Download - Acute Peripheral Neurological Lesions
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Acute Peripheral Neurological Lesions
George Filiadis, D. O.
November 17, 2005
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Peripheral Nervous System
• Serves sensory, motor, and autonomic functions• Sensory symptoms-numbness, tingling,
dysesthesias, pain, and ataxia, due to proprioceptive dysfunction
• Motor symptoms-weakness• Autonomic symptoms-orthostatic symptoms,
bowel or bladder dysfunction, gastroparesis, and sexual dysfunction.
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Peripheral Nervous System
• In peripheral nerve process there is reduction or absence of reflexes.
• When the sensory component is involved, test for proprioception, vibratory sensation, and pain and temperature sensibility
• When the motor system is involved there is wasting, fasciculations, and weakness.
• Autonomic dysfunctions may cause anhidrosis, pupillary dysfunction, orthostatic hypotension, and tachy- and bradyarrhythmias.
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Localization of neurological disease
• See Figure 233-1• Most muscle-related processes result in weakness of
large proximal muscles along as pain, tenderness, and elevation of CK.
• Diseases that affect other components of the peripheral nervous system seldom cause tenderness and elevation of CK.
• Neuromuscular junction processes can affect large proximal muscles and affect bulbar musculature resulting in pupillary dysfunction, diplopia, dysarthria, or dysphagia.
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Myopathies
• Polyomyositis-Inflammatory myopathy-chronic complaints of proximal symmetric weakness-may have muscle pain and tenderness-may have dysphagia and few progress to respiratory failure-no sensory loss, reflexes should be intact
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Polyomyositis
• Management-should be assessed for potential respiratory compromise and aspiration risk.-long term treatment-immunosuppressive
agents such as steroids and methotrexate• Differential diagnosis includes Lambert-Eaton
myasthenic syndrome, inclusion body myositis, toxic myopathies, and dermatomyositis.
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Myopathies
• Dermatomyositis-Can affect children-similar to polyomyositis except for violaceous rash over face and hands-muscle weakness-no sensory or reflex abnormalities-treatment is immunosuppression-elevated sed rate and CPK
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Other Myopathies
• Drug induced –see table 233-1
• Viral myositis causes an acute myopathy involving the heart, associated with febrile illness, myalgia, and elevated CK levels.
• Suspect trichinosis in pt with myalgias, proximal and bulbar muscle weakness, facial edema, and eosinophilia.
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Disorders of the Neuromuscular junction- Botulism
• Ingestion of food contaminated with Clostridium botulinum.
• Adults often report exposure to home canned foods
• Infants exposure to honey• Bulbar weakness• Exraoccular movements are sometimes
abnormal
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Botulinism
• Absence of pupillary light reflex
• Proximal limb weakness
• Sensation is intact, normal mentation, reflexes are usually normal
• Treatment-antibiotics in infants and immune serum and admission to the hospital
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Guillain-Bare Syndrome
• Most common form of acute generalizedneuropathy
• Patients often report recent viral illness, especially gastroenteritis
• Associated with Campylobacter jejuni
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Guillain-Barre Syndrome
• Numbness and tingling of the lower extremities followed by weakness of the legs and then arms.
• Weakness more pronounced in the legs• Lack of deep tendon reflexes• May be facial weakness involving the forehead• Chance of respiratory failure and lethal autonomic
fluctuations
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Guillain-Barre Syndrome
• Management-Lumbar puncture (high CSF protein,
nl cell count and glucose)-Should be admitted for monitoring-When vital capacity is under 1 liter, intubate.-Plasma exchange or IV immunoglobulin
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Focal neuropathies-Carpal Tunnel Syndrome
• Most commonly see entrapment neuropathy.
• Intermittent pain and/or numbness in the thumb and first two fingers.
• Symptoms reproduced with compression of the nerve over the carpal tunnel or by tapping over the nerve.
• Treatment-wrist splints and ortho referral
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Focal neuropathies
• Ulnar neuropathy-Numbness of the fourth and fifth fingers
-weakness and wasting of hypothenar eminence is late finding
• Entrapment of deep peroneal nerve-at the fibular head causing foot drop
and numbness of the web between great and second toe
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Focal Neuropathies
• Meralgia paresthetica-entrapment of lateral femoral
cutaneous nerve of the thigh.-numbness and
dysesthesias on lateral aspect of upper leg. -usually after weight loss or pelvic procedures
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Focal neuropathies
• Mononeuritis multiplex-multiple nerve dysfunctions
caused by vasculitis-usually affects both
sides of the body -differential diagnosis includes multiple compression neuropathies and multifocal motor neuropathy
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Focal Neuropathies-Bell’s Palsy
• Most common cause of acute facial paralysis
• Sudden facial weakness, difficulty with articulation, problems keeping an eye closed, or inability to keep food in the mouth one side.
• One sided weakness of the face involving the forehead
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Bell’s Pulsy
• Treatment-acyclovir
-Steroid controversial-Eye care to avoid corneal
abrasions -lacrilube and patching
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Focal neuropathies-Lyme disease
• Multiple neurologic manifestations
• Arthralgias and fatique initially
• Common neurologic sign is seventh nerve pulsy
• Weakness in the limbs
• May see selected decreased deep tendon reflexes
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Lyme Disease
• Management-serum and CSF lyme antibodies
-CSF pleocytosis and increased protein with a normal glucose -treat with 3 week course of IV antibiotics either rocephin or doxycycline
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Plexopathies-Brachial Neuritis
• Affects younger individuals• Excruciating back, shoulder, or arm pain
followed by weakness of arm or shoulder girdle.
• On exam there is weakness along the distribution of brachial plexus.
• Differential diagnosis includes cervical radiculopathies, Pancoast tumor
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Plexopathies-lumbar
• Occurs in diabetic patients
• Presents with back pain followed by weakness.
• Sensory findings are absent
• Deep tendon reflexes are diminished on the affected side.
• Bowel and bladder function are not affected
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HIV-Associated Peripheral Neurologic Disease
• CMV radiculitis-may be seen in the latter stages of AIDS-Acutely weak-Primarily lower extremity involvement-Varying degrees of bowel and bladder dysfunction-Hyporeflexia and decreased sensation-Rectal tone may be impaired
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CMV Radiculitis
• Management-lumbar puncture reveals pleocytosis and increased protein-MRI of lumbarosacral spine demonstrates swelling and clumping
of cauda equina-IV gancyclovir started at 5mg/kg q 12
h X 14 d
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Questions
• Which of the following includes bulbar muscle weakness, absent pupillary reflex, and proximal muscle weakness
a. polyomyositisb. botulism
c. Guillain-Barred. Lyme disease
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Questions
• All of the following are associated with Lyme disease except
a. Tick Exposure b. Seventh nerve pulsy
c. Arthralgias and fatigued. abnormal mentantion
e. treatment with rocephin or doxycycline.
Answers: b, f, t, d
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Questions
• In Guillain-Barre Syndrome, deep tendon reflexes are intact T/F
• Myalgias, proximal and bulbar muscle weakness, facial edema and eosinophilia are associated with Trichinosis T/F