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  1. What are the symptoms and signs of peripheral neuropathy?

  2. Which patients with peripheral neuropathies require hospitalization?

  3. Which peripheral neuropathies are seen in the inpatient setting?

  4. What are the common causes of peripheral neuropathies?

  5. How are peripheral neuropathies evaluated?

  6. What are the best treatment options for peripheral neuropathy?

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Case 214-1

A 31-year-old man was seen for inpatient consultation for possible polyneuropathy. His history dates back 1 year when he developed asthma for the first time. At the same time, he noted progressive paresthesias that started in his feet and then progressed to involve his hands. He was unsure when the weakness in his left leg developed. He was later found to have eosinophilia and eventually treated for Churg–Strauss syndrome. He developed sepsis and required bowel resection. After his bowel resection, he noted bilateral arm weakness, which was worse on the right side. His medical course was complicated by renal failure, malabsorption, and Clostridium difficile infection currently treated with metronidazole. His examination was significant for bilateral footdrop, with significant but asymmetric weakness in the left greater than the right leg, and the right greater than the left arm. Vibration sense was absent, and joint position sense was impaired in his toes. Light touch, cold, and pinprick were diminished to his knees and elbows. He was areflexic.

The new onset of paresthesias and/or weakness in an asymmetric fashion should alert the clinician to a vasculitic process. The presence of asthma and eosinophilia with multiple mononeuropathies is diagnostic for Churg–Strauss syndrome. The presence of inflammation, fibrinoid necrosis, and hemosiderin on nerve biopsy would have been diagnostic for vasculitis. Addressing the neuropathic symptoms should lead to earlier diagnosis and treatment of the underlying disorder. This patient has multiple causes for peripheral neuropathy in addition to this vasculitis: medications (metronidazole), sepsis, malabsorption leading to vitamin deficiencies, and immobility, predisposing to compressive neuropathies.

Nontraumatic peripheral neuropathy is present in 2.4% of the general population and in as many as 8% of individuals over the age of 55. Diabetes is the most common cause in developed nations. At least 60% of diabetics have objective evidence for peripheral neuropathy. Overall, diabetic neuropathy ranks third behind macrovascular disease and nephropathy in lifetime expenditures associated with diabetic complications. Neuropathy is responsible for more hospital admissions than all the other diabetic complications combined and is a causative factor in up to 75% of all nontraumatic amputations.

Peripheral neuropathy is classified by the level of anatomical involvement (Table 214-1).

Table 214-1 Patterns of Peripheral Neuropathy

Radiculopathy affects the spinal root, leading to pain, paresthesias, and weakness in the distribution of the nerve ...

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