1. Dr. Ahmed Hassan MD internal medicine KSA

2. Systemic diseases may case central and peripheral nervous system disorders The effect of systemic diseases depend on many factors: Duration severity of the diseases receiving treatment or not other comorbidity 3. Nervous System Central nervous system, CNS Brain Spinal cord Meninges: surrounding membranes Neurons (nerve cells) and neuroglia (supporting cells) Sensory or afferent nerve: transmits impulses to the nervous system Motor or efferent nerve: transmits impulses from brain or spinal cord to muscle Transmission of a nerve impulse via neurotransmitters Acetylcholine, norepinephrine, dopamine 4. Brain Cerebrum Cerebellum Brain stem Brain: four cavities called ventricles Tissues of brain and spinal cord Nerve cells = neurons Supporting cells = neuroglia Arterial blood supply Large vessels enter base of skull Vessels join to form arterial circle at base of brain Venous blood From brain into large venous sinuses in dura Sinuses eventually drain into jugular veins 5. Sensory pathway: Posterior columns Axons in the posterior columns whose cell bodies are in the ipsilateral gracile and cuneate nuclei in the medulla carry sensory modalities of vibration, joint position (proprioception), light touch and two-point discrimination. Axons from second-order neurones then cross in the brainstem to form the medial lemniscus, passing to the thalamus. Spinothalamic tracts Axons carrying pain and temperature sensation synapse in the dorsal horn of the cord cross within the cord and pass in the spinothalamic tracts to the thalamus and reticular formation. 6. Types of neuropathies Mononeuropathy Mononeuritis multiplex Polyneuropathy Radiculopathy The neuropathy could be Motor Sensory Axonal and myelin sheath 7. Sensory symptoms : pain pins and needles numbness tingling deadness sensory level: stocking gloves sensory loss Sensory symptoms of special sense (Vision and hearing) 8. Stocking gloves sensory loss usually due to axonal neuropathy: Diabetes mellitus Alcohol Vitamin B12 deficiency Syphilis Human immunodeficiency virus Lyme disease Uremia Chemotherapy Vasculitis Paraneoplastic neuropathy Amyloidosis 9. Predominantly sensory neuropathies diabetes thiamine deficiency and B12 deficiency malignancy leprosy hereditary sensory neuropathies amyloid uraemia sarcoid 10. Predominantly motor neuropathies Guillain-Barre syndrome and CIDP porphyria diphtheria botulism lead Charcot-Marie-Tooth 11. Carpal tunnel syndrome symptoms and signs due to compression of the median nerve. Patients commonly experience pain and paresthesia, and less commonly weakness, in the median nerve distribution. Symptoms provoked by activities CTS is the most frequent compressive focal mononeuropathy seen in clinical practice Nerve conduction studies (NCS) and electromyography (EMG) are a standard part of the evaluation for CTS 12. RISK FACTORS A number of conditions have been associated with CTS, include the following: Obesity Female gender Pregnancy Diabetes Rheumatoid arthritis Hypothyroidism Connective tissue diseases Preexisting median mononeuropathy Genetic predisposition Workplace factors 13. Diabetes Neuropathy Retinopathy symmetrical sensorimotor polyneuropathy autonomic neuropathy polyradiculopathy cranial mononeuropathy amyotrophy focal mononeuropathy 14. Mechanism of neuropathy Course of neuropathy 15. Symptoms include: Polyneuropathy usually develops slowly, with initial sensory disturbances in distal extremities aching or cramping pain and paresthesias Clinical findings in diabetic neuropathy include: absent ankle jerks impaired vibration sense on soles of feet distal motor weakness is less frequent. neuropathic ulcers and joint deformity (Charcot joints) How to differentiate vascular from neuropathic ulcers 16. Diabetic amyotrophy A symmetrical pelvic girdle weakness Hyperthesia Objective sensory loss Muscle wasting EMG finding Treatment by good blood sugar control 17. Renal failure Up to 60% of patient with CRF develops polyneuropathy The risk of Uremic polyneuropathy depend on the severity and duration creatinine clearance falls below 10% of normal It is sensorimotor in nature There is axonal degeneration Restless leg syndrome characterized by burning sensation, crawling and aching sensation in the leg Electrolyte disturbance both dialysis and renal transplantation has a role 18. Electrolyte disturbance Hypocalcaemia Calcium is necessary for neuronal membrane stability hypocalcaemia result in CNS hyper excitability like seizures and mental changes peripheral and cranial nerve irritability like tetany, muscle cramps, spasm and paresthesia Hypercalcemia can cause polyneuropathy circumoral numbness 19. Other endocrinological problems Hypo and hyperthyroidism may have a wide rang of CNS manifestation hypothyroidism associated with peripheral neuropath and carpal tunnel syndrome 20. Connective tissue diseases SLE RA Antiphsopholipid syndrome Polyartritis nodosa 21. SLE Immune mediated multisystem inflammatory disorder Affect joints, skin, renal, pulmonary, cardiovascular CNS affected late in the course of the diseases The pathology is due to vasculitis Sensory manifestation include polyneuropathy, mononeuritis multiplex and myopathy Usually asymmetrical other CNS manifestation include : mental changes, seizures, stroke, cranial nerve envelopment, myopathy, fatigue, spinal cord involvement, depression, aseptic meningitis. 22. Rheumatoid arthritis Disease characterized by morning stiffness, symmetrical polyarthritis, and subcutaneous nodule. The predominant neurological complication is atlantoaxial subluxation involving C1 and C2 Cervical myleopathy Peripheral neuropathy Carpal tunnel syndrome , ulnar neuropathy and tarsal tunnel syndrome 23. Polyarteritis nodosa Vasculitis affecting the medium and small vessels The arteritis leads to thrombosis, ischemia and infraction. CNS manifestation include stroke, mononeuritis multiplex, peripheral neuropathy and myopathy. Treatment by steroids and cyclophosphamide 24. Antiphospholipide syndrome Neurological manifestation Stroke Epilepsy Psychosis Chorea and hemiballismus Transverse myelopathy Sensorineural hearing loss Orthostatic hypotension Migraine 25. Vitamin B12 deficiency caused by lack of 1-loss of intrinsic factor in the parietal cells 2- malabsorption Causes of malabsorption include Crohns disease Whipples disease Tuberculosis Tropical sprue Surgical resection of the distal ileum Sub acute combined degeneration of the cord 26. Neurological symptoms include: numbness and paresthesias sensory loss particularly to proprioception and vibration ataxia increased reflexes often with hyporeflexia or areflexia of the ankle jerk Behavioral and cognitive dysfunction like depression and irritability memory impairment to dementia. Optic atrophy can occur but is rare 27. Amyloid neuropathy: symmetrical sensorimotor carpal tunnel syndrome 28. Polyneuropathy due to infectious diseases Leprosy HIV Lyme disease Herpes zoster 29. Leprosy Leprosy, a mycobacterial infectious disease of peripheral nerves Sensory loss is the cardinal symptom of leprosy Specially over the external ears, the zygomatic arches, and extensor surfaces of joints. Involvement of cutaneous nerves is generally sharply demarcated, especially in the tuberculoid form of leprosy The overlying dermis and epidermis are affected, producing the classic anesthetic macule The diagnosis by? Treatment ? 30. HIV Distal, painful neuropathy is very common in patients with AIDS continuous burning discomfort, mostly in the feet, whit some degree of sensory loss Motor involvement is usually minor Sensory polyneuropathy of late-stage HIV infection must be distinguished from toxic polyneuropathy that may result from the use of nucleoside analogue treatment Some antiretroviral can cause neuropathy 31. Neurological manifestation of malabsorption headache peripheral neuropathy ataxia, depression Dysthymia anxiety Epilepsy Peripheral neuropathies, characterized by burning, tingling, and numbness in hands and feet 32. Diagnosis Nerve conduction studies Electromyography Nerve biopsy Establish diagnosis of polyneuropathy Distinguish demyelinating from axonal Differentiate radiculopathy, plexopathy Normal in small fiber and autonomic neuropathy 33. Hematology: complete blood count erythrocyte sedimentation rate C-reactive protein vitamin B12, folate, Methylmalonic acid, homocysteine 34. Biochemical and endocrine: comprehensive metabolic panel (fasting glucose) thyroid function tests serum immunofixation. glucose tolerance test if indicated Urine: urinalysis urine immunofixation. Drugs and toxins 35. Connective tissue diseases and vasculitis: antinuclear antigen profile rheumatoid factor anti-Ro/SSA, anti-La/SSB, antineutrophil cytoplasmic antigen antibody (ANCA) profile cryoglobulins. 36. Malignancies: skeletal radiographic survey mammography computed tomography or magnetic resonance imaging of chest, abdomen, and pelvis ultrasound of abdomen and pelvis positron emission tomography cerebrospinal fluid analysis including cytology serum paraneoplastic antibody profile 37. Infectious agents: Campylobacter jejuni Cytomegalovirus hepatitis panel (B and C) HIV Lyme disease herpes viruses West Nile virus cerebrospinal fluid analysis. 38. Treatment of sensory symptoms Treat any underlying condition or cause for your peripheral neuropathy. Control any symptoms that you may have.