Sensory Polyneuropathies

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Taxonomy

The terms "polyneuropathy," "peripheral neuropathy," and "neuropathy" are often often used interchangeably but in fact have distinct definitions.

• Polyneuropathy is a generalised relatively homogenous disease process where many peripheral nerves are affected with the distal nerves being most prominently affected
• Peripheral neuropathy refers to any disorder of the peripheral nervous system which can include radiculopathies and mononeuropathies.
• Neuropathy is even more general, referring to disorders of the central and peripheral nervous system

Anatomy

Characteristics of peripheral nerve fibres

Nerve Fibre	Myelin	Diameter (µm)	Conduction velocity (m/s)	General Function
Aα (I)	Yes	13-20	80-120	Proprioception: muscle spindle primary endings (Ia), golgi tendon organs (Ib), and alpha motor neurons
Aβ (II)	Yes	6-12	35-75	Discriminative sensitivity to mechanical stimuli (touch, vibration), proprioception, pain modulation (block nociceptive information, allodynia in sensitisation)
Aγ	Yes	4-8	15-40	Touch, pressure, and gamma motor neurons.
Aδ (III)	Thin	1-5	5-30	"rapid" pain, crude touch, pressure, temperature. AMH type I for rapid mechanical pain (high heat threshold >53C), AMH type II for rapid heat pain (lower heat threshold 43-47C).
B	No	1-3	3-14	preganglionic autonomic
C (IV)	No	0.2-1.5	0.5-2.0	"second" pain, mechanical, chemical, thermal, pruritis, and postganglionic autonomic. polymodal

Differential Diagnosis

The differential diagnosis for polyneuropathy can be categorised in several ways

1. Large fibre vs small fibre: Large fibre neuropathies will typically show reduced reflexes, weakness, and reduced vibration and position sense. On the other hand, small fibre neuropathies have normal reflexes and strength, and more minimal findings of reduced sensation to pin prick and temperature.

2. Hereditary vs acquired: Hereditary polyneuropathies can manifest in adulthood or childhood and there is often a family history. Charcot-Marie-Tooth can be suspected with the presence of a distinctive pes cavus foot.

3. Primary vs secondary: Primary polyneuropathy e.g. chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), and secondary polyneuropathy e.g. diabetes, toxin, and monoclonal gammopathy.

4. Axonal vs demyelinating: Axonal loss for example in diabetic polyneuropathy, or demyelination for example in CIDP. Polyneuropathies can be associated with axonal loss (e.g., diabetic polyneuropathy) or demyelination (e.g., CIDP)

Investigations

Painful neuropathies and their laboratory tests

Neuropathy	Blood	Urine	Biopsy
Diabetic	HbA1c	Glucose
Alcohol	LFTs
Vitamin Deficiency	B12
Vasculitis	Antinuclear antibodies		Biopsy
Sjogrens disease	Sjogren antibodies
AIDS	HIV antibodies, CD4
Primary amyloid	Protein electrophoresis	Protein electrophoresis	Biopsy
Fabry's disease	d-galactosidase Globotriasosylceramide	Globotriasosylceramide
Uraemic	UECs
Porphyric		d-aminolevulinic acid Porphobilinogen
Tangier's disease	Low cholesterol Low HDLs Low apoprotein
Churg-Strauss	Eosinophilia
Heavy metal	Arsenic, thallium
Familial amyloid			Biopsy
Hereditary			Biopsy
Charcot-Marie-Tooth			Biopsy
Cryoglubulinaemic			Biopsy

Reading

• Media:Peripheral_Neuropathy_-_Watson_2015.pdf