Transcript Acute Peripheral Neurologic Lesions

Acute Peripheral Neurological
Lesions
George Filiadis, D. O.
November 17, 2005
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.
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.
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.
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
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.
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
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.
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
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
Guillain-Bare Syndrome
• Most common form of acute generalized
neuropathy
• Patients often report recent viral illness,
especially gastroenteritis
• Associated with Campylobacter jejuni
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
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
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
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
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
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
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
Bell’s Pulsy
• Treatment
-acyclovir
-Steroid controversial
-Eye care to avoid corneal abrasions
-lacrilube and patching
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
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
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
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
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
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
Questions
• Which of the following includes bulbar
muscle weakness, absent pupillary reflex,
and proximal muscle weakness
a. polyomyositis
b. botulism
c. Guillain-Barre
d. Lyme disease
Questions
• All of the following are associated with Lyme
disease except
a. Tick Exposure
b. Seventh nerve pulsy
c. Arthralgias and fatigue
d. abnormal mentantion
e. treatment with rocephin or
doxycycline.
Answers: b, f, t, d
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