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Sensory Predominant Peripheral Neuropathy


Physical Examination

Inspection:

  • Muscle wasting, especially distal

  • Presence of fasciculations, particularly in calves

  • Trophic changes like thinning of the skin, loss of hair, shiny appearance, or presence of ulcers or infections

  • Possible deformities resulting from chronic neuropathy or unnoticed injuries due to loss of sensation (Charcot joints)

Motor Examination:

  • Decreased tone, limbs may feel flaccid

  • Muscle strength reduced, "stocking" distribution

  • Lower limb reflexes diminished or absent

  • Absence of ankle clonus or the Babinski sign

Cerebellar Examination:

  • No expected cerebellar signs in pure peripheral neuropathy

Sensory Examination:

  • Reduced or absent sensation to soft touch

  • Pain sensation (pinprick) diminished or absent

  • Diminished or absent vibration sense, tested using a tuning fork

  • Impaired proprioception or joint position sense

Additional Examination:

  • Palpate for peripheral pulses

  • Examine the upper limbs

  • Presence of a positive Romberg's sign

  • Look for underlying causes - fingerprint prick marks, CGM, insulin pump

Differential Diagnosis

Metabolic and Endocrine Causes:

  • Diabetic neuropathy

  • Hypothyroidism-associated neuropathy

  • Vitamin B12 deficiency

Infectious Causes:

  • HIV-associated neuropathy

  • Lyme disease

  • Leprosy

  • Neurosyphilis

Autoimmune and Inflammatory Causes:

  • Guillain-Barre syndrome

  • Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)

  • Vasculitis-associated neuropathy

Genetic/Hereditary Causes:

  • Charcot-Marie-Tooth disease

  • Fabry disease

  • Hereditary sensory and autonomic neuropathies

Toxic and Drug-Induced Causes:

  • Alcoholic neuropathy

  • Drug-induced neuropathy (e.g., from chemotherapy)

  • Lead poisoning

Neoplastic and Paraneoplastic Causes:

  • Paraneoplastic syndromes

Other Causes:

  • Amyloidosis

Investigations

Laboratory Tests:

  • Complete Blood Count: Anemia may indicate vitamin B12 deficiency; high white blood cell count may suggest infection or malignancy.

  • Biochemical profile: Renal, liver, and thyroid function tests for systemic causes.

  • Fasting glucose, HbA1c: To assess diabetes.

  • Vitamin B12 and folate levels: Deficiency can cause neuropathy.

  • Serum protein electrophoresis: To check for monoclonal gammopathy.

  • Antinuclear antibodies, rheumatoid factor, anti-neutrophil cytoplasmic antibodies: Indicate connective tissue diseases.

  • Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP): Raised in inflammatory or malignant conditions.

  • Serological tests for infections: Lyme, HIV, Hepatitis B and C.


Invasive:

  • Nerve conduction studies and electromyography: To confirm peripheral neuropathy and define its extent and type.

  • Lumbar puncture: May be necessary if Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy (CIDP), or central causes are suspected.

  • Nerve biopsy: Rarely done, but can be helpful in certain cases (e.g., suspected vasculitis).

Other Tests:

  • Skin biopsy: Small fiber neuropathy assessment.

  • Autonomic function tests: If autonomic neuropathy is suspected.

  • Genetic testing: In suspected inherited neuropathies.

Management

General Management:

  • Patient education: Understanding the nature of the condition, prognosis and lifestyle adaptations.

  • Control of underlying conditions: Optimal control of diabetes, vitamin supplementation for deficiencies, etc.

  • Physical therapy: To maintain muscle strength and function.

  • Regular foot care: Particularly in diabetic neuropathy to prevent complications.

Medical Management:

  • Analgesia: Start with simple analgesics, then consider neuropathic pain agents such as amitriptyline, gabapentin, or pregabalin.

  • Topical treatments: Capsaicin or lidocaine patches for localised pain.

  • Treatment of underlying condition: E.g., sugar control for diabetes, antibiotics for Lyme disease, antiretrovirals for HIV, immunosuppressive drugs for vasculitis.

Surgical Management:

  • Management of complications: Such as surgical care for non-healing ulcers in diabetic neuropathy.

Other Management:

  • Psychological support: Chronic pain can lead to depression or anxiety, which may require management.

  • Occupational therapy: Adaptations to daily activities may be needed.

  • Dietary advice: Particularly in diabetic neuropathy or in vitamin deficiencies.

  • Referral to specialist pain clinics or neurologists: For complex cases or where first-line treatments have not been effective.


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