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Toxic Polyneuropathy

Polyneuropathy Due to Toxic Agents

Toxic polyneuropathy is a term encompassing the injury of the peripheral nerves by pharmacological agents, drugs of abuse, and toxic compounds found in different occupations. Sensory loss, motor weakness, and pain are typical signs. The differential diagnosis is quite broad, which is why a detailed patient history, a complete physical exam, and a thorough laboratory workup are vital in order to identify the underlying cause.


Presentation

The list of substances that may cause toxic polyneuropathy is quite long with some of the most important being [1] [2] [3] [4] [5] [6]:

  • Therapeutic drugs - Chemotherapeutics, lithium, antimicrobial agents (isoniazid, metronidazole, nitrofurantoin), cardiovascular (amiodarone, digoxin, hydralazine, nitroprusside), vinca alkaloids, misoprostol, and phenytoin are listed as some of the most common drugs that might induce toxic polyneuropathy [1] [3] [4] [6].
  • Occupational pollutants and substances - Heavy metals (arsenic, lead, thallium, mercury) and a number of industrial agents (ethylene oxide, organophosphates, hexacarbons, acrylamide, and several other) [1] [2] [7].
  • Drugs of abuse - Alcohol and heroin are the two main substances of abuse that can cause polyneuropathy [1] [6].

The clinical presentation, usually appearing weeks after exposure to the harmful agent, is centered around two main components - sensory and motor deficits [1] [4]. A tingling sensation or numbness in the distal extremities is considered to be one of the first signs of sensory involvement, particularly after the use of chemotherapeutic drugs, which may lead to disturbances in gait, pruritus, and moderate to severe sharp pain [5]. Conversely, motor weakness, typical for heavy metal exposure, manifests as weakness in the extremities (eg. wrist drop) and loss of deep tendon reflexes [1] [5].

Peripheral Neuropathy
  • Textbook of Peripheral Neuropathy is a practical but authoritative reference for clinicians in any medical specialty who are evaluating and treating patients with signs and symptoms of a peripheral neuropathy.[books.google.de]
  • Peripheral neuropathy is the most common neurological complication in patients with HIV/AIDS with an estimated incidence of nearly one-third of all people with HIV/AIDS: For patients with HIV/AIDS, peripheral neuropathy can be caused by the virus itself[atmph.org]
  • Peripheral Nerve Disorders Also called: Neuritis, Peripheral neuritis, Peripheral neuropathy Your peripheral nerves are the ones outside your brain and spinal cord.[icdlist.com]
  • This hypothesis is now supported by the development of a peripheral neuropathy in chickens, rats, and cats exposed to MBK at atmospheric concentrations of 200 to 600 parts per million, 24 hours per day, 7 days per week.[science.sciencemag.org]
  • Chemotherapy-induced peripheral neuropathy (CIPN) occurs commonly in cancer patients and is individually unpredictable. We used CIPN as a clinical model to investigate the association of non-CMT polyneuropathy with CMT genes.[mayoclinic.pure.elsevier.com]

Workup

Numerous symptoms involving different systems, including additional neurological manifestations, can be present along with the polyneuropathy, such as gastrointestinal irritation (heavy metal exposure), anemia and constitutional complaints [1] [6]. For this reason, a meticulous clinical workup is necessary. Physicians must obtain a complete patient history that will assess the patient's occupation (and to which substances the individual is exposed), presence of underlying diseases (as several systemic and metabolic diseases can present with polyneuropathy, such as hypothyroidism and diabetes mellitus), and history of alcohol and substance abuse [1] [6]. Additionally, a thorough nutritional evaluation must be conducted, keeping in mind that several vitamin deficiencies (thiamine, B6, B12, and also copper) might manifest as a polyneuropathy [1] [6]. History of drug use, however, is the main focus of history taking. Furthermore, a detailed physical examination, focusing on the neurological system (reflex and sensory perception testing, as well as coordination and proprioception) will confirm the extent of peripheral nerve involvement and possibly detect other neurological symptoms that might lead the physician to a presumptive diagnosis [1] [5]. Laboratory studies should be employed later on, including a complete blood count (CBC), a full metabolic panel, serum inflammatory markers (erythrocyte sedimentation rate, or ESR), serum glucose, vitamin B12, thyroid hormone levels, and urinalysis, which is particularly useful for heavy metal exposure [1] [6] [8]. When the diagnosis is inconclusive, nerve conduction studies and electromyography might be performed [5].

Treatment

  • Features of the treatment of the disease Toxic polyneuropathy, the treatment of which primarily comes down to eliminating the causes of its occurrence, should be considered comprehensively.[acikgunluk.net]
  • Treatment Treatment options for HIV-related and drug-induced DSP are limited and challenging to practicing physicians particularly in the prevailing situation in the developing world where access to ART is limited and changing regimens may be difficult[atmph.org]
  • The textbook provides an evidence-based approach to testing, differential diagnosis, and treatment, and should serve as a trusted resource for healthcare professionals confronting the many manifestations of peripheral neuropathy in clinical practice.[books.google.de]
  • Polyneuropathy as a result of treatment kordarony Segmented demyelination with involvement of axial cylinders is characteristic of the PNP-syndrome as a result of reception of a kordaron (drug for treatment of coronary insufficiency) in a dose of 400[infomeds.net]
  • They include Numbness Pain Burning or tingling Muscle weakness Sensitivity to touch Treatment aims to treat any underlying problem, reduce pain and control symptoms.[icdlist.com]

Prognosis

  • The prognosis for getting rid of the disease is favorable. Arsenic polyneuropathy Arsenic can penetrate into the human body along with insecticides, medicines, paints. This disease is a professional for smelters.[acikgunluk.net]
  • What is the Prognosis for Drug-Induced Neuropathy? (Outcomes/Resolutions) The prognosis of Drug-Induced Neuropathy is good with adequate treatment and management of the signs and symptoms.[dovemed.com]
  • Clinicopathologic findings and prognosis of chronic inflammatory demyelinating polyneuropathy. Neurology. 1999;52:498-503. Lewis RA. Multifocal motor neuropathy and Lewis Sumner syndrome: two distinct entities. Muscle Nerve. 1999;22:1738-39. Nevo Y.[rarediseases.org]
  • The outlook (prognosis) for peripheral neuropathy depends on the underlying cause. In general, if a problem can be identified early and treated successfully, the prognosis is very good.[patient.info]
  • Prognosis  Each patient's prognosis depends on the severity of the neuropathy when exposure is ceased or reduced to levels that will not affect health negatively. 44.[slideshare.net]

Etiology

  • Code First Code First Help Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10data.com]
  • The etiologic factor in common turned out to be consumption, ritually, of gingili oil, which is used in a ritual at menarch and after childbirth.[popline.org]
  • The findings raise the possibility that other acquired polyneuropathies may also be codetermined by genetic etiological factors, of which some may be related to genes already known to cause the phenotypically related Mendelian disorders of CMT.[mayoclinic.pure.elsevier.com]
  • This survey provided a crude etiological picture of generalized neuropathy on this island. 1993 S. Karger AG, Basel Article / Publication Details First-Page Preview[karger.com]
  • Progressive ascending motor neuron paralysis of unknown etiology, frequently following an enteric or respiratory infection.[icd9data.com]

Epidemiology

  • Abstract: The epidemiological and clinical aspects of an unusual type of polyneuropathy which reached epidemic proportion in Sri Lanka in 1977-1978 are reported. 20 young women in Sri Lanka were affected by this illness, characterized by pain in the calves[popline.org]
  • Epidemiological data suggested strongly that methyl N -butyl ketone (MBK) was responsible for the outbreak.[science.sciencemag.org]
  • The epidemiology of human immunodeficiency virus-associated neurological disease in the era of highly active antiretroviral therapy. J Neurovirol 2002;8:115-21. [ PUBMED ] [ FULLTEXT ] 20.[atmph.org]
  • Causation and causal inference in epidemiology. Am J Public Health 95 (Suppl 1): S144–50, 2005. Dalakas MC. Peripheral neuropathy and antiretroviral drugs. J Periph N Syst 6:14-20, 2001. Gaist D, Jeppesen U, Anderson M, et al.[now.aapmr.org]
  • Lead  Epidemiology of lead toxicity  Common in children: Especially black non-hispanic children (22%)  Most common in homes built from 1920 to 1950  Identical twins often have concordant lead levels  Lead neuropathy: Especially from industrial exposure[slideshare.net]
Sex distribution
Age distribution

Pathophysiology

  • The first chapter begins with basic information on anatomy at the macroscopic, cytologic and histologic levels and continues with pathophysiological and dissection techniques.[books.google.com]
  • Pathophysiology Although peripheral neuropathy has multiple etiologies, the nerve has a limited number of ways to respond to injury. 4 , 5 The damage can occur at the level of the axon (i.e., axonopathy).[aafp.org]
  • Back to Top Pathophysiology and Natural History Despite the diverse array of medical disorders that cause peripheral neuropathies, peripheral nerves exhibit only a few distinct pathologic reactions to an insult or disease: wallerian degeneration, axonal[clevelandclinicmeded.com]
  • Pathophysiology Neuropathy may be categorized by presentation (ie, motor or sensory symptoms), electrodiagnostic features, and neuroanatomical location within the peripheral nerve (ie, demyelinating or axonal, neuronopathy, ion channel neuropathy, neuromuscular[emedicine.medscape.com]

Prevention

  • Knowledge of the pathogenesis, genetics, and molecular biology of neuromuscular disorders is essential both in developing and applying new therapies and preventive measures, and in formulating genetic and prognostic advice.[books.google.com]
  • This may improve your symptoms and help prevent further nerve damage.[healthline.com]
  • Prevention Peripheral neuropathies are preventable only to the extent that the underlying causes are preventable.[encyclopedia.com]

References

Article

  1. Staff NP, Windebank AJ. Peripheral Neuropathy Due to Vitamin Deficiency, Toxins, and Medications. Continuum (Minneap Minn). 2014;20(5 Peripheral Nervous System Disorders):1293-1306.
  2. Ratnaike RN. Acute and chronic arsenic toxicity. Postgrad Med J. 2003;79(933):391– 396.
  3. Marchettini P, Lacerenza M, Mauri E, Marangoni C. Painful Peripheral Neuropathies. Curr Neuropharmacol. 2006;4(3):175-181.
  4. Ludolph AC, Spencer PS. Toxic neuropathies and their treatment. Baillieres Clin Neurol. 1995;4(3):505-527.
  5. Grisold W, Cavaletti G, Windebank AJ. Peripheral neuropathies from chemotherapeutics and targeted agents: diagnosis, treatment, and prevention. Neuro Oncol. 2012;14(4):iv45-iv54.
  6. Azhary H, Farooq MU, Bhanushali M, Majid A, Kassab MY. Peripheral neuropathy: differential diagnosis and management. Am Fam Physician. 2010;81(7):887-892.
  7. Krishnan AV, Phoon RK, Pussell BA, et al. Ischaemia induces paradoxical changes in axonal excitability in end-stage kidney disease. Brain. 2006;129(pt 6):1585– 1592.
  8. Willison HJ, Winer JB. Clinical evaluation and investigation of neuropathy. J Neurol Neurosurg Psychiatry. 2003;74(2):ii3–ii8.

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Last updated: 2017-08-09 14:41