novel episode III - medkorat.in.th episode III... · (Chronic Inflammatory...
Transcript of novel episode III - medkorat.in.th episode III... · (Chronic Inflammatory...
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LOCALIZATION
NEUROLOGY
EPISODE IIIPERIPHERAL NEUROPATHY
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DISEASE of PERIPHERAL NERVE
� LMN weakness in distribution of
peripheral nerves, or distal > proximal
� Sensory loss in distribution of peripheral
nerves or distal distribution
� Hyporeflexia
� Disturbance of autonomic nervous system
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CLASSIFICATION
� MONONEURITIS SIMPLEX
� MONONEURITIS MULTIPLEX
� POLYNEUROPATHY
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Mononeuritis Simplex
Involve 1 nerve in 1 time
eg. Bell’s palsy, Entrapment, Radiculopathy
Mononeuritis Multiplex
Involve 1 nerve in 1 time but additive
eg. Vasculitic neuropathy
Polyneuropathy
Involve many nerves in the same time
eg. GBS, CIDP
NEUROPATHY
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Mononeuropathy
Simplex
Polyneuropathy
Axonal type
Mononeuropathy
Multiplex
NEUROPATHY
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DEMYELINATION
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DEMYELINATION
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POLYNEUROPATHY
AXONOPATHY
� Distal sensory loss (glove and stocking pattern)
� Distal weakness, leg > arm
� Loss of distal DTR > proximal DTR
� Length dependent
Bilateral symmetrical distal weakness
and sensory loss
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� Metabolic disease: DM
� Toxic substance, drugs, alcohol
� Vitamin deficiency : B1, B6
� Vasculitis
� Infectious: HIV, Hepatitis
� Paraneoplastic Syndrome
� Monoclonal gammopathy
� Rare: hereditary, amyloidosis
AXONOPATHY
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Alcohol
Amiodarone
Dapsone (motor)
Disulfuram
Hydralazine
INH
Metronidazole
Nitrofurantoin
ARV
Phenytoin
Pyridoxine (sensory)
Vincristine
Taxol
Arsenic
Thallium
Organophosfate
Lead (motor)
Hydrocarbon
Hydrocarbon
Amiodarone
Perhexiline
DEMYELINATING
POLYNEUROPHY
AXONAL
POLYNEUROPATHY
toxic
AXONAL
POLYNEUROPATHY
drug
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� Not length dependent
� Proximal and distal weakness
� Distal sensory loss little
(not in length dependent)
� Generalized absent or decreased reflexes
Bilateral symmetrical or asymmetrical distal
weakness without sensory loss
POLYNEUROPATHY
DEMYELINATION
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ACQUIRE
� AIDP
(Acute Inflammatory Demyelinating Polyneuropathy)
� CIDP
(Chronic Inflammatory Demyelinating Polyneuropathy)
� MMN
(Multifocal Motor Neuropathy with conduction block)
� Drug (amiodarone)
DEMYELINATION
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CONGENITAL
� HNPP (Hereditary Neuropathy with Labiality to Pressure Palsy)
� CMT(Charchot-Marine-Tooth) (HMSN)
DEMYELINATION
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AIDP : GBS and its variants
� AIDP anti GD1a (65%)
� AMAN anti GM1 (C. jujuni), anti GD1a
(acute motor axonal neuropathy)
� AMSAN anti GM1 (C. jujuni), anti GD1a
(acute motor sensory axonal neuropathy
� Miller-Fischer variant anti GQ1b (Ab to cerebellar layer)
� Pure Autonomic
DEMYELINATION
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CIDP : clinical as AIDP but progress more than
4 weeks anti-MAG (myelin associated glycoprotein)
associated with systemic diseases
� Monoclonal gammopathy (MGUS)
� Multiple myeloma
� Waldenstromm macroglobulinemia
� Cryoglobulinemia
� Osteosclerotic myeloma (POEMS)
� Infections eg. Hepatitis B, Hepatitis C, HIV
DEMYELINATION
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� Lead neuropathy
Predominantly involve upper extremities
Wrist drop
� Dapsone
� Multifocal motor neuropathy with
conduction blocks (MMN)
Middle age male, distal upper extremities,
hand atrophy, chronic course
DDx from ALS
DEMYELINATION
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ENLARGE NERVE
� Leprosy
� CIDP
� Genetic: CMT, HNPP
NEUROPATHY with FACIAL INVOLVEMENT
� GBS
� CIDP (rare)
� Lyme disease
� Sarcoidosis
ADDITIONAL CLUE
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� ACUTE
GBS, Porphyria, Diphtheria
� CHRONIC
CIDP
� VERY CHRONIC
Hereditary neuropathy (CMT)
ADDITIONAL CLUE
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MONONEURITIS MULTIPLEX
� Multiple nerve in multiple time
� Many nerve = polyneuropathy
� 3 major cause
1. Idiopathic
2. Autoimmune disease and vasculitis
3. Paraneoplastic syndrome
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VASCULITIS
� Vasculitic syndrome:
Wegener granulomatosis,
Churg-Strauss syndrome, PAN
� Systemic connective tissue disease: SLE, RA
� Other vasculitis:
� Cryoglobulinemia, Hepatitis B, Heptitis C
MONONEURITIS MULTIPLEX
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� Entrapment syndrome
eg. CTS, Saturday night palsy
� Ulnar nerve palsy
� Nerve ischemia : DM
� Infection : Leprosy, Ramsay Hunt
� Idiopathic : Bell’s palsy
MONONEURITIS SIMPLEX
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APPROACH to NEUROPATHY
polyneuropathymononeuropathy
simplex
mononeuropathy
multiplex
• entrapment
• idiopathic
• vasculitis
• paraneoplastics
• idiopathicdemeyelination axonopathy
acutechronic
AIDP and
varients
• CIDP
• lead
• CMT (HMSN)
• HNPP
• drug (cordarone)
• Metabolic disease: DM
• Toxic substance, drugs
• Vitamin deficiency : B1, B6
• Vasculitis
• Infectious: HIV, Hepatitis
• Paraneoplastic Syndrome
• Monoclonal gammopathy
• Rare: hereditary, amyloidosis
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APPROACH to NEUROPATHY
� Duration
� Function
• Motor nerves
• Sensory nerves
• Motor and sensory nerves
• Autonomic nerves
• Small fiber sensory nerves
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APPROACH to NEUROPATHY
� Proximal or distal
� Symmetrical or asymmetrical
� Distal DTR loss or loss all DTR
� Nerve enlargement
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� Systemic disease: DM, thyroid
� Toxic substance: heavy metal
� Drug: CMT, ARV
� Alcoholic drinking
� Nutritional deficiency
� Autoimmune disease: PAN, Wegener
� Family history: CMT
� Infectious disease: leprosy, HBV, HCV,
HIV, HSV
APPROACH to NEUROPATHY
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GUILLIAN BARRE’S SYNDROME
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peripheral polyneuropathy
demyelination in nature (but axonal involve can occur)
GBS
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isolated condition (post infectious disorder)
not associated with systemic disease, autoimmune
infectious condition URI (40%), diarrhea (27%)
2/3 have anticedent infection (three weeks before)
post vaccination, post surgical, stress event
pathogen
- CMV, EBV, M. pneumoniae, H. influinzae, HIV
- Campylobactor jejuni
GBS
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PATHOPHYSIOLOGY
infection with pathogen
antigen and antibody complex
antibody to myelin
complement activation
demyelination
involve axon (severe)
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VARIANT and ANTIBODY
AIDP Unknown
AMAN GM1, GM1b, GD1a, GalNAc-GD1a
AMSAN GM1, GM1b, GD1a, GalNAc-GD1a
MFS GQ1b, GT1a, GD3
Pure Dysautonomia
AIDP = acute inflammatory demyelinating polyradiculoneuropathy
AMAN = acute motor axonal neuropathy
AMSAN = acute motor sensory axonal neuropathy
MFS = Miller-Fischer syndrome
Variant Antibody
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rapidly progressive bilateral weakness
relatively symmetrical
distal and proximal weakness
involve cranial muscle (facial)
MFS = ocular muscle
triad (ataxia, areflexia, ophthalmoplegia)
decrease or absent DTR
involve respiratory muscle (25%)
reach to maximum within 4 weeks (mostly 2 weeks)
CLINICAL PROFILES
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INVESTIGATIONS
Lumbar Puncture
increase protein content but normal WBC
call “albuminocytodissociation”
may be normal in first week but 90% abnormal in second week
increase cell = carcinomatosis, HIV, lymphoma
Electrodiagnostic Test
demyelination pattern (decrease velocity)
may be normal in first week
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CLINICAL PROFILES
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Require for diagnosis
Progressive weakness both arms and legs (start in the leg)
Decrease or absent DTR
GBS DIAGNOSIS
Support diagnosis
Progressive over day to 4 weeks
Relative symmetry of symptoms
Mild sensory symptoms
Cranial muscle involvement (bifacial weakness)
Autonomic dysfunction
Pain
High concentration of CSF protein
Typical electrodiagnostic features
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Doubt about diagnosis
Severe pulmonary dysfunction with limited limb weakness
Severe sensory signs or sharp sensory level
Bladder/bowel dysfunction at onset
Mark persistent asymmetrical weakness
Increase CSF cell count (> 50) or PMN in CSF
GBS DIAGNOSIS
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intracranial/cord abnormalities
- brain stem encephalitis
- meningitis carcinomatosis/lymphomatosis
- transverse myelitis
- cord compression
DIFFERENTIAL DIAGNOSIS
Peripheral nerve abnormalities
- CIDP
- porphyria
- critical illness neuropathy
- Beri beri
Neuromuscular junction and muscle abnormalities
- MG, botulinum toxin
- polymyositis/dermatomyositis
- critical illness myopathy
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common complication (2/3)
cardiac arrhythmia (3-10%)
blood pressure fluctuation
sweating
pupillary abnormality
bowel/bladder dysfunction
AUTONOMIC FAILURES
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HUGHES’S SEVERITY SCORE
MEANING
1 Minor signs or symptoms
2 Able to walk 5 meters without assistance
3 Able to walk 5 meters with the help of one
person or stick
4 Unable to walk or wheelchair
5 Require assisted ventilation
6 Death
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TREATMENT
supportive treatment/PTPlasma exchange (severity score ≥ 3)
Intravenous immunoglobulin (IVIg) 0.4 g/kg/d five days
oral steroid and/or methylprednisolone not effective
20% dependent walk at 6 months
Data limit
- after 2 weeks of disease- mild symptoms (severity score ≤ 2)
- pediatrics
- MFS