“Approach to Peripheral Neuropathy” Joseph S. Lubeck, D.O.

Peripheral Neuropathy JOSEPH LUBECK, DO

Case Study oA 55 YO overweight man presents with numbness and burning in both feet. It began 6 months ago in his toes and has ascended to the midfoot. It is worse at night, less troublesome when weight bearing oPMH – hypertension, hyperlipidemia oMeds – Lisinopril, Atorvastatin, ASA oExam o feet warm, good pulses o Mild loss of pinprick in the toes, feels a fully percussed tuning fork for 12s in each foot o All reflexes present

POMA 108th Annual Clinical Assembly May 4-7, 2016

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“Approach to Peripheral Neuropathy” Joseph S. Lubeck, D.O.

Case Study •What could it be? •What diagnostic studies are necessary? •What can we do for him?

Question #1 The most common cause of neuropathy worldwide is: ◦ ◦ ◦ ◦ ◦

A. Alcoholism B. Nutritional deficiency C. Diabetes D. Leprosy E. HIV

POMA 108th Annual Clinical Assembly May 4-7, 2016

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“Approach to Peripheral Neuropathy” Joseph S. Lubeck, D.O.

Prevalence of Peripheral Neuropathy Overall prevalence = 2-4% Increases to 8% in patients >55 In developed world, diabetes is most common cause, affecting ~ 50% of diabetics In developing world, most common is leprosy

Question #1 Answer slide A. B. C. D. Leprosy

E.

POMA 108th Annual Clinical Assembly May 4-7, 2016

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“Approach to Peripheral Neuropathy” Joseph S. Lubeck, D.O.

Axonal Degeneration Pathology begins distally and spreads proximally Most metabolic neuropathies Usually begins as stocking glove sensory loss Distal neuropathic pain Loss of distal reflexes Generally sensory > motor

Segmental Demyelination Demyelinating neuropathies Focal ◦ Carpal tunnel syndrome ◦ Peroneal neuropathy

Generalized ◦ Guillain Barre Syndrome ◦ CIDP (chronic immune demyelinating polyneuropathy) ◦ Hereditary (Charcot Marie Tooth)

POMA 108th Annual Clinical Assembly May 4-7, 2016

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“Approach to Peripheral Neuropathy” Joseph S. Lubeck, D.O.

Clinical Presentation Sensory ◦ Stocking > glove sensory loss ◦ Loss of vibratory sensation ◦ Record perception (in seconds) in great toe of maximally percussed tuning fork

◦ Loss of proprioception ---- imbalance without dizziness ◦ Distal loss of pinprick or temperature sensation ◦ Record point of normal perceived pinprick sensation

◦ Pain ◦ Burning, stinging, tightening

Motor – usually occur later than sensory symptoms ◦ Distal weakness ◦ Atrophy ◦ Usually seen first in intrinsic foot muscles

POMA 108th Annual Clinical Assembly May 4-7, 2016

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“Approach to Peripheral Neuropathy” Joseph S. Lubeck, D.O.

Peripheral Neuropathy - Etiologies Motor predominant ◦ ◦ ◦ ◦ ◦

Guillain-Barre CIDP Porphyria Hereditary neuropathies Toxic exposure (amiodorone, vincristine)

Peripheral Neuropathy - Etiologies Sensory Predominant ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦

Diabetes B12 deficiency HIV Amyloid Uremia Sarcoid Paraproteinemias – responsible for 10% of neuropathies originally classified as cryptogenic Toxic ◦ Amiodorone, metronidazole, platinoids, phenytoin, antiretrovirals

◦ Statins – 1 additional case / 2200 patient years ◦ However, diabetics treated with statins have lower incidence of neuropathy

POMA 108th Annual Clinical Assembly May 4-7, 2016

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“Approach to Peripheral Neuropathy” Joseph S. Lubeck, D.O.

Question #2 The most common mimic of peripheral neuropathy in the elderly is: ◦ ◦ ◦ ◦ ◦

A. Alcoholism B. Vascular disease C. Nutritional deficiency D. Spinal stenosis E. Thyroid disease

POMA 108th Annual Clinical Assembly May 4-7, 2016

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“Approach to Peripheral Neuropathy” Joseph S. Lubeck, D.O.

Initial Laboratory Evaluation of Distal Sensory Neuropathy Fasting glucose* HbA1C BMP CBC Sedimentation rate Urinalysis B12, Folate* (Methylmalonic Acid if B12