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Acute Peripheral Neurological Lesions
 

Acute Peripheral Neurological Lesions

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    Acute Peripheral Neurological Lesions Acute Peripheral Neurological Lesions Presentation Transcript

    • 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