PERIPHERAL NEUROPATHY Flashcards by Deependra Singh

Nerve Fibers Types

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Nerve FIBER SUSCEPTIBILITY
🧠⚡MOST SUSCEPTIBLE: PALAC helps to raise HB ⚡
🧠⚡ POL⚡

Pressure a > b > c
Hypoxia b > c > a
Local Anaesthesia c > b > a

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Ascending TRACTS

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⚡⚡ MOST COMMON CAUSE of MONONEUROPATHY

Carpal Tunnel Syndrome

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CTS in MALE is ASSOCIATED with

Amyloidosis

✨CTS in Female is MORE COMMON

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Causes of CTS
🧠⚡MEDIAN TRAP ⚡

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Site of COMPRESSION of Nerves in MONONEUROPATHY

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Entrapment Neuropathies are seen commonly in
MEDIAN TRAP

Diabetes
Myxedema
Acromegaly
Amyloidosis
Hereditary Neuropathies susceptible to Pressure palsy
Pregnancy
Rheumatoid arthritis

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Multiple MONONEUROPATHIES/ Mononeuritis MULTIPLEX

Involvement of multiple nerves without any organization or association

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⚡⚡ MOST COMMON CAUSE of MONONEURITIS MULTIPLEX

LEPROSY

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Causes of MONONEURITIS MULTIPLEX
🧠⚡WARDS PLC ⚡

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All MONONEUROPATHY and MONONEURITIS MULTIPLEX are AXONAL except
🧠⚡ MAX: MCD⚡

Demyelinating conditions:
✨ Multi focal motor neuropathy with Conduction block MMN-CB

✨ Carpal Tunnel Syndrome

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⚡⚡ MOST COMMON TYPE OF NEUROPATHY

POLYNEUROPATHY

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Cause of Polyneuropathy
🧠⚡DANG THERAPIST ⚡

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LARGE FIBER NEUROPATHY
involves A alpha
➕
A BETA fibers damage

Motor activity affected
Reflexes LOST
Proprioception lost

⭐ Vibration lost
Fine touch Lost

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LARGE FIBER PREDOMINANT NEUROPATHY (A-ALPHA, A-BETA)
synonyms

ATAXIC NEUROPATHIES

Responsible for:
Muscle weakness
Reflex lost
Proprioception
Joint Pain
Fine touch
Vibration

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LARGE FIBER PREDOMINANT NEUROPATHY (A-ALPHA, A-BETA)
🧠⚡PVT Friedrich SC⚡

✨ Pyridoxine toxicity
✨ Vitamin B12 deficiency
✨ Taxanes
✨ Friedrich’s ATAXIA

✨ Sjogren’s SYNDROME
✨ Cisplatin

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SMALL FIBER PREDOMINANT NEUROPATHY (A-DELTA, C type)
Features

SYMMETRICAL
REFLEXES PRESERVED
MOSTLY SENSORY

Pain
Temperature sensation altered
ANS involvement
Reflex Loss MINIMAL

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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

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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

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Stocking and Glove pattern

Glove and Stocking pattern

⭐ Small fiber neuropathy

⭐ Cervical Compressive Myelopathy

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⚡⚡ MOST COMMON which fiber polyneuropathy

SMALL FIBER POLYNEUROPATHY

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Small Fiber Neuropathy is AXONAL or DEMYELINATING

Axonal
Length dependent ➕ Distal to Proximal
Symmetrical
Distal fibers involved

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VASCULITIS USUALLY PRESENT WITH WHICH NEUROPATHY

Polyneuropathy
Except
PAN
Cryoglobulinemia
EGPA

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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⚡

1. GBS 2. PORPHYRIA 3. LEAD 4. DAPSONE 5. MMN with CB 6. DIPHTHERIA 7. 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 ⚡

1. Hereditary Coproporphyria 2. AIP 3. 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