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Laboratory Diagnosis of Peripheral Neuropathy

Laboratory Diagnosis of Peripheral Neuropathy

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Laboratory Diagnosis of Peripheral Neuropathy

  

Contents:

Introduction - Table  

Endocrine and Metabolic Causes

Nutritional and Toxic Causes

Immune-mediated Peripheral Neuropathies

Autoimmune Encephalitis

Paraneoplastic Neuropathies, Monoclonal Gammopathies, and Primary Amyloidosis

Polyneuropathies Caused by Infections or Inflammatory Diseases

References

 
Introduction [return to contents]

Peripheral neuropathy usually presents with weakness and sensory loss or pain in the arms and legs. It is estimated that 10% to 22% of people in the United States suffer from neuropathy, the incidence of which increases with age. Neuropathies are classified according to cause (endocrine, metabolic, nutritional, toxic, etc) or clinical presentation (sensory, motor, autonomic, mixed sensory and motor, mononeuritis, mononeuritis multiplex, etc). Due to the diverse causes of neuropathy, laboratory testing is invariably required for diagnosis or etiologic identification.

The following is a brief review of the known causes of acquired peripheral neuropathies and the laboratory tests available for their evaluation and diagnosis. The Table is provided for informational purposes only and is not intended as medical advice. A physician's test selection and interpretation, diagnosis, and patient management decisions should be based on his/her education, clinical expertise, and assessment of the patient.

Table.  Acquired Peripheral Neuropathies and Associated Laboratory Tests
[return to contents]

Cause of Neuropathy Laboratory Test

Endocrine and Metabolic Diseases

Diabetes Blood glucose, glycated hemoglobin
Hypothyroidism Thyroid function
Renal failure BUN, serum creatinine
Porphyria Urine porphyrins

Nutritional Diseases

Vitamin B12 deficiency CBC; serum B12
Vitamin B6 deficiency Plasma B6
Vitamin B6 toxicity Plasma B6
Vitamin B1 deficiency Blood B1
Vitamin E deficiency Serum vitamin E
Folate deficiency Serum folate

Heavy Metal Toxicity

Lead 24-hour urine heavy metals panel
Arsenic 24-hour urine heavy metals panel
Mercury 24-hour urine heavy metals panel

Autoantibodies to Peripheral Nerve Antigens

Ganglioside asialo-GM-1 antibody neuropathy Asialo-GM-1 antibody
Ganglioside GD1a antibody neuropathy GD1a antibody
Ganglioside GD1b antibody neuropathy GD1b antibody
Ganglioside GM-1 antibody neuropathy GM-1 antibody
Ganglioside GQ1b antibody neuropathy GQ1b antibody
MAG/SGPG antibody neuropathy MAG/SGPG antibody
Sulfatide antibody neuropathy Sulfatide antibody

Rheumatologic, Autoimmune, and Vasculitic Disease

Polyarteritis Cryoglobulins, immune complexes, CH50, hepatitis B and C serology, parvovirus serology, HIV-1 serology
Systemic lupus erythematosus ANA, dsDNA antibodies
Rheumatoid arthritis Cyclic citrullinated peptide antibody, rheumatoid factor, 14-3-3 eta protein
Granulomatosis with polyangiitis (Wegener) Anti-neutrophil cytoplasmic antibody (ANCA), myeloperoxidase (MPO) antibody, proteinase 3 (PR3) antibody
Sjögren syndrome ANA, mitochondrial antibody, rheumatoid factor, SS-A/Ro antibody, SS-B/La antibody, and thyroid peroxidase antibody
Celiac disease Gliadin, transglutaminase, and endomysial antibodies

Paraneoplastic Disease

Lung cancer Hu, Ri, Yo, Ma2/Ta, CV2, and amphiphysin antibodies
Monoclonal gammopathy Immunofixation (IFE), serum and urine
Myeloma Immunofixation (IFE), serum and urine
Macroglobulinemia Immunofixation (IFE), serum and urine
Chronic lymphocytic leukemia Immunofixation (IFE), serum and urine

Primary Amyloidosis

Immunofixation (IFE), serum and urine
Kappa/lambda light chains, free with ratio, serum

Infectious and Inflammatory Disease

AIDS HIV-1 antibody
Lyme disease Borrelia burgdorferi antibodies (total, IgG, IgM)
Herpes zoster Varicella zoster antigen, antibodies (IgG, IgM), and DNA
Cytomegalovirus CMV antibodies (IgG, IgM) and DNA
Hepatitis B HBs antigen, HBc antibodies (IgG, IgM)
Hepatitis C Hepatitis C antibody and RNA
Sarcoidosis Angiotensin converting enzyme

Endocrine and Metabolic Causes [return to contents]

Endocrine causes of neuropathy include diabetes mellitus and hypothyroidism. The most common cause of neuropathy is diabetes mellitus, which accounts for approximately 30% of cases. Approximately 50% of individuals with diabetes will develop neuropathy, and in some cases, neuropathy is the presenting complaint. The most frequent presentation is distal sensory polyneuropathy, but patients may also present with small fiber neuropathy (commonly caused by glucose intolerance), sensorimotor neuropathy, amyotrophy, mononeuritis, or mononeuritis multiplex. Diagnostic tests for diabetes mellitus include glycated hemoglobin (ie, hemoglobin A1c), blood glucose, and glucose tolerance assays. Hemoglobin A1c is also useful for monitoring diabetic control. Hypothyroidism presents predominantly as a sensory neuropathy and can be diagnosed with thyroid function tests including TSH and T4.

Metabolic causes of neuropathy include renal failure and porphyria. Renal failure, indicated by elevated serum creatinine and BUN, is associated with a predominantly sensory axonal neuropathy. Porphyria is associated with an acute, predominantly motor, neuropathy and is detected by urine porphyrin analysis.

Nutritional and Toxic Causes [return to contents]

Vitamin deficiency (B1, B6, B12, and E) and folate deficiency, as well as excessive intake of vitamin B6, can cause peripheral neuropathy. B12 deficiency is associated with achlorhydria or pernicious anemia and sometimes with parietal cell or intrinsic factor antibodies. Vitamin E deficiency is often associated with ataxia. Measurement of serum vitamin levels is useful in making the diagnosis.

Peripheral neuropathy may also be caused by several heavy metals. Lead toxicity is associated with motor neuropathy, whereas arsenic and mercury cause sensory neuropathy. The 24-hour urine heavy metal test is the most useful test for diagnosis of heavy metal toxicity.

Immune-mediated Peripheral Neuropathies [return to contents]

The immune system mediates peripheral neuropathies in autoimmune diseases, in systemic diseases such as vasculitis and primary amyloidosis, and in paraneoplastic syndromes. Autoimmune neuropathies are usually divided into Guillain-Barre syndrome, variants that are of acute onset and self-limiting, and variants that are chronic and follow a progressive or relapsing course. Glycoconjugate antigens, both glycoproteins and glycolipids, have been identified as putative targets for many of these autoimmune polyneuropathies. In general, IgG glycoconjugate autoantibodies have been associated with acute neuropathies, whereas IgM autoantibodies are associated with the chronic neuropathic syndromes.

Acute immune-mediated neuropathies include the Guillain-Barre syndrome (GBS; acute inflammatory demyelinating polyneuropathy), acute motor axonal polyneuropathy, acute sensory polyneuropathy, acute autonomic polyneuropathy, and the Miller-Fisher syndrome in which the extra-ocular muscles are affected. Increased titers of IgG GM1 or GD1a ganglioside antibodies have been associated with GBS and acute motor axonal neuropathy, whereas increased IgG GQ1b ganglioside antibodies are closely associated with the Miller-Fisher syndrome. Tests for these autoantibodies are useful aids in the evaluation of patients suspected of having these syndromes.

Chronic immune-mediated polyneuropathies in which the peripheral nerves are selectively affected include chronic inflammatory demyelinating polyneuropathy (CIDP), demyelinating polyneuropathy associated with IgM MAG (myelin-associated glycoprotein) antibodies or SGPG (sulfoglucuronyl paragloboside) antibodies, multifocal motor neuropathy associated with IgM GM1 or GD1a antibodies, and sensory polyneuropathy associated with IgM sulfatide antibodies or GD1b or disialosyl ganglioside antibodies. Other neuropathies may be associated with GM2 antibodies. The presence of increased titers of these autoantibodies helps diagnose an immune-mediated polyneuropathy that may respond to specific immunotherapy. Some of these autoantibodies also occur as IgM monoclonal gammopathies in patients with non-malignant monoclonal gammopathies or in association with B-cell lymphoproliferative disorders (see paraneoplastic syndromes below).

Peripheral neuropathy can also occur in patients with rheumatologic diseases or systemic vasculitis, including systemic lupus erythematosus, Sjögren syndrome, rheumatoid arthritis, and granulomatosis with polyangiitis (GPA; Wegener). SLE can be diagnosed with the aid of tests for anti-nuclear antibodies (ANA). SS-A/Ro and SS-B/La antibodies are consistent with Sjögren syndrome, and rheumatoid factor and cyclic citrullinated peptide antibody are consistent with rheumatoid arthritis. Anti-neutrophil cytoplasmic antibodies (ANCA), myeloperoxidase (MPO) antibody, and proteinase 3 (PR3) antibody are helpful for diagnosing GPA. Polyarteritis nodosa is another disease that is associated with vasculitis of the peripheral nerves, sometimes associated with hepatitis B. Chronic hepatitis C virus infection is associated with cryoglobulinemia, in which deposition of cryoglobulin-containing immune complexes causes small- and medium-size vessel disease. Vasculitis can also result from viral infections such as parvovirus. In viral infections, circulating immune complexes, cryoglobulins, or decreased complement levels (CH50) may be present. Vasculitic neuropathies typically present as mononeuritis, mononeuritis multiplex, or polyneuritis. However, Sjögren syndrome sometimes presents with sensory neuropathy or ganglioneuritis. Ribosomal P antibody may be present in these individuals. Celiac disease, an inflammatory disease of the gut that results from gluten intolerance, may be associated with a sensory neuropathy, sometimes with ganglioside antibodies. It can be recognized by the presence of gliadin, transglutaminase, or endomysial antibodies. Endomysial antibodies commonly, but not always, react with transglutaminase.

Other neuropathies that are, in part, mediated by the immune system are those associated with neoplasia, monoclonal gammopathies, and primary amyloidosis (see below).

Autoimmune Encephalitis [return to contents]

Symptoms of autoimmune encephalitis include seizures; changes in memory, behavior, and cognition; and psychosis. These encephalopathies may be caused by antibodies to neurotransmitter receptors such as N-methyl-D-aspartate receptor 1 (NMDAR1), glutamate receptors AMPAR1 and AMPAR2, and GABAB receptors. Encephalitis may also be caused by antibodies to proteins within the voltage-gated potassium channel (VGKC) complex such as leucine-rich glioma inactivated 1 (LGI1) and contactin-associated protein 2 (CASPR2). Some cases of autoimmune encephalitis have been associated with neoplasms such as teratomas.

Paraneoplastic Neuropathies, Monoclonal Gammopathies, and Primary Amyloidosis  [return to contents]

Paraneoplastic syndromes are thought to be caused by indirect effects of tumors, usually via immune or metabolic mechanisms. Several paraneoplastic neuropathic syndromes have been recognized. One of these is a predominantly sensory neuropathy that occurs in patients with carcinoma of the lung in association with Hu antibodies, which serve as a marker for the disease. Neuropathy is also associated with IgM monoclonal gammopathies in patients with Waldenstrom macroglobulinemia or B-cell leukemia or lymphoma and with IgG or IgA monoclonal gammopathies in myeloma. The monoclonal IgMs in patients with neuropathy frequently exhibit reactivity to one of the glycoconjugate antigens in peripheral nerves (see above). In myeloma, the monoclonal IgG or IgA antibodies do not have demonstrable autoantibody activity. Monoclonal gammopathy of any isotype, or light chain disease, can also be associated with primary amyloidosis in which the amyloid deposits contain fragments of the monoclonal light chains. The same neuropathic syndromes can also be associated with non-malignant IgM, IgG, or IgA monoclonal gammopathies, or monoclonal gammopathies of unknown significance (MGUS). Laboratory tests that are useful for detecting monoclonal gammopathies include an immunoglobulin profile (IgA, IgG, IgM) and immunofixation electrophoresis of serum and urine. Measurement of free kappa and free lambda light chain is useful for detecting light chain disease.

Polyneuropathies Caused by Infections or Inflammatory Diseases [return to contents]

Several infectious diseases also cause peripheral neuropathy. Human immunodeficiency virus-1 (HIV-1) infection is typically associated with a distal sensory neuropathy. Lyme disease can cause mononeuritis multiplex or diffuse polyneuropathy. Cytomegalovirus (CMV) infection of nerves causes an ascending polyradiculopathy. Herpes zoster infection can cause radiculopathy (shingles). Hepatitis B or C infections, or parvovirus infection in immunocompromised patients, can be associated with polyarteritis nodosa and vasculitic neuropathy. Sarcoidosis can also cause a multifocal or diffuse neuropathy. Serologic testing for suspected infections or for angiotensin converting enzyme (ACE) levels in sarcoidosis is helpful in the evaluation and diagnosis of patients with neuropathy.

References [return to contents]

  1. Asbury AK, Thomas PK. Peripheral Nerve Disorders 2. Oxford: Butterworth Heinemann Ltd; 1995.

  2. Bollensen E, Schipper HI, Steck AJ. Motor neuropathy with activity of monoclonal IgM antibody to GD1a ganglioside. J Neurol. 1989;236:353-355.

  3. Chiba A, Kusunoki S, Obata H, et al. Serum anti-GQ1b antibodies are associated with ophthalmoplegia in Miller-Fisher syndrome and Guillain-Barre syndrome: clinical and immunohistochemical studies. Neurology. 1993;43:1911-1917.

  4. Dalmau J, Tuzun E, Wu HY, et al. Paraneoplastic anti-N-methyl-D-aspartate receptor encephalitis associated with ovarian teratoma. Ann Neurol. 2007;61:25-36.

  5. Duane GC, Farrer RG, Dalakas MC, et al. Sensory neuropathy associated with immunoglobulin M to GD1b ganglioside. Ann Neurol. 1992;31:683-685.

  6. Dyck PJ, Thomas PK, Griffin JW, et al. Peripheral Neuropathy, 3rd Ed. Philadelphia: WB Saunders; 1993.

  7. Kelly JJ Jr, Kyle RA, Miles JM, et al. The spectrum of peripheral neuropathy in myeloma. Neurology. 1981;31:24-31.

  8. Kelly JJ Jr, Kyle RA, O’Brien PC, et al. The prevalence of monoclonal gammopathy in peripheral neuropathy. Neurology. 1981;31:1480-1483.

  9. Kinsella LJ, Lange DJ, Trojaborg W, et al. The clinical and electrophysiological correlates of elevated anti-GM1 antibody titers. Neurology. 1994;44:1278-1282.

  10. Koopman RJ, Mainous AG, Liszka HA, et al. Evidence of nephropathy and peripheral neuropathy in US adults with undiagnosed diabetes. Ann Fam Med. 2006;4:427-432.

  11. Kyle RA, Greip PR. Amyloidosis (AL): clinical and laboratory features in 229 cases. Mayo Clin Proc. 1983;58:665-683.

  12. Lai M, Huijbers MG, Lancaster E, et al. Investigation of LGI1 as the antigen in limbic encephalitis previously attributed to potassium channels: a case series. Lancet Neurol. 2010;9:776-785.

  13. Latov N. Pathogenesis and therapy of neuropathies associated with monoclonal gammopathies. Ann Neurol. 1995;37(S1):S32-42.

  14. Latov N, Steck AJ. Neuropathies associated with glycoconjugate antibodies and IgM monoclonal gammopathies. In: Asbury A, Thomas PK (eds). Peripheral Nerve Disorders II. Boston: Butterworth-Heinemann;1995:153-173.

  15. Ogino M, Orazio N, Latov N. IgG anti-GM1 antibodies from patients with acute motor neuropathy are predominantly of the IgG1 and IgG3 subclasses. J Neuroimmunol. 1995;58:77-80.

  16. Pestronk A, Li F, Griffin J, et al. Polyneuropathy syndromes associated with serum antibodies to sulfatide and myelin associated glycoprotein. Neurology. 1991;41:357-362.

  17. van den Berg LH, Hays AP, Nobile-Orazio E, et al. Anti-MAG and anti-SGPG antibodies in neuropathy. Muscle Nerve. 1996;19:637-643.
     

Content reviewed 09/2015

 
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