Sensory manifestations of systemic diseases

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Sensory manifestations of systemic diseases

  1. 1. Dr. Ahmed Hassan MD internal medicine KSA
  2. 2. Systemic diseases may case central and peripheral nervous system disorders The effect of systemic diseases depend on many factors:  Duration  severity of the diseases  receiving treatment or not  other comorbidity
  3. 3. Nervous System  Central nervous system, CNS  Brain  Spinal cord  Meninges: surrounding membranes  Neurons (nerve cells) and neuroglia (supporting cells)  Sensory or afferent nerve: transmits impulses to the nervous system  Motor or efferent nerve: transmits impulses from brain or spinal cord to muscle  Transmission of a nerve impulse via neurotransmitters  Acetylcholine, norepinephrine, dopamine
  4. 4. Brain  Cerebrum  Cerebellum  Brain stem  Brain: four cavities called ventricles  Tissues of brain and spinal cord  Nerve cells = neurons  Supporting cells = neuroglia  Arterial blood supply  Large vessels enter base of skull  Vessels join to form arterial circle at base of brain  Venous blood  From brain into large venous sinuses in dura  Sinuses eventually drain into jugular veins
  5. 5. Sensory pathway: Posterior columns  Axons in the posterior columns whose cell bodies are in the ipsilateral gracile and cuneate nuclei in the medulla  carry sensory modalities of vibration, joint position (proprioception), light touch and two-point discrimination.  Axons from second-order neurones then cross in the brainstem to form the medial lemniscus, passing to the thalamus. Spinothalamic tracts  Axons carrying pain and temperature sensation synapse in the dorsal horn of the cord  cross within the cord and pass in the spinothalamic tracts to the thalamus and reticular formation.
  6. 6. Types of neuropathies  Mononeuropathy  Mononeuritis multiplex  Polyneuropathy  Radiculopathy The neuropathy could be  Motor  Sensory Axonal and myelin sheath
  7. 7.  Sensory symptoms : pain pins and needles numbness tingling deadness sensory level: stocking gloves sensory loss  Sensory symptoms of special sense (Vision and hearing)
  8. 8. Stocking gloves sensory loss usually due to axonal neuropathy:  Diabetes mellitus  Alcohol  Vitamin B12 deficiency  Syphilis  Human immunodeficiency virus  Lyme disease  Uremia  Chemotherapy  Vasculitis  Paraneoplastic neuropathy  Amyloidosis
  9. 9. Predominantly sensory neuropathies – diabetes – thiamine deficiency and B12 deficiency – malignancy – leprosy – hereditary sensory neuropathies – amyloid – uraemia – sarcoid
  10. 10. Predominantly motor neuropathies – Guillain-Barre syndrome and CIDP – porphyria – diphtheria – botulism – lead – Charcot-Marie-Tooth
  11. 11. Carpal tunnel syndrome  symptoms and signs due to compression of the median nerve.  Patients commonly experience pain and paresthesia, and less commonly weakness, in the median nerve distribution.  Symptoms provoked by activities  CTS is the most frequent compressive focal mononeuropathy seen in clinical practice  Nerve conduction studies (NCS) and electromyography (EMG) are a standard part of the evaluation for CTS
  12. 12. RISK FACTORS — A number of conditions have been associated with CTS, include the following:  Obesity  Female gender  Pregnancy  Diabetes  Rheumatoid arthritis  Hypothyroidism  Connective tissue diseases  Preexisting median mononeuropathy  Genetic predisposition  Workplace factors
  13. 13. Diabetes  Neuropathy  Retinopathy  symmetrical sensorimotor polyneuropathy autonomic neuropathy  polyradiculopathy  cranial mononeuropathy  amyotrophy  focal mononeuropathy
  14. 14.  Mechanism of neuropathy  Course of neuropathy
  15. 15. Symptoms include:  Polyneuropathy usually develops slowly, with initial sensory disturbances in distal extremities  aching or cramping  pain and paresthesias Clinical findings in diabetic neuropathy include:  absent ankle jerks  impaired vibration sense on soles of feet  distal motor weakness is less frequent.  neuropathic ulcers and joint deformity (Charcot joints)  How to differentiate vascular from neuropathic ulcers
  16. 16. Diabetic amyotrophy  A symmetrical pelvic girdle weakness  Hyperthesia  Objective sensory loss  Muscle wasting  EMG finding  Treatment by good blood sugar control
  17. 17. Renal failure  Up to 60% of patient with CRF develops polyneuropathy  The risk of Uremic polyneuropathy depend on the severity and duration  creatinine clearance falls below 10% of normal  It is sensorimotor in nature  There is axonal degeneration  Restless leg syndrome characterized by burning sensation, crawling and aching sensation in the leg  Electrolyte disturbance  both dialysis and renal transplantation has a role
  18. 18. Electrolyte disturbance Hypocalcaemia  Calcium is necessary for neuronal membrane stability  hypocalcaemia result in CNS hyper excitability like seizures and mental changes  peripheral and cranial nerve irritability like tetany, muscle cramps, spasm and paresthesia Hypercalcemia can cause polyneuropathy  circumoral numbness
  19. 19. Other endocrinological problems  Hypo and hyperthyroidism may have a wide rang of CNS manifestation  hypothyroidism associated with peripheral neuropath and carpal tunnel syndrome
  20. 20. Connective tissue diseases  SLE  RA  Antiphsopholipid syndrome  Polyartritis nodosa
  21. 21. SLE  Immune mediated multisystem inflammatory disorder  Affect joints, skin, renal, pulmonary, cardiovascular  CNS affected late in the course of the diseases  The pathology is due to vasculitis  Sensory manifestation include polyneuropathy, mononeuritis multiplex and myopathy  Usually asymmetrical  other CNS manifestation include : mental changes, seizures, stroke, cranial nerve envelopment, myopathy, fatigue, spinal cord involvement, depression, aseptic meningitis.
  22. 22. Rheumatoid arthritis  Disease characterized by morning stiffness, symmetrical polyarthritis, and subcutaneous nodule.  The predominant neurological complication is atlantoaxial subluxation involving C1 and C2  Cervical myleopathy  Peripheral neuropathy  Carpal tunnel syndrome , ulnar neuropathy and tarsal tunnel syndrome
  23. 23. Polyarteritis nodosa  Vasculitis affecting the medium and small vessels  The arteritis leads to thrombosis, ischemia and infraction.  CNS manifestation include stroke, mononeuritis multiplex, peripheral neuropathy and myopathy.  Treatment by steroids and cyclophosphamide
  24. 24. Antiphospholipide syndrome Neurological manifestation  Stroke  Epilepsy  Psychosis  Chorea and hemiballismus  Transverse myelopathy  Sensorineural hearing loss  Orthostatic hypotension  Migraine
  25. 25. Vitamin B12 deficiency caused by lack of 1-loss of intrinsic factor in the parietal cells 2- malabsorption Causes of malabsorption include Crohn’s disease Whipple’s disease Tuberculosis Tropical sprue Surgical resection of the distal ileum  Sub acute combined degeneration of the cord
  26. 26. Neurological symptoms include:  numbness and paresthesias  sensory loss particularly to proprioception and vibration  ataxia  increased reflexes often with hyporeflexia or areflexia of the ankle jerk  Behavioral and cognitive dysfunction like depression and irritability  memory impairment to dementia.  Optic atrophy can occur but is rare
  27. 27. Amyloid neuropathy:  symmetrical sensorimotor  carpal tunnel syndrome
  28. 28. Polyneuropathy due to infectious diseases  Leprosy  HIV  Lyme disease  Herpes zoster
  29. 29. Leprosy  Leprosy, a mycobacterial infectious disease of peripheral nerves  Sensory loss is the cardinal symptom of leprosy  Specially over the external ears, the zygomatic arches, and extensor surfaces of joints.  Involvement of cutaneous nerves is generally sharply demarcated, especially in the tuberculoid form of leprosy  The overlying dermis and epidermis are affected, producing the classic anesthetic macule  The diagnosis by?  Treatment ?
  30. 30. HIV  Distal, painful neuropathy is very common in patients with AIDS  continuous burning discomfort, mostly in the feet, whit some degree of sensory loss  Motor involvement is usually minor  Sensory polyneuropathy of late-stage HIV infection must be distinguished from toxic polyneuropathy that may result from the use of nucleoside analogue treatment  Some antiretroviral can cause neuropathy
  31. 31. Neurological manifestation of malabsorption  headache  peripheral neuropathy  ataxia, depression  Dysthymia  anxiety  Epilepsy Peripheral neuropathies, characterized by burning, tingling, and numbness in hands and feet
  32. 32. Diagnosis Nerve conduction studies Electromyography Nerve biopsy  Establish diagnosis of polyneuropathy  Distinguish demyelinating from axonal  Differentiate radiculopathy, plexopathy  Normal in small fiber and autonomic neuropathy
  33. 33. Hematology:  complete blood count  erythrocyte sedimentation rate  C-reactive protein  vitamin B12, folate,  Methylmalonic acid, homocysteine
  34. 34. Biochemical and endocrine:  comprehensive metabolic panel (fasting glucose)  thyroid function tests  serum immunofixation.  glucose tolerance test if indicated Urine:  urinalysis  urine immunofixation. Drugs and toxins
  35. 35. Connective tissue diseases and vasculitis:  antinuclear antigen profile  rheumatoid factor  anti-Ro/SSA, anti-La/SSB,  antineutrophil cytoplasmic antigen antibody (ANCA) profile  cryoglobulins.
  36. 36. Malignancies:  skeletal radiographic survey  mammography  computed tomography or magnetic resonance imaging of chest, abdomen, and pelvis  ultrasound of abdomen and pelvis  positron emission tomography  cerebrospinal fluid analysis including cytology  serum paraneoplastic antibody profile
  37. 37. Infectious agents:  Campylobacter jejuni  Cytomegalovirus  hepatitis panel (B and C)  HIV  Lyme disease  herpes viruses  West Nile virus  cerebrospinal fluid analysis.
  38. 38. Treatment of sensory symptoms  Treat any underlying condition or cause for your peripheral neuropathy.  Control any symptoms that you may have.

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