European Journal of Cardiovascular Medicine

Peripheral nerve disorders are common neurological problems caused by dysfunction of peripheral motor, sensory, or autonomic nerves. The causes of neuropathies and their clinical Presentation is highly variable. The main causes of neuropathy are entrapments, systemic diseases, inflammatory, autoimmune disorders, inherited disorders, ischemic settings, paraneoplastic conditions, deficiency states, infections, and toxins¹. The prevalence of peripheral neuropathy is 2.4% but in elderly above 55 years age group, it rises to 8%. Based on the duration of symptoms, the neuropathy can be categorized into acute (<4 weeks), subacute (4–12 weeks), or chronic (>12 weeks)².

Mononeuropathy means focal involvement of a single nerve and implies a local process. Direct trauma, compression or entrapment, vascular lesions, and neoplastic infiltration are the most common causes. Multiple mononeuropathy or mononeuropathy multiplex signifies simultaneous or sequential damage to multiple non-contiguous nerves.

Electrophysiological studies provide a more precise localization of the lesion than may be possible by clinical examination and can separate axonal loss from focal segmental demyelination.

Objectives:

In patients of peripheral neuropathy,

1. To study the clinical profile
2. To study the electrophysiological profile
3. To evaluate the etiological profile.

Sample size and duration of study:

85 consecutive cases of chronic peripheral neuropathy attending the neurology department, Guntur during the period of January 2024 to December 2024 were enrolled in the study.

Study design:

It is a prospective observational study.

Inclusion criteria:

     1.All patients presenting with symptoms and signs suggesting of chronic peripheral neuropathy.

2.   All the suspected cases of chronic peripheral neuropathy

Exclusion criteria:

1. Acute and sub-acute cases of peripheral neuropathy
2.   Myelopathy cases
3.    Traumatic neuropathy cases.
4. carpel tunnel syndrome cases.

Detailed history of the presenting complaints, past history, family history comorbid illnesses, past relevant medical history was taken. Detailed neurological examination was done. Complete blood hemogram, ESR, random blood glucose, renal function tests, liver function tests, serum thyroid profile, serum lipid profile, viral markers sent.  Specific tests like serum vitamin B12, HBA1C, serum electrophoresis, urine for Bence jones proteins, RA factor, ANA profile, vasculitis panel, Lymes serology, VDRL, MRI spine with contrast were done in selective cases. Electro diagnostic tests performed in all cases to know the pattern of involvement. Demyelinating neuropathy confirmed, if the distal latency exceeds 115% of the upper limit of the normal with the normal CMAP or more than 150% of the normal with reduced CMAP.  Axonal neuropathy is confirmed if amplitude was decreased with normal distal latency and conduction velocity³. Split Skin smear or nerve biopsy done, genetic testing done when necessary.

Table 1: Age & Sex distribution

Table 2: Symptomatology

Table 3: Pattern of Neuropathy

Table 4: Aetiology

Table 5: Pure Sensory Neuropathy

Table 6: Pure Motor Neuropathy

Peripheral neuropathy is a common neurological disorder, with variable presentation and numerous causes.

In our study age at presentation ranged from 18 year to 75 years, majority of cases are in the age range of 51 to 70 years, followed by 31 to 50 years age. There is male predominance i.e 67%, which is in accordance with study done by Sase and coworkers⁴, (62%) and Goel and coworkers, (61%)⁵.

The commonest cause of neuropathy includes diabetes and nutritional deficiencies⁶. Study done by Vishali et al⁷, found diabetes is the most common cause followed by entrapment neuropathy and idiopathic. In our study, prevalence of diabetic neuropathy was, which was in accordance with the study done by Bansal et al⁸.

Diabetes is the most common cause of insidious onset, gradually progressive neuropathy. It has variable presentations. Distal symmetrical poly neuropathy, with length dependent pattern is the most common finding. Entrapment neuropathy seen in 2 cases of diabetes, one had unilateral meralgia paresthetica, one person had asymmetrical progressive entrapment neuropathy of femoral nerve, with poor glycaemic control, for which plexopathy was ruled out by imaging. One middle aged diabetic with poor glycaemic control presented with progressive quadriparesis for which work up done including genetic panel, autoimmune, paraneoplastic panel were negative and nerve biopsy showed mixed. she was given rituximab, considering immune mediated neuropathy.

From the study done by Sase and coworkers⁴ GBS was the second most common cause. In study by Mygland and coworker’s⁹, alcoholic and toxic neuropathy was the next common cause. The second common cause in our study was immune mediated neuropathy. CIDP is reported as 6.2% in a study by Lubec and co- workers¹⁰, less compared to our study. Entrapment neuropathy was reported in 9% cases, in study by Sase and co wokers⁴, and it was 17% in study by Vishali et al⁷, followed by infective neuropathy.

Immune mediated neuropathy is the second most common aetiology in our study. Most of the CIDP cases were with diabetes, one case was nerve biopsy proven MADSAM. One case was DADS variant, one case was, bone marrow biopsy proven multiple myeloma, one was pure motor variant, 2 cases were sensory variant, 2 cases remitting and relapsing type, one case was childhood CIDP, one case GM1, GM2 antibody positive MMNCB, one case was GM1, GD1a antibody positive. Among connective tissue diseases, presented with mononeuritis multiplex pattern, 2 cases have been found to have Rheumatoid arthritis, 2 cases positive for SSA& SSB antibody.one pt had progressive quadriparesis with dysphagia, with oesophageal spasm and functional gut motility disorder with hearing deficit, work up done for systemic sclerosis and came positive. One case presented with insidious onset gradually progressive sensory ataxia with severe dysautonomia, autoimmune and paraneoplastic panel was negative, he responded with steroids than iv immunoglobulins. 2 cases clinically suspected as vasculitis with mononeuritis multiplex presentation, but panel was negative, but responded with steroids.

Among infective causes, 8 cases were of Hansen’s neuropathy.  They presented as mononeuritis multiplex neuropathy. Out of them, 5 cases were on MDT treatment, 1 case completed the course, one case is defaulter and one case newly diagnosed with split skin smear .one case still had hypasthetic patch, one case had deformities, one case had peripheral nerve thickening. 2 cases had large fiber involvement. Electrodiagnostic studies showed motor involvement in 3 cases. It emphasises the need for considering any drug resistance of Hansen’s disease.

2 cases have insidious onset, gradually progressive quadriparesis with significant weight loss and wasting, with spine imaging showed root enhancement at conus, turned out to be positive for Lymes serology, improved with doxycycline. One case   had similar history with bladder involvement, turned out to be positive for brucella antibody.

Alcohol related neuropathy seen in 6 cases, most of them are painful. One case, presented with both small and large fiber neuropathy, dramatically improved with thiamine supplementation.

Among pure sensory neuropathy, one case had GIT symptoms, for the past 3 years. Due to constraints, antigliadin antibody could not be done. We could get duodenal biopsy showed lymphocytic infiltration but periodic acid Schiff base stain negative. But she responded with doxycycline.,

For chronic idiopathic neuropathy, Smith and his co-workers¹¹ found only 31% to be idiopathic, remaining cases turned to be of impaired glucose intolerance. Another study by Hughes and co-workers¹² did not find glucose intolerance, as the significant risk factor.

Among idiopathic cases, still we would like to consider immune mediated neuropathy where panel was negative, as research is going on for new antibodies.

Diabetes is the most common cause which emphasises the need for glycemic control apart with life style modification. Immune mediated neuropathy is in increasing trend, might be due to changes in environmental factors, life style and genetic and epigenetic factors. Infective causes also need to considered as a preventable cause. More studies in large sample are needed for better understanding the disease profile.

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