Neuropathy final
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AN APPROACH TO NEUROPATHY
Dr Bhupendra ShahAsssistant ProfessorB.P.koirala institute of health sciences
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WHAT WE WILL DISCUSS?
• DEFINITION
• TYPES OF NEUROPATHY
• HISTORY AND EXAMINATION
• APPROACH
• INVESTIGATIONS
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DEFINITION
• Functional disturbance or pathological change in peripheral nervous system
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Prevalence 2-8%- 1/3rd genetic- 1/3rd acquired
- 1/3rd idiopathic
Diabetes mellitus
Inherited
Infection&
Immune
Alcohol
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TYPES OF NERVE FIBERS(Erlanger/Gasser classification)
alpha beta gamma delta
A fibers
B fibers
C fibers
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CLASSIFICATION OF PERIPHERAL NEUROPATHIES
Peripheral neuropathies
Axonopathies
Large and small fiber
Small fiber
Myelinopathies
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IS THIS PERIPHERAL NEUROPATHY ?
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TYPES OF NEUROPATHIES
Generalised
Multifocal
Focal
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TYPES OF NEUROPATHIES
Focal • Entrapment Neuropathies
Multifocal• Diabetes Mellitus• Vasculitis• SLE, PAN• HIVMeralgia paresthetica
MyxedemaRheumatoid Amyloid AcromegalyHansen’s Disease
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TYPES OF NEUROPATHIESMOTOR
• GBS and CIDP
• Diphtheria and Botulism
AUTONOMIC
• Alcoholism
• Amyloidosis and DM
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TYPES OF NEUROPATHIES
SENSORY
Small fiberLeprosyDM
Large fiberParaneoplasticCisplatin and other chemotherapeutics
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TYPES OF NEUROPATHIES
AXONAL• Insidious• Glove and stocking pattern• Preservation of all DTRs
except ankle jerk• Recovery in months to years• More Residual deformity• e.g- Vasculitis, Toxins,
Metabolic
DEMYELINATING• Generally Acute• Minimal sensory loss• Loss of all DTRs• Rapid recovery• Residual deformity minimal• e.g- GBS, CIDP
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HISTORY
• Ethnicity and globalisation• Dietary History• Family History• Drug History(including abused drugs)• Concurrent systemic Illness• Toxins exposure• Behavioural related(HIV, Hepatitis C, Nutritional)• Vaccination history
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CLINICAL PROFILE
How patient presents in our setup?झम्झम गर्छ�लाटो हुन्र्छहात खुट्टा पोल्र्छलुलो भयो झत्का लाग्र्छ चप्पल फुस्कि�कन्र्छबसेर उथ्न गाह& हुन्र्छ
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APPROACH TO NEUROPATHY
Sensory Motor Autonomic Combinations
Global Distribution
Distribution along nerves
WHAT?
WHERE?
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APPROACH TO NEUROPATHY
Acute Sub-acute Chronic
WHEN
WHAT SETTING?
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PHYSICAL EXAMINATION
• 1st step
• PNS vs CNS
• CNS- speech, diplopia, ataxia, CN involvement/ myelopathy bowel,bladder involvement
• Single or multiple nerve root or peripheral nerve plexus
• PNS- peripheral nerve roots vs plexus
• Fundoscopy optic pallor - leukodystrophies and vitamin B12 deficiency
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PHYSICAL EXAMINATION • Motor examination -fasciculations or cramps, or loss of muscle bulk
• Tone normal or reduced
• Deep tendon reflexes reduced or absent.
• Bilateral foot drop steppage gait
• Proximal weakness inability to squat or to rise unassisted from a chair
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PHYSICAL EXAMINATION
• Orthostatic hypotension Autonomic fibers involvement
• Respiratory rate and vital capacity GBS
• Lymphadenopathy, hepatomegaly or splenomegaly, and skin lesions Systemic disease
• Mees' lines Arsenic poisoning
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HOW TO TEST ?
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ELECTRODIAGNOSTIC TEST• Cofirmation of presence
of neuropathy
• Small or large fiber involved
• Motor, Sensory or mixed
• Axonal Vs Demyelination
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ELECTRODIAGNOSTIC TEST
• Velocity of conduction• Distal latency• Conduction block• Temporal dispersion• F wave latency
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NERVE BIOPSY
• If diagnosis is in doubt even after lab and electrodiagnostic findings
• Vasculitis, Amyloid neuropathy, Leprosy, CIDP, Inherited disorders of myelin
• Sural nerve M/C
• Superficial peroneal nerve – alternative; allows simultaneous biopsy of the peroneus brevis muscle
• Combined nerve and muscle biopsy Vasculitis
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MOSQUITO VERSUS
ZEBRA
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LEPROSY
• Tendon reflex – Preserved
• No autonomic neuropathy
LepromatousWidespread invasion of cutaneous nerve
Tuberculoid Patch of superficial sensory loss
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VITAMIN B12 DEFICIENCY
• Spinal cord, Brain, Optic nerve and Peripheral nerves all affected
• Sub-acute Combined degeneration of cord
• Visual impairment Optic neuropathy
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DIABETES MELLITUSDiabetic
Ophthalmoplegia
Acute Diabetic
Mononeuropathy
Thoracoabdominal
Radiculopathy
Distal Polyneuropa
thy
Multiple Mononeuropathy and
Radiculopathy
Autonomic Neuropathy
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HYPOTHYROIDISM
Neurological endemic cretinism Proximal limb and truncal rigid-spastic motor disorder
Myxedematous No spastic rigidity Loss of reflexes,loss of vibration, position and touch
Sporadic Delayed tendon reflexes
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ALCOHOLISM
•More common in our settings•Slow and insidious progression
•Distal and symmetrical involvement•Positive sensory symptoms
•Autonomic neuropathy coexistent•Multi-factorial damage
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THANK YOU