcinomatous sensory neuropathyHereditary sensory neuropathyHereditary sensory neuropathyDiabetic sensory neuropathyDiabetic sensory neuropathyVacor intoxicationVacor intoxicationXanthomatous neuropathy of primary Xanthomatous neuropathy of primary
biliary cirrhosisbiliary cirrhosis
Motor predominant neuropathyMotor predominant neuropathy
Immune neuropathiesImmune neuropathiesHeriditary motor sensory neuropathiesHeriditary motor sensory neuropathiesAcute intermittent porphyriaAcute intermittent porphyriaDiphtheritic neuropathyDiphtheritic neuropathyLead neuropathyLead neuropathyBrachial neuritisBrachial neuritisDiabetic lumbosacralplexus neuropathyDiabetic lumbosacralplexus neuropathy
Autonomic Autonomic
Acute-pandysautonomiaAcute-pandysautonomia -botulism-botulism -porphyria-porphyria -GBS-GBS -Amiodarone-Amiodarone -vincristine-vincristineChronic-amyloid,diabetes,sjogren’s,HSN Chronic-amyloid,diabetes,sjogren’s,HSN
1&3,chagas,paraneoplastic1&3,chagas,paraneoplastic
Distribution of neuropathyDistribution of neuropathy
??MONONEUROPATHMONONEUROPATHYY
Focal involvement of Focal involvement of a single nervea single nerve
Weakness & sensory Weakness & sensory loss in the territory of loss in the territory of a single peripheral a single peripheral nervenerve
Pain along the Pain along the pathway of the nervepathway of the nerve
Direct Direct traumatrauma
compressiocompressionn
entrapmententrapment Vascular Vascular lesionslesions
neoplasmsneoplasms
?MONONEUROPATHY ?MONONEUROPATHY MULTIPEXMULTIPEX
Random pattern of nerve involvementRandom pattern of nerve involvement In distribution of separate nerves,asymmetricIn distribution of separate nerves,asymmetric May/may not be painfulMay/may not be painful Not length dependentNot length dependent Isolated reflex lossIsolated reflex loss CAUSESCAUSES—inflammatory-leprosy,sarcoid—inflammatory-leprosy,sarcoid Vascular-DiabetesVascular-Diabetes Pressure,Trauma,InfiltrationPressure,Trauma,Infiltration Vasculitis-PAN,SLE,RA,sclerodermaVasculitis-PAN,SLE,RA,scleroderma Immune-vaccinationImmune-vaccination
?POLYNEUROPATHY?POLYNEUROPATHY
MC type –Distal symmetric polyneurpathyMC type –Distal symmetric polyneurpathyBurning sensation,tingling,numbnessBurning sensation,tingling,numbnessLength dependent patternLength dependent patternStarts in feet,distal stocking glove patternStarts in feet,distal stocking glove patternFairly symmetricFairly symmetricSymmetrically decreased reflexesSymmetrically decreased reflexesSensory>motorSensory>motor
CAUSESCAUSES
Diabetes mellitusDiabetes mellitusAlcoholAlcoholVit B12 deficiencyVit B12 deficiencyHIVHIVAlthough more than Although more than one nerve involved one nerve involved one will be prominantone will be prominant
DDs of distal symmetricNPDDs of distal symmetricNP
Lumbosacral polyradiculopathy/stenosisLumbosacral polyradiculopathy/stenosisMyelopathy-structuralMyelopathy-structural -nonstructural-nonstructuralVascular insufficiency-exercise related Vascular insufficiency-exercise related
cramps,aching pain>numbnesscramps,aching pain>numbnessOrthopedics –stress #,plantar fascitisOrthopedics –stress #,plantar fascitis
?POLYRADICULOPATHY?POLYRADICULOPATHYDisease of multiple peripheral nerve rootsDisease of multiple peripheral nerve rootsAsymmetric with erratic distribution-proximal in Asymmetric with erratic distribution-proximal in
one,distal in anotherone,distal in anotherPain is a common featurePain is a common feature?MONORADICULOPATHY?MONORADICULOPATHYRoot disease by disease of spinal columnRoot disease by disease of spinal columnChanges in distribution of spinal nerve rootChanges in distribution of spinal nerve root
?SENSORY NEURONOPATHY?SENSORY NEURONOPATHYGanglion cells predominantly affectedGanglion cells predominantly affectedBoth proximal & distal involvementBoth proximal & distal involvementSensory ataxia is commonSensory ataxia is commonNo weaknessNo weaknessBut awkward movement d/t sensory But awkward movement d/t sensory
disturbancesdisturbances?MOTOR NEURONOPATHY?MOTOR NEURONOPATHYDisorder of ant horn cellsDisorder of ant horn cellsWeakness,fasciculation,atrophyWeakness,fasciculation,atrophyNot properly a process of peripheral NPNot properly a process of peripheral NP
?PLEXOPATHY?PLEXOPATHYAsymmetricAsymmetricPainful onsetPainful onsetMultiple nerves in a single limbMultiple nerves in a single limbRapid onset of weakness,atrophyRapid onset of weakness,atrophy Isolated reflex lossIsolated reflex loss
?polyneuritis cranialis?polyneuritis cranialisa/c idiopathic polyneuritisa/c idiopathic polyneuritisPeripheral nerve+cranial nerve Peripheral nerve+cranial nerve
involvementinvolvementSelf limiting painful ophthalmoplegiaSelf limiting painful ophthalmoplegiaCAUSES-TB meningitisCAUSES-TB meningitis osteomyelitis skull osteomyelitis skull otitis mediaotitis media syphilitic meningitissyphilitic meningitis sarcoidosissarcoidosis carcinomatous meningitis carcinomatous meningitis
ANATOMIC PATTERN?ANATOMIC PATTERN?
AXONALAXONAL DEMYELINATINGDEMYELINATING NEURONALNEURONAL
Distal>proximalDistal>proximal
Length Length dependentdependent
Proximal=distalProximal=distal Non length Non length dependentdependent
UE,LE,faceUE,LE,face
Slow evolutionSlow evolution Acute/subacuteAcute/subacute rapidrapid
Dysesthesia&distDysesthesia&distal weaknessal weakness
Paraesthesia&weaParaesthesia&weaknesskness
ataxia,paraesthesataxia,paraesthesiaia
Pain&temp Pain&temp affected>vib,proaffected>vib,proprioceptionprioception
Vibration&propriocVibration&proprioception>pain&tempeption>pain&temp
Vibration&proprioVibration&proprioception>pain&temception>pain&tempp
Distal weaknessDistal weakness Distal & proximal Distal & proximal weaknessweakness
Proprioceptive Proprioceptive weaknessweakness
AXONALAXONAL DEMYELINATINGDEMYELINATING NEURONALNEURONAL
Distal areflexiaDistal areflexia areflexiaareflexia areflexiaareflexia
Amplitude Amplitude affected>velocitaffected>velocityy
Velocity>amplitudVelocity>amplitudee
SensoryamplitudeSensoryamplitudeaffected.affected.
radial>suralradial>sural
Axonal Axonal degeneration&rdegeneration®enerationegeneration
Demyelination&reDemyelination&remyelinationmyelination
Axonal Axonal degeneration,no degeneration,no regenerationregeneration
Slow recoverySlow recovery Rapid recoveryRapid recovery Poor recoveryPoor recovery
AXONALAXONAL DEMYELINATINGDEMYELINATING NEURONALNEURONAL
ToxicToxic GBSGBS Sjogren’sSjogren’s
metabolicmetabolic diphtheriadiphtheria cisplatincisplatin
HIVHIV CIDPCIDP pyridoxinepyridoxine
Diabetes Diabetes mellitusmellitus
Diabetes mellitusDiabetes mellitus
CMTCMT MMNMMN
COURSE OF DISEASECOURSE OF DISEASE1.syndrome of a/c ascending motor paralysis1.syndrome of a/c ascending motor paralysis
a.acute idiopathic polyneuritisa.acute idiopathic polyneuritis
b.IMN with polyneuritisb.IMN with polyneuritis
c.diphtheriac.diphtheria
d.hepatitis with polyneuritisd.hepatitis with polyneuritis
e.porphyriae.porphyria
f.TOCP poisoningf.TOCP poisoning
g.paraneoplasticg.paraneoplastic
h.post vaccinialh.post vaccinial
2.syndome of subacute sensorymotor NP2.syndome of subacute sensorymotor NPA.Deficiency=alcoholic beriberiA.Deficiency=alcoholic beriberi pellagrapellagra vit B12vit B12B.Toxins=arsenic,lead,Hg,PbB.Toxins=arsenic,lead,Hg,PbC.Drugs=nitrofurantoin,INHC.Drugs=nitrofurantoin,INH dapsone,disulfiramdapsone,disulfiram clioquinolclioquinolD.UremicD.UremicE.DM,PAN,sarcoidosisE.DM,PAN,sarcoidosisA,B,C,D====SYMMETRICA,B,C,D====SYMMETRIC
3.C/C sensorimotor polyneuropathy syndrome3.C/C sensorimotor polyneuropathy syndrome
GENETICGENETIC ACQUIREDACQUIRED
Peronealmuscle atrophy/CMTPeronealmuscle atrophy/CMT leprosyleprosy
Dejerine sottas diseaseDejerine sottas disease Diabetes mellitusDiabetes mellitus
Hereditary sensory NPHereditary sensory NP uremiauremia
Portugeseamyloidosis/Portugeseamyloidosis/
andrade’s diseaseandrade’s disease
carcinomacarcinoma
Refsum’s diseaseRefsum’s disease myelomamyeloma
A beta lipoproteinemiaA beta lipoproteinemia paraproteinemiaparaproteinemia
Tangier’s diseaseTangier’s disease amyloidosisamyloidosis
MetachromaticleucodystrophyMetachromaticleucodystrophy
RECURRENT POLYNEUROPATHYRECURRENT POLYNEUROPATHYRelapsing CIDPRelapsing CIDPPorphyriaPorphyriaRefsum’s diseaseRefsum’s diseaseHNPPHNPPGBSGBSBeriberi Beriberi Toxic neuropathyToxic neuropathy
SENSORY ATAXIC NEUROPATHYSENSORY ATAXIC NEUROPATHYSensory NP(polyganglionopathy)Sensory NP(polyganglionopathy)Paraneoplastic sensory NP=sjogren’s Paraneoplastic sensory NP=sjogren’s =idiopathic=idiopathicToxic=cisplatinToxic=cisplatin =vit B6 excess=vit B6 excessDemyelinating polyradiculopathy=MGUSDemyelinating polyradiculopathy=MGUS =Millerfisher=Millerfisher
HOW TO DISTINGUISH HOW TO DISTINGUISH VARIOUS LMN LESIONS?VARIOUS LMN LESIONS?
AHCAHC NeuropatNeuropathyhy
NMJNMJ MyopatMyopathyhy
Fatigue,diurFatigue,diurnalweaknesnalweakness variations variation
---------- ------------ More in More in eveningevening
----------
Distribution Distribution of weaknessof weakness
distaldistal distaldistal ExtraoccExtraoccular,bulbular,bulbarar
Prox Prox exceptexcept
SMASMA
fasciculationfasciculation markedmarked Maybe+veMaybe+ve absentabsent absentabsent
wastingwasting severesevere Can occurCan occur Usually Usually negneg
absentabsent
SensorylossSensoryloss absentabsent Usually+Usually+ absentabsent ++
DTRDTR dec/Nldec/Nl absentabsent normalnormal Nl/decNl/dec
INVESTIGATIONSINVESTIGATIONS
BLOODBLOODTC,DC,ESRTC,DC,ESRUrea,electrolytes,LFTUrea,electrolytes,LFTRBS,HbA1CRBS,HbA1CSerum protein electrophoresisSerum protein electrophoresisAuto Ab=ANA,Antiganglioside,AntineuronalAuto Ab=ANA,Antiganglioside,AntineuronalVit B 12 levelVit B 12 levelDNA analysis=chr 17 duplication-HMSN1&1ADNA analysis=chr 17 duplication-HMSN1&1A =chr 17 deletion -HLPP=chr 17 deletion -HLPP
URINEURINEBJ proteinBJ proteinPorphyrPorphyriaiaHeavy metalsHeavy metalsCSF ANALYSISCSF ANALYSISNERVE CONDUCTION STUDYNERVE CONDUCTION STUDYVariation in axonal,demyelinating neuropathyVariation in axonal,demyelinating neuropathyConduction block-CIDP,GBS,MMNConduction block-CIDP,GBS,MMNEMGEMG-muscle denervation changes-muscle denervation changesSensory thresholdSensory thresholdThermal & vibration thresholdThermal & vibration threshold
IMAGESIMAGESCXR-sarcoidosis,malignancyCXR-sarcoidosis,malignancySkeletal survey-multiple myelomaSkeletal survey-multiple myelomaScreening for malignancyScreening for malignancy
AUTONOMIC FUNCTION TESTSAUTONOMIC FUNCTION TESTS
Diagnostic tests imp inDiagnostic tests imp in Asymmetric,motor Asymmetric,motor
predominant,rapid onset,demyelinating predominant,rapid onset,demyelinating neuropathyneuropathy
NERVE BIOPSY-indicationsNERVE BIOPSY-indicationssural,sup peroneal&sup radialNsural,sup peroneal&sup radialN
VASCULITISVASCULITIS GIANT AXONAL NPthyGIANT AXONAL NPthy
AMYLOIDOSISAMYLOIDOSIS Infantile neuroaxonal Infantile neuroaxonal dystrophydystrophy
SARCOIDOSISSARCOIDOSIS CMT 1&3CMT 1&3
LEPROSYLEPROSY CIDPolyradiculoneuropathyCIDPolyradiculoneuropathy
KRABBE’SKRABBE’S Paraprotein neuropathyParaprotein neuropathy
METACHROMATIC METACHROMATIC LEUKODYSTROPYLEUKODYSTROPY
ETIOLOGICAL CLASSIFICATIONETIOLOGICAL CLASSIFICATION1.1.metabolicmetabolic-DM,amyloidosis,porphyria-DM,amyloidosis,porphyria2.2.infectionsinfections-leprosy,HIV,CMV,syphilis,-leprosy,HIV,CMV,syphilis, diphtheria,lymediseasediphtheria,lymedisease3.3.immuneimmune- GBS,CIDN,MMN- GBS,CIDN,MMN4.4.hereditaryhereditary-CMT-CMT55.Toxic.Toxic-drugs,alcohol,heavymetals-drugs,alcohol,heavymetals6.6.vasculitisvasculitis-PAN,CSS,cryoglobulinemia-PAN,CSS,cryoglobulinemia7.7.paraneoplasticparaneoplastic-lung-lung8.8.nutritionalnutritional- B1,B6,B12- B1,B6,B12
H/O & EXAMINATION
Mononeuropathy
EDx
Axonal/demyeln?
Any systemic disorder
Entrapment/compression
MNPthy multiplex
axonal Demyeln +focal condcn block
Vasculitis/multifocal
Nerve biopsy
CIDP
Paraprotein,HIV,lyme
polyNPthy
axonal
Sub a/c c/c
Toxins/systemic disease family h/o,genetics
demyelination
Uniform slowing,C/C Nonuniform slowing,condnblock
paraprotein
Family h/o,genetics
c/c or suba/c-CIDP a/c-GBS
THANK YOUTHANK YOU