axonal neuropathies

[Atlas1496]

I have had multiple patient's I have seen with axonal neuropathies for years with ongoing denervation seen on EMG. A lot of these people are fairly symptomatic with paresthesias, distal weakness, gait disturbance etc. I'm just not sure what to make of it. I have done the million dollar workup for many of these patient's and cannot ever find a good explanation.

I had one gentleman I sent for nerve biopsy which showed "axonal loss with active denervation" which is also what the EMG showed. MRI of the lumbar spine has always been negative for these aside from one guy who I found CES in lol.

I'm assuming there is some level of fairly rapid axonal loss causing the denervation so I tend to think it would have to be a toxicity of some kind. One person had a fairly high uric acid and another w/ average glucose around 300 which I suppose could be a reasonable enough explanation.

Do y'all have any advice on these? I'm at a loss as to where to take workup and usually end up referring out for second opinion.

---

Members don't see this ad.

 

[chexmyx]

Check vitamin levels. Lots of polynutritional neuropathy goes undiagnosed. B1, B6, Copper, vitamin E besides the usual

 

[deathmerchant]

I have had multiple patient's I have seen with axonal neuropathies for years with ongoing denervation seen on EMG. A lot of these people are fairly symptomatic with paresthesias, distal weakness, gait disturbance etc. I'm just not sure what to make of it. I have done the million dollar workup for many of these patient's and cannot ever find a good explanation.

I had one gentleman I sent for nerve biopsy which showed "axonal loss with active denervation" which is also what the EMG showed. MRI of the lumbar spine has always been negative for these aside from one guy who I found CES in lol.

I'm assuming there is some level of fairly rapid axonal loss causing the denervation so I tend to think it would have to be a toxicity of some kind. One person had a fairly high uric acid and another w/ average glucose around 300 which I suppose could be a reasonable enough explanation.

Do y'all have any advice on these? I'm at a loss as to where to take workup and usually end up referring out for second opinion.

I didn't understand the exact advice you are looking for. Just like many other neurological disorders (esp progressive neurodegenerative disorders), the exact etiology is not always clear. Based on literature, 90% causes for acquired 'Axonal' neuropathies are the following- Diabetic; Toxic (alcohol/drugs/chemo), Immune/inflammatory like- (Vasculitis/CTDs, Amyloid), Metabolic (Uremic, Vitamins, Thyroid).
And this is why my first line workup includes- A1c, ESR/CRP/ANA with reflex, CBC, CMP, TSH, Vit B12, UPEP/SPEP, RPR.

If there are red flags like early onset or rapid progression (and none of the above), I will check for things like other vitamin levels, Heavy metals, More elaborate immune workup and sometimes look for hereditary/genetic etiologies like CMTs. In these cases, I will also consider MRI L spine, EMG/NCS, skin biopsy and CSF analysis esp. to look for demyelinating neuropathies. I have also seen more than a few patients with bad axonal neuropathies after gastric bypass despite vitamin supplementation and normal levels. (Likely micronutrient deficiencies)

Once you have done the above, and the workup is negative, its just symptomatic management. Starting with first line like gaba's, TCA, Cymbalta etc by themselves or combo. After that its usually Opiods/tramadol, Neurostimulation, pain management and non pharmacological therapies. I have recommended CBD/THC products to be used locally and otherwise to some patients with benefits.

 

[Atlas1496]

Thanks, exactly the advice I'm looking for. Just wanted to make sure that I'm not missing something because a lot of these people come back and endorse worsening symptoms.

I usually get the deer in the headlights look after we have done all this workup with still no answer.