Paresthesias

Paresthesias are abnormal sensations, such as numbness or tingling, that may occur secondary to lesions anywhere in the nervous system. They may be accompanied by hypesthesia (decreased sensation), most commonly noticed in response to painful or tactile stimuli. The etiology of paresthesias are usually suggested by the distribution of the finding and the associated symptoms.

Differential Diagnosis

• Nerve compression or entrapment neuropathy
  –Lumbosacral disc herniation with nerve root compression
  –Posterior tibial nerve compression (tarsal tunnel syndrome)
  –Peroneal nerve compression (foot drop)
  –Cervical spine spondylosis/disc herniation with nerve root compression
  –Median nerve compression (carpal tunnel syndrome, often seen in hypothyroidism and pregnancy)
  –Ulnar nerve compression
  –Long thoracic nerve compression (winged scapula)
• Infections (e.g., HIV/AIDS, herpes zoster, Lyme disease)
• Diabetic neuropathy (bilateral symptoms)
• Alcoholic neuropathy
  –Bilateral symptoms
  –Due to thiamine deficiency (vitamin B₁)
• and/or direct toxic effect of alcohol
• Vitamin B₁₂ deficiency
• Uremia
• Vasculitis or collagen vascular disease
• Tumor (including hematologic malignancy)
  –Carcinomatous infiltration or direct compression
  –Paraneoplastic syndrome (especially lung cancer)
• Toxins
  –Industrial exposures (e.g., lead, mercury, pesticides)
  –Medications (e.g., pyridoxine, isoniazid, vincristine, cisplatin, antiretrovirals, hydralazine)
• Guillain-Barré syndrome (usually bilateral)
• Hereditary motor or sensory neuropathies
• Amyloidosis
• Porphyria
• Paraproteinemias (e.g., multiple myeloma)
• Amyotrophic lateral sclerosis
• Alcohol withdrawal (sensation of “crawling bugs”)
• Trigeminal neuralgia

Workup and Diagnosis

• A complete history and physical examination is necessary to determine the etiology of most cases
  –Time course of onset
  –Anatomic distribution (focal, unilateral, bilateral)
  –History of trauma, diabetes, alcohol abuse, cancer, or collagen vascular disease
  –Associated weakness, cramping, pain, or loss of position or temperature sense
  –Comprehensive neurologic exam with a focus on cervical or lumbosacral nerve patterns
• Initial tests may include fasting CBC, electrolytes, calcium, magnesium, TSH, glucose, BUN/creatinine, hemoglobin A_1C, ESR, vitamin B₁₂, thiamine level, and chest X-ray
  –Additional tests may be indicated based on history (e.g., lead level, SPEP and UPEP to rule out paraproteinemia, Lyme titers)
• Electromyography may be used to differentiate neuropathic versus myopathic causes of muscle atrophy
• Nerve conduction studies
• Nerve biopsy (usually the sural nerve) is reserved for proof of histologic processes that have an impact on management (e.g., amyloidosis)

Treatment

• Compression or entrapment neuropathy
  –Avoid aggravating activities and repetitive trauma
  –Immobilization/splinting of affected limb
  –Physical therapy and proper ergonomics/biomechanics
  –NSAIDs and/or acetaminophen
  –Epidural steroids in severe cases
  –Surgical release of entrapped nerve/herniated disc if conservative measures fail and symptoms persist
  –Surgical removal of compressive tumors
• Treat and control underlying diseases (e.g., diabetes, alcoholism, HIV, renal disease, vasculitis)
• Treat underlying infections (e.g., zoster treated by acyclovir or famciclovir for 7 days)
• Supplement vitamin deficiencies
• Discontinue offending medications or toxic exposures
• Painful peripheral neuropathies (diabetic, alcoholic) may be relieved by amitriptyline or desipramine, phenytoin or carbamezapine, or topical capsaicin cream

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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