Toxic/Drug Induced Neuropathy
Many drugs, toxins and environmental chemicals can produce a peripheral neuropathy, with or without other manifestations.
Industrial/environmental agents:
Arsenic:
• chronic exposure malaise, burning sensation and sensory loss in ‘stocking and glove’ distribution; garlic odour of breath (if high dose); loss of plantar foot reflexes; hyperkeratosis of hands and feet; also get a vasculitis “black foot disease”; white transverse striations of nails (Mees lines)
• more common in industries which arsenic is involved (eg copper smelting)
• can mimic Guillain-Barre syndrome
• treatment – chelation
Acrylamide:
• skin exposure is neurotoxic (impairs axoplasmic transport); often have a dermatitis of hands
• numbness (loss of vibration sense is most noticeable; stocking & glove distribution), weakness, gait ataxia, hyperhidrosis of feet and hands, diffuse areflexia
• withdrawal from exposure slow recovery (some weakness or sensory loss may remain)
Lead:
• lead binds to sulfur groups disruption of enzymes; produces demyelination
• chronic exposure anaemia, colic, neuropathy
• neuropathy is mostly motor – affects mostly arm, but foot plantarflexors and peroneals may affected; starts with bilateral weakness; may have symmetrical sensory loss (could be subclinical, affecting legs>arms)
Mercury:
• if inhaled toxic; used in electrical and chemical industries
• get a peripheral motor dysfunction and painful dysthaesias – especially distally; tremor
• mimics Guillain-Barre syndrome
Methyl bromide:
chronic exposure to high to moderate levels distal sensory and motor neuropathy (symmetric numbness, parathesias, distal weakness, calf muscle tenderness)
also have pyramidal tract signs and signs of cerebellar dysfunction
resolves following withdrawal from exposure
Others:
• carbon disulfide (usually a lower limb numbness, parathesia and weakness); cadmium (often a subclinical motor and sensory neuropathy); dimethylaminopropionitrile; ethylene oxide (stocking and glove parathesia; mild motor changes); hexacarbons (distal weakness; parathesias in hands and feet; ankle reflexes lost); vacor (rapid onset of weakness with mild sensory loss); cyanide (neuropathy presents with dysthesias in feet; insidious onset; ataxia some weakness and muscle wasting; reduced reflexes); allyl chloride (distal neuropathy; sensory>motor; recovery after withdrawal of agent); thallium (reflexes generally normal; pain and parathesias in legs; weakness is mild)
Glue Sniffer Syndrome:
Exposure to n-Hexane occurs due to inhalation; muscle weakness – can progress o quadriplegia in severe cases; autonomic involvement of hands and feet – hyperhidrosis, blue discoloration, Mee’s lines in nails; feet and hands feel cooler
Drugs:
Colchicine:
• used to treat gout
• inhibits axonal flow by inhibiting microtubule formation
• mild distal sensory peripheral neuropathy and myopathy – usually mild
Chloroquine:
• antimalarial and used in autoimmune diseases
• neuropathy can develop after 1-2 years use
• can get a mild, painless proximal muscle weakness – buy may also get a mild distal mixed sensorimotor polyneuropathy
Gold:
• used for rheumatoid arthritis – side effects are common
• peripheral neuropathy is rare complication – usually a burning sensation, pain or loss of distal sensation
Phenytoin:
• antiepileptic
• most will show mild sensory loss on plantar surface of feet and diminished deep tendon reflexes
• can develop dysesthesias and mild weakness – especially distal legs
Statins:
lipid lowering drugs
neuropathy can develop after several years of use
sensory loss affecting feet greater than the hands; parathesias; distal weakness; occasional gait instability
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