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Electrodiagnosis & Rehabilitation Associates–Experience & Expertise brings Excellence 2
Table 2. Specialized Laboratory Investigation Acute & Chronic Polyneuropathies
Medical Conditions
Laboratory
Connective tissue diseases and vasculitis: Sjogren’s dis-
Antinuclear antigen profile; Rheumatoid factor/RF, anti-Ro/SS- ease; SLE; Rheumatoid; Mixed Connective Tissue Dis- A, anti-La/SS-B (Sjogren’s); Cryoglobulins; Eosinophil count; ease; Polyarteritis Nodosa; Churg-Strauss disease; Complement levels; Anti-neutrophil cytoplasmic antigen anti- Wegener’s granulomatosis; ANCA syndrome body/ANCA; Cryoglobulins; CXR for infiltrates (Wegner’s) Infectious agents : Syphilis; campylobacter jejuni; CMV; RPR/VDRL/FTA; CMV titers; Hepatitis panel (B&C), HIV tests,
Lyme; Leprosy; HIV; West Nile; Herpes virus. Note: Risk Lyme titers, West Nile & Herpes viral tests, CSF analysis
Varicella Zoster/VZV = 1/3 (1> 60 y.o.). PHN = 10-18%
Diseases of gut : Malabsorption; Short bowel syndrome; Vitamin/Mineral Levels: B1/Thiamine, B6 , Foltate, B12; D& E;
Sequalae bariatric Surgery (reference AANEM: Muscle & Iron, Calcium, Magnesium, Phosphorus, Selenium, Cooper & Zinc. Celiac disease antibodies: Gliadin, transglutaminase, Endomysial; Endoscopic biopsy for confirmation Sarcoidosis
Serum angiotensin converting enzyme/ACE; ACE CSF Heavy metal toxicity: most common – Arsenic,
Blood, urine, hair & nail analysis for heavy metals Bismuth, Cadmium, Lead, Mercury, Thallium
Blood Disorders: Pernicious Anemia; Porphyria (e.g.
Anti-intrinsic cell IgG Ab in up to 70% patients with Pernicious Acute Intermittent Porphyria/AIP (Autosomal dominant) Anemia; Anti-Parietal cell Ab by ELISA has advantage over RIA detecting Abs to both type I & II (absent RIA false + when high B12 levels due to treatment); Urine, blood & stool for por- phyrins: Porphobilinogen deaminase deficiency   urinary lev- els of -Aminolevulinic acid (ALA) & Porphobilinogen (PBG) which establishes the diagnosis of acute Porphyria Hereditary: CMT, Hereditary Neuropathy Liability to
Specific genetic tests provides 100 % specificity (0% False +). Pressure Palsies (HNLPP) & Hereditary Amyloidosis (HA) Available for  # hereditary PN: CMT; HNLPP; HA Malignancies: Carcinoma, myeloma, lymphoma
Skeletal survey & bone scan; Mammography; CT &/or MRI Chest, ( US) Abdomen &/or Pelvis; PET; CSF with cytology; Serum para-neoplastic Ab profile: Anti-Hu & Anti-CV2 Table 3. Focus on Newer Medications; and a Multi-Modal Tiered Approach to Painful Peripheral Neuropathies
Therapy– First Line
Dose Range
Common Side Effects
TCA/SSRIs
Nausea, dizziness, fatigue, constipation Anti-Epileptic Drugs (AEDs)
100 mg  slowly: 100-300 mg up to 2400 - 3200 Nausea, sedation, dizziness/ataxia, fa-  slowly: 50-300 mg divide b.i.d.-t.i.d. Second Line Anti-Epileptic Drugs (AED) and Non-Opioid Analgesics
Tegretol (Carbemezapine)
100 mg  100-200 mg ->1600 mg/d divide t.i.d. Sedation, unsteadiness, nausea/vomit- ing, rash,  WBCs/platelets; hepatitis 50-400 mg/day divide t.i.d.-q.i.d. or ER GI side effects, sedation Other AEDs: Gabitril (Tiagabine); Lamictal (Lamotrigine);Topamax (Topiramate); Depakote (Valproate); Zonegran (Zonisamide)
Third Line & Alternatives
Mexitil (Mexiletine)
100 mg  by 100 mg up to 900 mg/d divide t.i.d. Arrhythmia, dizziness, vertigo, nausea (Not if AV conduction block)
Topicals: Capsaicin (Zostrix)(Sub P depletion); Lidoderm patch; Diclofenac; Compounding pharmacy combinations:
Anesthetics, Salicylates, Ketoprofen, TCA, Ketamine, Cyclobenzaprine, Baclofen, AEDs (Gabapentin, etc.)
Multi-modal therapy is often best: Non-narcotic and/or Opioid analgesics in combination with TCA/SSRIs & AEDs
Varicella Zoster/VZV): Acute- Oral antiviral agents, i.e. Acyclovir, Valacyclovir, Famicyclovir  Corticosteroids + analge-
sics (oral &/or topical), &/or TCA/SSRIs &/or AED/SSRIs. Consider root or epidural blocks; Prevention– Zoster Vaccine
Pending FDA approval– NGX-4010 (8% Capsaicin patches) for Post-herpetic neuralgia (PHN) & DPN
Drs. Ansari, Posuniak, Sundarum & Wang welcome Musculoskeletal & Spinal Management Referrals

Source: http://electrodiagnosis.net/NewsResearch/EandRNewsletter/Volume%2010%20Issue_1_2_09%20EVALUATION%20AND%20TREATMENT%20OF%20PERIPHERAL%20NEUROPATHY.pdf