WEAKNESS OR PARALYSIS OF ONE OR MORE EXTREMITIES
WEAKNESS OR PARALYSIS OF ONE OR MORE EXTREMITIES: Excerpt from Differential Diagnosis in Primary Care
This symptom, as opposed to generalized weakness and fatigue , is almost invariably due to a
neurologic disorder. Consequently, a comprehensive list of causes is
developed using neuroanatomy. Muscle weakness or paralysis may be
due to disease of the muscle, myoneural junction, peripheral nerve, nerve
roots and anterior horn cells, and pyramidal tract involvement in the spinal
cord, brainstem, or cerebrum. Table 61 has been constructed with
these anatomic components cross-indexed with the various etiologies
suggested by the mnemonic VINDICATE. The most important of these
will be covered in the following discussion.
-
Muscle. This should suggest muscular dystrophy and
dermatomyositis.
-
Myoneural junction. Primary and symptomatic myasthenia gravis
are promptly brought to mind here. The toxic effects of succinylcholine
chloride (Anectine), cholinergic drugs, and antispasmodics should also be
mentioned.
-
Nerve. The many causes of peripheral neuropathy should be
recalled here. The most important are diabetic neuropathy, alcoholic and
nutritional neuropathies, Guillain–Barré syndrome, Buerger disease,
periarteritis nodosa, porphyria, peroneal muscular atrophy, and lacerations
or contusions from blunt trauma or surgery.
-
Nerve root or anterior horn. Poliomyelitis, lead neuropathy, and
progressive muscular atrophy are a few diseases that specifically attack the
anterior horn and roots; the roots may also be compressed by herniated
disks, fractures, tuberculosis, or metastatic carcinomas of the spine. The
spinal cord is often involved in the compression, too. Cervical spondylosis
and spondylolisthesis may also compress the nerve root.
-
Spinal cord. The pyramidal tracts are involved in
malformations such as syringomyelia, arteriovenous anomalies, and
Friedreich ataxia; in inflammatory diseases like syphilis,
tuberculosis of the spine, and transverse myelitis; in neoplasms
(both primary and metastatic); and in traumatic lesions such as
fractures, herniated discs, and hematomas. Thus, the mnemonic MINT
is helpful in recalling these lesions. Cervical spondylosis, amyotrophic
lateral sclerosis, syringomyelia, pernicious anemia, and multiple sclerosis
may be forgotten, however, if only this mnemonic is used.
-
Brainstem. Brainstem gliomas and multiple sclerosis are
important causes of pyramidal tract disease, but vascular occlusions of the
basilar artery and its branches far exceed these in number.
-
Cerebrum. Any space-occupying lesions such as neoplasms,
cerebral abscesses, subdural hematomas, and large aneurysms may cause focal
monoplegia, hemiplegia, or paraplegia (parasagittal meningioma). Occlusions
and hemorrhages of the cerebral arteries, however, are much more common
causes of focal paralysis. Diffuse paralysis may result from the toxic and
inflammatory encephalitides, presenile dementia, lipoidosis, and diffuse
sclerosis. Multiple sclerosis and lupus erythematosus may also attack the
cerebral peduncles.
Approach to the Diagnosis
The site of weakness is determined by associated symptoms and signs.
Fasciculations suggest nerve root or anterior horn cell involvement, whereas
sensory changes suggest peripheral nerve or spinal cord involvement. A
combination of spasticity in the lower extremities and flaccid and atrophic
weakness in the upper extremities suggests cervical cord involvement.
Cranial nerve lesions in association with paraplegia or quadriplegia usually
indicate a brainstem lesion.
The workup will depend on the site in which the pathology is suspected to be
located. If muscle is the site, then an EMG or biopsy is indicated. If the
myoneural junction is involved, a Tensilon test is done. Peripheral nerve
lesions require a more extensive workup, including a glucose tolerance test,
blood lead level, urine for porphobilinogens, EMG, nerve conduction velocity
(NCV) test, and possibly a muscle biopsy. Spinal cord lesions may require
x-ray of the spine, CT scan or MRI, myelography, discography, and spinal
fluid analysis. Brainstem and cerebral lesions are best screened with a
skull x-ray, MRI, or CT scan before a spinal tap or arteriogram is
considered.
Other Useful Tests
-
CBC (pernicious anemia with neurologic involvement)
-
Chemistry panel (muscle disease, liver or kidney disease with
neurologic involvement)
-
ANA analysis (collagen disease with neuropathy or myopathy)
-
Acetylcholine receptor antibody titer (myasthenia gravis)
-
Urine creatine and creatinine levels (muscular dystrophy)
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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