Common causes of distal symmetric polyneuropathy (DSPN)

Diseases	Comment
Metabolic
Diabetes	Most common cause, accounting for 32 to 53% of cases^*
Prediabetes	Glucose tolerance test has highest sensitivity^*
Chronic kidney disease	Neuropathy particularly severe when chronic kidney disease is caused by diabetes
Chronic liver disease	Neuropathy typically mild
Idiopathic	24 to 27% of all cases^*
Toxin (alcohol)	Second most common cause (requires in-depth questioning)^*
Inherited	Detailed family history required; ask about hammer toes, high arches^*
Charcot-Marie-Tooth disease type 1	Inherited demyelinating sensory motor neuropathy
Charcot-Marie-Tooth disease type 2	Inherited axonal sensory motor neuropathy
Familial amyloidosis	Transthyretin mutation most common
Nutritional
Vitamin B₁₂ deficiency	Methylmalonic acid level important when vitamin B₁₂ level is 200 to 400 picogram/mL^*
Vitamin E deficiency	Can cause cerebellar ataxia
Vitamin B₆ deficiency	Can cause neuropathy when level is too high or too low
Thiamine deficiency	Can present with ataxia, ophthalmoparesis, and confusion
Copper deficiency	Often presents with a myeloneuropathy
Gastric bypass surgery	Often difficult to determine which factor responsible
Malabsorption syndromes	Often difficult to determine which factor responsible
Medication
Chemotherapy (vincristine, cisplatin, taxol, bortezomib)	Known dose limiting side effect of many agents
Amiodarone	Can cause a demyelinating neuropathy
Phenytoin	Typically after many years of use
Nucleosides	Can be difficult to distinguish cause of neuropathy (HIV versus medication)
Nitrofurantoin	Worse in the setting of kidney failure
Metronidazole	Usually after high, prolonged intravenous doses
Hydralazine	Avoid by concomitant use of vitamin B₆
Isoniazid	Avoid by concomitant use of vitamin B₆
Colchicine	Can also cause myopathy
Autoimmune
Rheumatoid arthritis	Can also cause mononeuritis multiplex
Lupus	Can also cause mononeuritis multiplex
Sjögren syndrome	Can also cause a sensory neuronopathy or mononeuritis multiplex
Sarcoidosis	Can present with several neurologic manifestations
Secondary amyloidosis	Diagnosis aided by fat pad biopsy or sural nerve biopsy
Infectious
HIV	Medications used to treat can also cause neuropathy
Hepatitis B/C	Can also cause mononeuritis multiplex associated with polyarteritis nodosa and cryoglobulinemia
Neoplastic
Monoclonal gammopathy of unclear clinical significance	Immunofixation increases sensitivity of paraprotein detection^*
Multiple myeloma	Associated with IgG or IgA paraproteinemia
Primary amyloidosis	Diagnosis aided by fat pad biopsy or sural nerve biopsy

IgA: immunoglobulin A; IgG: immunoglobulin G.

* These statements are the most important take-home points.

Reproduced with permission from: Callaghan BC, Price RS, Feldman EL. Distal Symmetric Polyneuropathy: A Review. JAMA 2015; 314(20):2172-81. Copyright © 2015 American Medical Association. All rights reserved.

Graphic 76476 Version 18.0

خرید پکیج

Common causes of distal symmetric polyneuropathy (DSPN)