PERIPHERAL NEUROPATHY Flashcards
Nerve Fibers Types
Nerve FIBER SUSCEPTIBILITY
🧠⚡MOST SUSCEPTIBLE: PALAC helps to raise HB ⚡
🧠⚡ POL⚡
Pressure a > b > c
Hypoxia b > c > a
Local Anaesthesia c > b > a
Ascending TRACTS
⚡⚡ MOST COMMON CAUSE of MONONEUROPATHY
Carpal Tunnel Syndrome
CTS in MALE is ASSOCIATED with
Amyloidosis
✨CTS in Female is MORE COMMON
Causes of CTS
🧠⚡MEDIAN TRAP ⚡
Site of COMPRESSION of Nerves in MONONEUROPATHY
Entrapment Neuropathies are seen commonly in
MEDIAN TRAP
Diabetes
Myxedema
Acromegaly
Amyloidosis
Hereditary Neuropathies susceptible to Pressure palsy
Pregnancy
Rheumatoid arthritis
Multiple MONONEUROPATHIES/ Mononeuritis MULTIPLEX
Involvement of multiple nerves without any organization or association
⚡⚡ MOST COMMON CAUSE of MONONEURITIS MULTIPLEX
LEPROSY
Causes of MONONEURITIS MULTIPLEX
🧠⚡WARDS PLC ⚡
All MONONEUROPATHY and MONONEURITIS MULTIPLEX are AXONAL except
🧠⚡ MAX: MCD⚡
Demyelinating conditions:
✨ Multi focal motor neuropathy with Conduction block MMN-CB
✨ Carpal Tunnel Syndrome
⚡⚡ MOST COMMON TYPE OF NEUROPATHY
POLYNEUROPATHY
Cause of Polyneuropathy
🧠⚡DANG THERAPIST ⚡
LARGE FIBER NEUROPATHY
involves A alpha
➕
A BETA fibers damage
Motor activity affected
Reflexes LOST
Proprioception lost
⭐ Vibration lost
Fine touch Lost
LARGE FIBER PREDOMINANT NEUROPATHY (A-ALPHA, A-BETA)
synonyms
ATAXIC NEUROPATHIES
Responsible for:
Muscle weakness
Reflex lost
Proprioception
Joint Pain
Fine touch
Vibration
LARGE FIBER PREDOMINANT NEUROPATHY (A-ALPHA, A-BETA)
🧠⚡PVT Friedrich SC⚡
✨ Pyridoxine toxicity
✨ Vitamin B12 deficiency
✨ Taxanes
✨ Friedrich’s ATAXIA
✨ Sjogren’s SYNDROME
✨ Cisplatin
SMALL FIBER PREDOMINANT NEUROPATHY (A-DELTA, C type)
Features
SYMMETRICAL
REFLEXES PRESERVED
MOSTLY SENSORY
Pain
Temperature sensation altered
ANS involvement
Reflex Loss MINIMAL
LARGE FIBER PREDOMINANT NEUROPATHY (A-ALPHA, A-BETA)
✨ Positive Symptoms
✨ Negative Symptoms
⭐ positive
Tingling and COTTON wool like sensation
Paresthesia
Dysasthesia
⭐ NEGATIVE
-Numbness
-Sensory Ataxia
-Romberg’s sign / Washbasin phenomenon / Pseudoathetosis
SMALL FIBER PREDOMINANT NEUROPATHY (A-DELTA, C)
Positive features
Positive Symptoms
✨ Burning PAIN : Stocking and Glove pattern
✨ ANS Manifestation
-erectile dysfunctions
-postural Hypotension
-Tachy-Brady syndromes
-sweating
-nocturnal diarrhea
-gustatory sweating
NEGATIVE SYMPTOMS
✨ BURNS
✨ Non Healing ulcer
✨ Charcot Joints
Stocking and Glove pattern
Glove and Stocking pattern
⭐ Small fiber neuropathy
⭐ Cervical Compressive Myelopathy
⚡⚡ MOST COMMON which fiber polyneuropathy
SMALL FIBER POLYNEUROPATHY
Small Fiber Neuropathy is AXONAL or DEMYELINATING
Axonal
Length dependent ➕ Distal to Proximal
Symmetrical
Distal fibers involved
VASCULITIS USUALLY PRESENT WITH WHICH NEUROPATHY
Polyneuropathy
Except
PAN
Cryoglobulinemia
EGPA
VASCULITIS presenting with MONONEURITIS MULTIPLEX
🧠⚡PCC ⚡
⭐ PAN
✨ Churg Strauss SYNDROME (EGPA)
✨ Cryoglobulinemia
Middle Molecules
Molecules that are larger than pore size
They remain in the body even after dialysis
-Uremic Toxins : Causes NEUROPATHY in UREMIA
-AB2 microglobulin : causes DIALYSIS associated AMYLOIDOSIS
Causes of SMALL FIBER NEUROPATHY
🧠⚡FADU VALTS H² ⚡
Fabry’s disease
Amyloidosis
Diabetes (⚡⚡ MOST COMMON)
Uremia
✨ VASCULITIS (except PAN)
A ✨ Idiopathic Pandysautonomias
✨ Leprosy
✨ Tangier’s disease
✨ Sjogren’s syndrome
✨ HIV
✨ Hereditary sensory and autonomic neuropathy
⚡⚡ MOST COMMON presentation of LEPRSOSY
⚡⚡MOST COMMON CAUSE of MONONEURITIS MULTIPLEX
⭐ SMALL FIBRE POLYNEUROPATHY
⭐ LEPROSY
⚡⚡ MOST COMMON NEUROLOGICAL PRESENTATION IN HIV
Small fiber Polyneuropathy
POSTEROLATERAL CORD SYNDROME
✨ Vitamin B12 DEFICIENCY
✨ Vitamin E deficiency
✨ COPPER deficiency
Extensor PLANTAR (UMN Feature)
➕
LARGE FIBER NEUROPATHY(LMN Feature)
(LOSS OF REFLEXES)
PAIN PREDOMINANT SMALL FIBER NEUROPATHY
🧠⚡ Fab! Hd TV⚡
⭐ Fabry’s Disease
Others
⭐ TANGIER’S disease
⭐ HIV
⭐ VASCULITIS
All Neuropathy caused by drugs are AXONAL except:
🧠⚡ DAXO⚡
🧠⚡CAGe : causes DEMYELINATING NEUROPATHY ⚡
Chloroquine
Amiodarone
Gold
Combined SMALL and LARGE FIBER NEUROPATHY
🧠⚡ CHVT (CHUTiya)⚡
✨ Carcinomatous sensory NEUROPATHY
✨ Hereditary Sensory Motor NEUROPATHY
✨ VINCRISTINE
✨ TAXANES
NEUROPATHY classification
Based on structure involved
⭐ AXONAL NEUROPATHY
⭐ DEMYELINATING NEUROPATHY
PURE HEREDITARY DEMYELINATING CONDITION
🧠⚡when it gets DE-Myelinated, it soon Re-Forms ⚡
Refsum’s Disease
Charcot Marie Tooth Disease shows which type of NEUROPATHY
Axonal
and
DEMYELINATING
RELAPSING NEUROPATHIES
🧠⚡CRP ⚡
⭐ DEMYELINATING:
CIDP
REFSUM’S DISEASE
⭐ AXONAL
PORPHYRIA
Only ACUTE NEUROPATHY which is AXONAL
⚡AXONAL are usually CHRONIC⚡
Porphyria
⭐ All CHRONIC NEUROPATHIES ARE AXONAL except
(OR)
⭐ CHRONIC NEUROPATHY THAT IS DEMYELINATING
🧠⚡ CND is CID⚡
Demyelinating Neuropathy
CIDP ➡️ 2° CAUSES : POEMS, Multiple Myeloma, MGUS
PURE SENSORY NEUROPATHY
GANGLIONOPATHY
MOTOR PREDOMINANT NEUROPATHY
🧠⚡Acute DEMYELINATING conditions are MOTOR PREDOMINANT ⚡
🧠⚡ Acute AXONAL conditions are MOTOR⚡
- GBS
- PORPHYRIA
- LEAD
- DAPSONE
- MMN with CB
- DIPHTHERIA
- DIABETIC AMYOTROPHY
PURE MOTOR NEUROPATHY
🧠⚡ LDM⚡
Lead
Dapsone
MMN with Conduction Block
(Multi focal motor neuron disease)
AUTONOMIC PREDOMINANT NEUROPATHY
🧠⚡Small fiber ➡️ sympathetic fibers ➡️ AXONAL(Small fibers involved) ⚡
✨ DIABETES
✨ AMYLOID
✨ PORPHYRIA
✨ VINCRISTINE (combined small and Large fiber)
✨ FABRY’S
✨ HIV
7 IMPORTANT QUESTIONS
Axonal NEUROPATHY
CS²D
⚡⚡ MOST COMMON CAUSE?
Diabetes MELLITUS
✨ CHRONIC ( > 2months)
✨ SENSORY PREDOMINANT
✨ SMALL FIBER NEUROPATHY
✨ DISTAL > PROXIMAL weakness
✨ REFLEXES ➕
✨ Muscle WASTING ➕
Which reflex is not preserved in AXONAL NEUROPATHY
Ankle JERK
DEMYLINATION NEUROPATHY
⚡⚡ MOST COMMON CAUSE
🧠⚡Gand me PD - DALA ⚡
⭐GBS: Acute Inflammatory Demyelinating Polyneuropathy
✨ Acute onset ( < 1month)
✨ LARGE FIBER
✨ MOTOR ➕ SENSORY
✨ PROXIMAL ➕ DISTAL weakness
✨ AREFLEXIA
✨ NO WASTING
Axonal vs Demyelinating
Causes of ACUTE DEMYELINATING NEUROPATHY
MYELINOPATHIES
⭐ AIDP
⭐ DIPTHERIA
⭐ AMIODARONE
⭐ CHLOROQUINE
⭐ GOLD
Causes of Chronic DEMYELINATING NEUROPATHY
MYELINOPATHIES
✨ CIDP ➡️ POEMS, Myeloma, MGUS
✨ HIV
Causes of Inherited DEMYELINATING NEUROPATHY
MYELINOPATHIES
🧠⚡CRL ⚡
✨ Charcot Marie Tooth Disease
✨ Refsum’s Disease
✨ Leukodystrophies
Word SUBSTITUTION in NEUROPATHY
-Symmetrical 🧠N-M
-Asymmetrical 🧠 GRP
-Proximal weakness
-Distal weakness 🧠 DAR
-Proximal ➕ Distal 🧠 Plus means aDD
-Pure Motor 🧠ANM
-Pure Sensory
-Sensorimotor 🧠 GRP N
-Symmetrical: NEUROPATHY
-Asymmetrical : Ganglionopathy, Radiculopathy, Plexopathy
-Proximal weakness :
-Distal weakness : AXONAL/Small fiber, RADICULOPATHY
-Proximal ➕ Distal: DEMYELINATING/Large Fiber
-Pure Motor: Anterior Horn Cell, NMJ, Muscle disorder
-Pure Sensory: Ganglionopathy
-Sensorimotor : Radiculopathy, Plexopathy, Neuropathy
Electro diagnostic features of AXONAL vs DEMYELINATING
🧠⚡FAT C²D ⚡
🧠⚡Amplitude is ⬇️ ⬇️ in A ⚡
Fasiculation, fibrillation ➕ in AXONAL DEGENERATIOM
Diseases ASSOCIATED with CIDP
🧠⚡SIP A HDL ⚡
NERVE CONDUCTION STUDIES
Electrodes
🧠⚡you can only MAP anything if you are in the central part of it ⚡
🧠⚡if you are at the periphery, you can only take a SNAP! ⚡
G1 : On MUSCLE BELLY ➡️ CMAP
Compound Motor Action Potential
G2 : On TENDON ➡️ SNAP
Sensory Axonal Action Potentials
INHERITED NEUROPATHIES
🧠⚡PeRFeCT ⚡
➕ HEREDITARY SENSORY AND AUTONOMIC NEUROPATHIES
💡🪔CLINICAL POINTER🪔
SEVERE SENSORY INVOLVEMENT ON NCS
➕
NO SENSORY SYMPTOMS FELT BY PATIENT
➕
LONG DURATION OF MOTOR Symptoms
20-30yrs
Charcot Marie Tooth Disease
Peripheral Nerve Fiber Thickening
➕
PES CAVUS
➕
HAMMER TOE
➕
SCOLIOSIS
Charcot Marie Tooth Disease
PROXIMAL WEAKNESS
⭐ PORPHYRIA
⭐
DISTAL WEAKNESS
DARC
⭐ Axonal NEUROPATHY / Small Fiber NEUROPATHY
⭐ Charcot Marie Tooth Disease
PROXIMAL ➕ DISTAL weakness
🧠⚡ Plus means aDD⚡
⭐ PLEXOPATHY
⭐ DEMYELINATING NEUROPATHY
Patterns of Charcot Marie Tooth Disease
HMSN Motor Sensory
HSAN Sensory Autonomic
Types of Charcot Marie Tooth Disease
🧬 MODE OF INHERITENCE 💉
🧠⚡ Start as DOMINANT, later becomes RECESSIVE⚡
Type
1 AD
2 AD
3 AD/AR
4 AR
⚡⚡ MOST COMMON type of Charcot Marie Tooth Disease
Type 1
AD
DEMYLINATION NEUROPATHY
Which CMT is ASSOCIATED with ONION BULB FORMATION IN NERVE BIOPSY
Type 1 CMT
AXONAL DEGENERATION TYPE OF CHARCOT MARIE TOOTH DISEASE
Type 2 CMT
Dejerine Sottas Syndrome
Synonyms
CONGENITAL HYPOMYELINATING NEUROPATHY
TYPE 3 CMT
Inverted CHAMPAGNE LEG appearance seen in
Charcot Marie Tooth disease
DUE TO: Distal > Proximal
Ankle JERK ABSENT
➕
UPPER LIMB REFLEXES NORMAL or Decreased
Motor weakness in CMT
Upper limb INVOLVEMENT in CMT in which decade
2nd to 3rd Decade
In NCS,
UNIFORM SLOWING
PATCHY SLOWING
🧠⚡ pAtCh⚡
⭐ HEREDITARY NEUROPATHY
⭐ ACQUIRED NEUROPATHY
Familial AMYLOID POLYNEUROPATHY
🧠⚡ A for A⚡
Axonal > > DEMYELINATING
Numbness ➕ Painful Paresthesia
➕
Severe ANS SYMPTOMS
➕
AXONAL Symptoms
FAP
PORPHYRIA that cause NEUROPATHY
🧠⚡HAV ⚡
- Hereditary Coproporphyria
- AIP
- Variegate Porphyria
⚡⚡ MOST COMMON PORPHYRIA associated WITH NEUROPATHY
Acute INTERMITTENT PORPHYRIA
5Ps of AIP
Tangier Disease
⭐ Gene Defect
⭐ Inheritance
⭐ ABCA1 gene
⭐ AR
🧑🏻⚕️ Clinical Features of TANGIER Disease
⭐ CHOLESTEROL accumulation in MACROPHAGES (esp. TONSILS)
⭐ Hepatospleenomegaly
⭐ Sensory POLYNEUROPATHY
⭐ Premature ASCVD (AtheroSclerotic Cardiovascular Disease)
NERVE FIBER THICKENING
🧠⚡ LA²ND²S RC⚡
Leprosy
Amyloidosis
Acromegaly
Neurofibromatosis
Diabetes
Dejerine Sottas disease
Sarcoidosis
IDIOPATHIC
Refsum’s disease
Relapsing GBS
CIDP
Charcot-Marie Tooth Disease
Plexiform Neurofibromas
Prophylactic drug given to patient of ATT Isoniazid therapy
Pyridoxine 10mg/day to prevent NEUROPATHY
1st LINE DRUGS in Treatment of painful sensory neuropathies
🧠⚡DLGT ⚡
First-line:
⭐ Lidoderm 5% patch
⭐ Tricyclic antidepressants (e.g., amitriptyline, nortriptyline)
⭐ Gabapentin, Pregabalin
⭐ Duloxetine
2nd LINE DRUGS for PAINFUL NEUROPATHY
🧠⚡C-PVT doctor ⚡
Second-line:
⭐ Carbamazepine
⭐ Phenytoin
⭐ Venlafaxine
⭐ Tramadol
3rd LINE DRUGS for PAINFUL NEUROPATHY
🧠⚡MIX drug ⚡
Third-line:
Mexiletine
Role of GLUCOSE CONTROL in Diabetic NEUROPATHY
Prevents development of NEUROPATHY
Score used to Assess DIABETIC NEUROPATHY
Michigan Diabetic NEUROPATHY Score
Cranial Neuropathy in DIABETES
⚡⚡ MOST COMMON nerve involved is OCCULOMOTOR NERVE
Motor neuropathy with symmetrical weakness
⭐️ SPINAL MUSCLE ATRROPHY
⭐️ HEREDITARY MOTOR NEUROPATHY (Atypical Charcot Marie Tooth Disease)(Distal spinal muscle atrophy)
Symmetrical + Distal weakness)with Sensory Loss
Acute Immune Demyelinating Polyneuropathy
ACUTE Form: GBS (AIDP)
CHRONIC form: CIDP
⭐ HSAN
⭐ HMSN
⭐ HSAN: Hereditary Sensory Autonomic NEUROPATHY Type 1-5
⭐ HMSN: Hereditary Motor Sensory NEUROPATHY aka CHARCOT MARIE TOOTH DISEASE
Burning FOOT SYNDROME
⭐ Vitamin B5 Deficiency
⭐ HSAN 1
Burning Sensation of Feet, Specially at NIGHT
➕
Sensory Loss
➕
Foot Ulcers
HSAN 1
HSAN 1
🧬 MODE OF INHERITENCE 💉
Age group
AD
⭐ Adolescent or Adulthood
Riley Day Syndrome
HSAN 3
Child with LABILE BP
➕
Decreased TEARING
➕
HYPERHIDROSIS
➕
REDUCED SENSTIVITY TO PAIN
➕
AREFLEXIQ
Riley Day Syndrome
Even after Multiple myeloma treatment
Polyneuropathy does not resolve