This slide contains case based discussion of how to evaluate a case of peripheral neuropathy, how to investigate and manage according to cause.

1. Morning Session
08-11-2017
Dr. Azim Anwar
Brown Unit
Dept of Internal Medicine
BSMMU

2. 65 Year Old Male, Presented
With Facial Swelling and Foot
Drop

3. • Mr. Ainuddin
• 65 years
• Normotensive, Nondiabetic
• DOA- 23 october, 2017 with the complaints of

4. • Early morning facial swelling and both ankles
for 8 months, associated with high color urine
and oligouria.
• No history suggestive of cardiac or liver
disease.
• Patient complaints of 12 kg weight loss in last
two month( 57 45) with normal diet,
normal bowel habit and no anorexia, nausea.

5. • He also complaints of
• Tingling, numbness and weakness of
distal part of both legs for same duration,
initially it started with foot drop,
gradually progressive and eventually he
was compelled on walking with walker.
• Bladder habit was normal.

6. No history of
• Preceeding diarrhoea or fever
• Offending drugs and Occupational exposure
• Alcohol
• Unsafe sexual exposure
• Symptoms suggestive of vasculitis
• Family history of such type of illness

7. • Outside the hospital,
• He was treated with single dose Inj. V-B12,
followed by oral V-B12 for several months
• And Oral diuretics.

8. On Examination
• Anemia
• Cyanosis
• Jaundice
• Clubbing
• Koilonychea Absent
• Leuconychea
• RR- 16/min
• Temp- Normal
• Dehydration- Absent
• Neck Vein- Not engorged

9. • Pulse- 78 bpm
• BP- 110/70 mmhg
• Edema- Present
• Lymph node- Not palpable
• Thyroid- Not enlarged
• Bony tenderness- Absent

10. Neurological Examination
• Higher cerebral function: Intact
• Cranial Nerves: Intact

11. Motor Examination
• No wasting or fasciculation, tone diminished
symmetrically of both lower limb
Power: Prox: 5, Distally: 1
Absent knee and ankle jerk bilaterally, Planter
bilaterally absent.
Coordination: Intact
Gait: Neuropathic Gait

12. Sensory Examination
Loss of position sense bilaterally
Loss of vibration sense bilaterally upto ankle
joints.
Other sensations intact.
• Sign of Meningeal Irritation: Absent

13. Other systemic examination revealed
• no abnormality.

14. Clinical Diagnosis

15. • Peripheral Sensory Motor Neuropathy
due to
 CKD (Uremic)
 Vitamin B12 deficiency
CIDP
Paraneoplastic Neuropathy

16. Investigations

17. CBC with PBF
09 June, 2017 24 oct, 2017
Hb% 11.4 10.6
ESR 22 35
TC 13000 9000
Neutrophil 64% 66%
MCV 90 90
MCH 31.3 29
MCHC 34.40 32
RDW 12.4 15
PBF Normocytic normochromic Dimorphic with
anisocytosis

18. Tsat: 33% (102/307)
• Vitamin B12 level: 478 pgm/ml (25/10/17)
312pgm/ml (09/06/17)
• FBS: 6.72mmol/L
• 2HAF: 8.20 mmol/L
• HbA1c: 5.6%
• SGPT: 35
• Urine R/E: Pus cell 0-2/hpf, Epi cell 1-2/hpf
• Fasting lipid profile: Normal

19. • S.Creatinine: 2.17 (3/11/17),
• 1.87 (9/6/17)
• BUN: 36 mg/dl
• eGFR: 33ml/min
• S.Ca: 8.0 mg/dl
• S. Albumin: 38gm/L
• iPO4: 6.1mg/dl
• PTH: 59pg/ml (10-65)
• UTP: 0.14gm/day
• UTV: 2200ml/day

20. S. Electrolytes:
25-10-17 03-11-17
Na 128 127
K 5.5 5.3
Cl 101 102
TCO2 22 18

21. • NCS of Both Lower Limb: Severe Sensory
Motor Axonal Polyneuropathy.
• CEA, Ca 19/9, PSA: Normal Range
• USG Whole Abdomen: Hepatomegaly
• Fibroscan: Median stiffness: 8.4 kpa
• Anti HBc Total: (-)
• Anti HCV: (-)
• TSH: Report Pending

22. • Peripheral Sensory Motor Neuropathy
due to
 CKD (Uremic)
 Vitamin B12 deficiency
Paraneoplastic Neuropathy
CIDP

23. • Peripheral Sensory Motor Neuropathy
due to
 CKD (Uremic)
 Vitamin B12 deficiency
Paraneoplastic Neuropathy
CIDP

24. CXR, P/A View

25. CT Chest With Contrast: Normal

26. MRI L-S Spine
• Central and paracentral disc bulge at L3/4,
L4/5, L5/S1
• Mild spinal canal stenosis
• Disc bulge at C3/4. C4/5, C5/6, C6/7
• Mild spinal canal stenosis in cervical and
lumber region.

27. • Peripheral Sensory Motor Neuropathy
due to
 CKD (Uremic)
 Vitamin B12 deficiency
Paraneoplastic Neuropathy
CIDP

28. • Peripheral Sensory Motor Neuropathy
due to
 CKD (Uremic)
 Vitamin B12 deficiency
Paraneoplastic Neuropathy
CIDP

29. Provisional Diagnosis
• Peripheral Sensory Motor Axonal Neuropathy
due to
CKD (Uremic)

30. Davidson: P 486, 22Ed

31. Literature Review
• Peripheral Sensory Motor Axonal Neuropathy
due to CKD (Uremic)

32. Uremia may be present to a lesser degree in people
with GFR barely 50% below normal.

33. Generally, Neuropathy ONLY developes at GFR below
12ml/min

34. Sighns of neuropathy were found ONLY
when CCR was 5ml/min or less.

35.  Q1. Peripheral Sensory Motor Axonal
Neuropathy due To ???

36. Possibilities…….???
Considerations In favor Against Favor
Occult Malignancy 12 kg weight loss Tumor markers negative,
No organ specific
symptom.
Vasculitis Raised S.Creatinine, BUN.
12 kg wt koss,
Hepatomegaly,
Polyneuropathy
No rash, HTN, Hematuria-
Proteinuria, Myalgia,
Fever, Night sweats,
Abdominal pain, oral ulcer.
HBV & HCV (-)
Amyloidosis Axonal Neuropathy
Renal Involvement
No Cardiac or Cutaneous
involvement.

37. • Q1. Peripheral Sensory Motor Axonal
Neuropathy due To ???
• Q2. What is the cause of CKD?

38. • Q1. Peripheral Sensory Motor Axonal
Neuropathy due To ???
• Q2. What is the cause of CKD?
• Q3. Can We Consider
 Renal Biopsy

39. • Q1. Peripheral Sensory Motor Axonal
Neuropathy due To ???
• Q2. What is the cause of CKD?
• Q3. Can We Consider
 Renal Biopsy
CSF Study

40. • Q1. Peripheral Sensory Motor Axonal
Neuropathy due To ???
• Q2. What is the cause of CKD?
• Q3. Can We Consider
 Renal Biopsy
CSF Study
Bone Marrow Study

41. THANK YOU

42. Plan