Toxic Neuropathy Differential Diagnoses

  • Author: Jonathan S Rutchik, MD, MPH; Chief Editor: Tarakad S Ramachandran, MBBS, FRCP(C), FACP   more...
 
Updated: Sep 26, 2011
 
 

Differential Diagnoses

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Contributor Information and Disclosures
Author

Jonathan S Rutchik, MD, MPH  Clinical Professor, Division of Occupational Medicine, Department of Neurology, Environmental and Occupational Medicine, University of California, San Francisco, School of Medicine

Jonathan S Rutchik, MD, MPH is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Occupational and Environmental Medicine, and Society of Toxicology

Disclosure: Nothing to disclose.

Specialty Editor Board

Milind J Kothari, DO  Professor and Vice-Chair, Department of Neurology, Pennsylvania State University College of Medicine; Consulting Staff, Department of Neurology, Penn State Milton S Hershey Medical Center

Milind J Kothari, DO is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Glenn Lopate, MD  Associate Professor, Department of Neurology, Division of Neuromuscular Diseases, Washington University School of Medicine; Director of Neurology Clinic, St Louis ConnectCare; Consulting Staff, Department of Neurology, Barnes-Jewish Hospital

Glenn Lopate, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and Phi Beta Kappa

Disclosure: Baxter Grant/research funds Other; Amgen Grant/research funds None

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Chief Editor

Tarakad S Ramachandran, MBBS, FRCP(C), FACP  Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital

Tarakad S Ramachandran, MBBS, FRCP(C), FACP is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners, American College of International Physicians, American College of Managed Care Medicine, American College of Physicians, American Heart Association, American Stroke Association, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, and Royal Society of Medicine

Disclosure: Abbott Labs None None; Teva Marion None None; Boeringer-Ingelheim Honoraria Speaking and teaching

References

  1. Hoitsma E, Reulen JP, de Baets M, et al. Small fiber neuropathy: a common and important clinical disorder. J Neurol Sci. Dec 15 2004;227(1):119-30. [Medline].

  2. Kimura J. Polyneuropathies. In: Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice. 1989. 2nd ed. Philadelphia: FA Davis; 462-81.

  3. Kimura J. Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice. 2nd ed. Philadelphia: FA Davis; 1989:149-162.

  4. Feldman RG. Occupational and Environmental Neurotoxicology. Philadelphia: Lippincott-Raven; 1999.

  5. Albers J, Bromberg MB. Chemically induced toxic neuropathy. In: Rosenberg NL, ed. Occupational and Environmental Neurology. Boston: Butterworth-Heinemann; 1995:175-234.

  6. Schaumberg HH. Human neurotoxic disease. In: Spencer P, Schaumberg HH, eds. Experimental and Clinical Neurotoxicology. 2nd ed. New York: Oxford University Press; 2000.

  7. Mellion M, Gilchrist JM, de la Monte S. Alcohol-related peripheral neuropathy: nutritional, toxic, or both?. Muscle Nerve. Mar 2011;43(3):309-16. [Medline].

  8. Monforte R, Estruch R, Valls-Solé J, Nicolás J, Villalta J, Urbano-Marquez A. Autonomic and peripheral neuropathies in patients with chronic alcoholism. A dose-related toxic effect of alcohol. Arch Neurol. Jan 1995;52(1):45-51. [Medline].

  9. Behse F, Buchthal F. Alcohol Neuropathy: Clinical, Electrophysiological and Biopsy Findings. Ann Neurol. 1977;2:95-110.

  10. Vittadini G, Buonocore M, Colli G, Terzi M, Fonte R, Biscaldi G. Alcoholic polyneuropathy: a clinical and epidemiological study. Alcohol Alcohol. Sep-Oct 2001;36(5):393-400. [Medline].

  11. Seppalainen AM, Tolonen E. Neurotoxicity of long term effects of carbon disulfide in the viscose rayon industry. Scand J Work Environ Health. 1974;1:145-153.

  12. Ruijten MW, Salle HJ, Verberk MM, Muijser H. Special nerve functions and colour discrimination in workers with long term low level exposure to carbon disulphide. Br J Ind Med. Sep 1990;47(9):589-95. [Medline].

  13. Ruijten MW, Salle HJ, Verberk MM. Verification of effects on the nervous system of low level occupational exposure to CS2. Br J Ind Med. Apr 1993;50(4):301-7. [Medline].

  14. Johnson BL, Boyd J, Burg JR, et al. Effects on the peripheral nervous system of workers' exposure to carbon disulfide. Neurotoxicology. 1983;4(1):53-65. [Medline].

  15. Gross JA, Haas ML, Swift TR. Ethylene oxide neurotoxicity: report of four cases and review of the literature. Neurology. Jul 1979;29(7):978-83. [Medline].

  16. Fukushima T, Abe K, Nakagawa A, et al. Chronic ethylene oxide poisoning in a factory manufacturing medical appliances. J Soc Occup Med. 1986;36(4):118-23. [Medline].

  17. Schroder JM, Hoheneck M, Weis J, Deist H. Ethylene oxide polyneuropathy: clinical follow-up study with morphometric and electron microscopic findings in a sural nerve biopsy. J Neurol. 1985;232(2):83-90. [Medline].

  18. Kuzuhara S, Kanazawa I, Nakanishi T, Egashira T. Ethylene oxide polyneuropathy. Neurology. Mar 1983;33(3):377-80. [Medline].

  19. Finelli PF, Morgan TF, Yaar I, Granger CV. Ethylene oxide-induced polyneuropathy. A clinical and electrophysiologic study. Arch Neurol. Jul 1983;40(7):419-21. [Medline].

  20. Andersen A, Ellingsen DG, Morland T, Kjuus H. A neurological and neurophysiological study of chloralkali workers previously exposed to mercury vapour. Acta Neurol Scand. Dec 1993;88(6):427-33. [Medline].

  21. Barber TE. Inorganic mercury intoxication reminiscent of amyotrophic lateral sclerosis. J Occup Med. Oct 1978;20(10):667-9. [Medline].

  22. Adams CR, Ziegler DK, Lin JT. Mercury intoxication simulating amyotrophic lateral sclerosis. JAMA. Aug 5 1983;250(5):642-3. [Medline].

  23. Ross AT. Mercuric polyneuropathy with albumino-cytologic dissociation and eosinophilia. JAMA. Jun 1 1964;188:830-1. [Medline].

  24. Warkany J, Hubbard DM. Acrodynia and mercury. J Pediatr. 1953;42:365-386.

  25. Yoshida Y, Kamitsuchibashi H, Hamada R, et al. Truncal hypesthesia in patients with Minamata disease. Intern Med. Feb 1992;31(2):204-7. [Medline].

  26. Thomson RM, Parry GJ. Neuropathies associated with excessive exposure to lead. Muscle Nerve. Jun 2006;33(6):732-41. [Medline].

  27. Bleecker ML, Bolla KI, Agnew J, Schwartz BS, Ford DP. Dose-related subclinical neurobehavioral effects of chronic exposure to low levels of organic solvents. Am J Ind Med. 1991;19(6):715-28. [Medline].

  28. Bleeker ML. Clinical presentations of selected neurotoxic compounds. In: Bleeker ML, Hansen JA, eds. Occupational Neurology and Clinical Neurotoxicology. Baltimore: Williams & Wilkins; 1994:207-234.

  29. Demers RY, Markell BL, Wabeke R. Peripheral vibratory sense deficits in solvent-exposed painters. J Occup Med. Oct 1991;33(10):1051-4. [Medline].

  30. Bove FJ, Letz R, Baker EL. Sensory thresholds among construction trade painters: a cross-sectional study using new methods for measuring temperature and vibration sensitivity. J Occup Med. Apr 1989;31(4):320-5. [Medline].

  31. Padilla SS, Lyerly DP. Effects of p-xylene inhalation on axonal transport in the rat retinal ganglion cells. Toxicol Appl Pharmacol. Dec 1989;101(3):390-8. [Medline].

  32. Feldman RG. Effect of toxins and physical agents on the nervous system. In: Bradley WG et al, eds. Neurology in Clinical Practice. Boston: Butterworth-Heinemann; 1991:1185-207.

  33. Feldman RG. The recognition and differentiation of neurotoxic and non-neurotoxic syndromes. In: Chang LW, Slikker W, eds. Neurotoxicology: Approaches and Methods. San Diego: Academic Press; 1995:689-694.

  34. Juntunen J, Antti-Poika M, Tola S, Partanen T. Clinical prognosis of patients with diagnosed chronic solvent intoxication. Acta Neurol Scand. May 1982;65(5):488-503. [Medline].

  35. Antti-Poika M. Overall prognosis of patients with diagnosed chronic organic solvent intoxication. Int Arch Occup Environ Health. 1982;51(2):127-38. [Medline].

  36. Seppalainen AM, Antti-Poika M. Time course of electrophysiological findings for patients with solvent poisoning. A descriptive study. Scand J Work Environ Health. Feb 1983;9(1):15-24. [Medline].

  37. Herruzo Perez A, Linares del Rio F, Moniche García-Pumarino M. [Sensitive painful polyneuropathy probably caused by poisoning by perchloroethylene. Apropos of 1 case]. Rev Esp Anestesiol Reanim. May-Jun 1989;36(3):180-1. [Medline].

  38. Baker EL. A review of recent research on health effects of human occupational exposure to organic solvents. A critical review. J Occup Med. Oct 1994;36(10):1079-92. [Medline].

  39. Orbaek P, Rosen I, Svensson K. Electroneurographic findings in patients with solvent induced central nervous system dysfunction. Br J Ind Med. Jun 1988;45(6):409-14. [Medline].

  40. Maizlish NA, Fine LJ, Albers JW, Whitehead L, Langolf GD. A neurological evaluation of workers exposed to mixtures of organic solvents. Br J Ind Med. Jan 1987;44(1):14-25. [Medline].

  41. Feldman RG. Neurotoxic effects of trichloroethylene in drinking water. In: Isaacson RL, Jensen KF, eds. The Vulnerable Brain and Environmental Risks: Toxins in Air and Water. Vol 3. Plenum Press; 1994.

  42. Smith AG, Howard JR, Kroll R, et al. The reliability of skin biopsy with measurement of intraepidermal nerve fiber density. J Neurol Sci. Jan 15 2005;228(1):65-9. [Medline].

  43. Sumner CJ, Sheth S, Griffin JW, et al. The spectrum of neuropathy in diabetes and impaired glucose tolerance. Neurology. Jan 14 2003;60(1):108-11. [Medline].

  44. Ohnishi A, Murai Y. Polyneuropathy due to ethylene oxide, propylene oxide, and butylene oxide. Environ Res. Feb 1993;60(2):242-7. [Medline].

  45. Deschamps D, Rosenberg N, Soler P, Maillard G, Fournier E, Salson D, et al. Persistent asthma after accidental exposure to ethylene oxide. Br J Ind Med. Jul 1992;49(7):523-5. [Medline].

  46. Seppalainen AM, Husman K, Martenson C. Neurophysiological effects of long-term exposure to a mixture of organic solvents. Scand J Work Environ Health. Dec 1978;4(4):304-14. [Medline].

  47. Seppalainen AM, Lindstrom K, Martelin T. Neurophysiological and psychological picture of solvent poisoning. Am J Ind Med. 1980;1(1):31-42. [Medline].

  48. Linz DH, de Garmo PL, Morton WE, et al. Organic solvent-induced encephalopathy in industrial painters. J Occup Med. Feb 1986;28(2):119-25. [Medline].

  49. Miyakawa T, Deshimaru M, Sumiyoshi S, et al. Experimental organic mercury poisoning--pathological changes in peripheral nerves. Acta Neuropathol (Berl). 1970;15(1):45-55. [Medline].

  50. Halat KM, Dennehy CE. Botanicals and dietary supplements in diabetic peripheral neuropathy. J Am Board Fam Pract. Jan-Feb 2003;16(1):47-57. [Medline].

  51. Argyriou AA, Chroni E, Koutras A, et al. Vitamin E for prophylaxis against chemotherapy-induced neuropathy: a randomized controlled trial. Neurology. Jan 11 2005;64(1):26-31. [Medline].

  52. Adams RD, Victor M, Ropper AH. Principles of Neurology. 6th ed. New York: McGraw-Hill; 1997:1278-1369.

  53. Albers JW, Cavender GD, Levine SP, Langolf GD. Asymptomatic sensorimotor polyneuropathy in workers exposed to elemental mercury. Neurology. Oct 1982;32(10):1168-74. [Medline].

  54. Albers JW, Kallenbach LR, Fine LJ, et al. Neurological abnormalities associated with remote occupational elemental mercury exposure. Ann Neurol. Nov 1988;24(5):651-9. [Medline].

  55. American Conference of Governmental Industrial Hygienist. Threshold Limit Values and Biological Exposure Indices. 1999.

  56. Angotzi G, Battistini N, Carboncini F, et al. Impairment of nervous system in workers exposed to inorganic mercury. Toxicol Eur Res. Nov 1981;3(6):275-8. [Medline].

  57. ATSDR. Toxicological profile for carbon disulphide. US Department of Health and Human Services;1994.

  58. Berger AR, Schaumberg HH. Disorders of the peripheral nervous system. In: Rosenstock L, Cullen MR, eds. Textbook of Clinical Occupational and Environmental Medicine. Philadelphia: Saunders; 1994:482-513.

  59. Bernad PG, Newell S, Spyker DA. Neurotoxicity and behavior abnormalities in a cohort chronologically exposed to trichloroethylene. Vet Hum Toxicol. 1987;29:475.

  60. Dyck PJ. Diabetic Neuropathy. Philadelphia: WB Saunders Co; 1998.

  61. Dyck PJ. Peripheral Neuropathy. Philadelphia: WB Saunders Co; 1993.

  62. Ellingsen DG, Morland T, Andersen A, Kjuus H. Relation between exposure related indices and neurological and neurophysiological effects in workers previously exposed to mercury vapour. Br J Ind Med. Aug 1993;50(8):736-44. [Medline].

  63. Elofsson SA, Gamberale F, Hindmarsh T, et al. Exposure to organic solvents. A cross-sectional epidemiologic investigation on occupationally exposed care and industrial spray painters with special reference to the nervous system. Scand J Work Environ Health. Dec 1980;6(4):239-73. [Medline].

  64. Eto K, Oyanagi S, Itai Y, et al. A fetal type of Minamata disease. An autopsy case report with special reference to the nervous system. Mol Chem Neuropathol. Feb-Apr 1992;16(1-2):171-86. [Medline].

  65. Feldman RG, White RF. Role of the neurologist in hazard identification and risk assessment. Environ Health Perspect. Apr 1996;104 Suppl 2:227-37. [Medline].

  66. Gilioli R, et al. Horvath M, ed. Adverse Effects of Environmental Chemicals and Psychotropic Drugs. Vol 2. Amsterdam: Elsevier Science; 1976:157-164.

  67. Iyer K, Goodgold J, Eberstein A, Berg P. Mercury poisoning in a dentist. Arch Neurol. Nov 1976;33(11):788-90. [Medline].

  68. Juntunen J. Neurotoxic syndromes and occupational exposure to solvents. Environ Res. Jan 1993;60(1):98-111. [Medline].

  69. Levine SP, Cavender GD, Langolf GD, Albers JW. Elemental mercury exposure: peripheral neurotoxicity. Br J Ind Med. May 1982;39(2):136-9. [Medline].

  70. Miller JM, Chaffin DB, Smith RG. Subclinical psychomotor and neuromuscular changes in workers exposed to inorganic mercury. Am Ind Hyg Assoc J. Oct 1975;36(10):725-33. [Medline].

  71. National Institute for Occupational Safety and Health (NIOSH). Tetrachloroethylene. Current Intelligence Bulletin; January 1978;number 20.

  72. Occupational Medicine Physician's Guide to Neuropathy in the Workplace Part 3: Case Presentation. J Occup Environ Med. Jul 2009;51(7):861-2. [Medline].

  73. Pleasure DE, Schotland DL. Peripheral neuropathies. In: Rowland LP, ed. Merritt's Textbook of Neurology. 8th ed. Philadelphia: Lea & Febiger; 1989:601-26.

  74. Rowland LP, ed. Merritt's Textbook of Neurology. 8th ed. Philadelphia: Lea & Febiger; 1989.

  75. Rutchik J. Occupational medicine physician's guide to neuropathy in the workplace, part 2: electromyography and cryptogenic and toxic neuropathy. J Occup Environ Med. May 2009;51(5):622-5. [Medline].

  76. Rutchik JS. Occupational medicine physician's guide to neuropathy in the workplace, Part 1. J Occup Environ Med. Mar 2009;51(3):390-3. [Medline].

  77. Schaumberg HH, Spencer PS. Clinical and experimental studies of distal axonopathy- A frequent form of brain and nerve damage produced by environmental chemical hazards. Ann NY Acad Sci. 1979;14-29.

  78. Schaumburg HH, Spencer PS. The neurology and neuropathology of the occupational neuropathies. J Occup Med. Nov 1976;18(11):739-42. [Medline].

  79. Shapiro IM, Cornblath DR, Sumner AJ, et al. Neurophysiological and neuropsychological function in mercury-exposed dentists. Lancet. May 22 1982;1(8282):1147-50. [Medline].

  80. Singer R, Valciukas JA, Rosenman KD. Peripheral neurotoxicity in workers exposed to inorganic mercury compounds. Arch Environ Health. Jul-Aug 1987;42(4):181-4. [Medline].

  81. Somjen S, Mercury. Schaumberg HH and Spencer PS, eds. Clinical Neurotoxicology. Baltimore: Lippincott Williams & Wilkins; 1980.

  82. Wang MS, Fang G, Culver DG, et al. The WldS protein protects against axonal degeneration: a model of gene therapy for peripheral neuropathy. Ann Neurol. Dec 2001;50(6):773-9. [Medline].

  83. Zampollo A, Baruffini A, Cirla AM, et al. Subclinical inorganic mercury neuropathy: neurophysiological investigations in 17 occupationally exposed subjects. Ital J Neurol Sci. Jun 1987;8(3):249-54. [Medline].

 
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Table 1. Exposure Limits, Common Organic Solvents and Metals
Compound OSHA



PEL TWA:



ppm (mg/m3)



NIOSH REL



TWA: ppm (mg/m3),



IDLH



ACGIH



ppm (mg/m3) TLV,



STEL



Acrylamide(0.3)(0.03), 60 Ca
Arsenic, inorganic(0.01)C (0.002)(0.01), -
Arsenic, organic0.5 mg/m3
Carbon disulfide20, 30, 100 for 30 min1 (3),



10 STEL (30),



500



10 (31)
Ethylene oxide1 < 0.1,



< 0.18, 5 C,



800



1 (1.8)
n -hexane500 (1800)50 (180), 110050, (176)
Lead0.05 mg/m30.100 mg/m3(0.05), -
Mercury, inorganicC 0.1 mg/m30.05 mg/m3,



C 0.01 mg/m3,



10 mg/m3



0.025 mg/m3
Mercury, organic0.01 mg/m3,



C 0.04 mg/m3



0.01 mg/m3,



ST 0.03 mg/m3,



2 mg/m3



0.01 mg/m3,



0.03 mg/m3



Methyl n -butyl



ketone



100 (410)5 (20)
Perchloroethylene100, 200 C,



300 for 5 min



in 3 h



150 Ca25 (170),



100 (685)



Styrene100, 200 C,



600 for 5 min



in 3 h



50 (215),



100 ST (425), 700



50 (213),



100 (428)



Thallium0.1 mg/m3 skin0.1 mg/m3,



15 mg/m3



0.1 mg/m3
Toluene200, 300, 500 for 10 min100 (375),



150 ST (560),



500



50 (188)
1,1,1



Trichloroethane



(methyl chloroform)



350 (1900)C 350(1900)



for 15 min,



700



350 (1910),



450 (2460)



Trichloroethylene100, 200 C,



300 for 5 min



in 2 h



1000 Ca50 (269),



100 (1070)



Vinyl chloride1, 5 for 15 minND
Xylene100 (435)100 (435),



150 ST (655)



100 (434),



150 (651)



Abbreviations: OSHA - Occupational Safety and Health Association; NIOSH - National Institute of Occupational Safety and Health; ACGIH - American Congress of Governmental Industrial Hygienists; TWA - time-weighted average; TLV - threshold limit value; PEL - permissible exposure limit; REL - recommended exposure limit; ppm - parts per million; STEL - short-term exposure limit; Ca - level for carcinogenicity; C - ceiling, should never be exceeded; ND - not determined
Table 2. Agency for Toxic Substances and Disease Registry Biological Exposure Indices
Compound Urine Blood Expired



Air



Other
Acrylamide
ArsenicInorganic arsenic: end of work week, 50 µg/g



monomethyl-arsonic acid, cacodylic acid (days)



Hair (ingestion chronic)
Carbon disulfide2-TTCA * 5 mg/gCarbon disulfideCarbon disulfide
Ethylene oxide
n -hexane2-5 hexanediol: end of shift, 5 mg/g



2 hexanol, total metabolites



n -hexanen -hexane
LeadLeadLead 30 μ g/100 mLErythrocyte protopor-phyrin
Mercury, inorganicMercury: start of shift, 35 µg/gMercury: end of shift at end of work week, 15 µg/L
Methyl n -butyl ketone2,5 hexane dione
Perchloro-ethylenePerchloro-ethylene, trichloroacetic acidPerchloroethylene 1 mg/LPerchloro-ethylene: before last shift of week, 10 ppm †
StyreneMandelic acid: start of shift, 300 mg/g; end of shift, 800 mg/g



Phenylglyoxylic acid: start of shift, 100 mg/g; end of shift, 240 mg/g



Styrene: start of shift, 0.02 mg/L; end of shift, 0.55 mg/L
ThalliumThallium
TolueneHippuric acidTolueneToluene
1,1,1 Trichloroethane (methyl chloroform)Trichloroacetic acid: end of work week, 10 mg/L



total trichloroethanol: end of shift at end of work week, 30 mg/L



Total trichloroethanol



1 mg/L



Methyl chloroform: prior to last shift of work week, 40 ppm †
Trichloro-ethyleneTrichloroethylene, trichloroacetic acid: end of work week, 100 mg/g or trichloroacetic acid plus trichloroethanol, 300 mg/gTrichloroethylene: end of work week, 4 mg/LTrichloro-



ethylene



Vinyl chloride
XyleneMethylhippuric acid: end of shift, 1.5 mg/gXyleneXylene
*2-TTCA - 2-thiothiazolidine-4-carboxylic acid



† ppm - parts per million



Table 3. Industrial Uses of Common Organic Solvents and Metals
Compound Industrial Uses
AcrylamideMining and tunneling, adhesives, waste treatment, ore processing, paper, pulp industry, photography, dyes
ArsenicPesticides, pigments, antifouling paint, electroplating, seafood, smelters, semiconductors, logging
Carbon disulfideViscose rayon, explosives, paints, preservatives, textiles, rubber cement, varnishes, electroplating
Ethylene oxideInstrument sterilization, chemical precursor
n -hexaneGlues and vegetable extraction, components of naphtha, lacquers, metal-cleaning compounds
LeadSolder, lead shot, illicit whiskey, insecticides, auto body shops, storage batteries, foundries, smelters, lead-based paint, lead stained glass, lead pipes
MercuryScientific instruments, electrical equipment, amalgams, electroplating, photography, felt making, taxidermy, textiles, pigments, chloroalkali industry
Methyl n -butyl ketonePaints, varnishes, quick-drying inks, lacquers, metal-cleaning compounds, paint removers
OrganochlorineInsecticides
OrganophosphatesInsecticides
PerchloroethyleneDry cleaning, degreaser, textile industry
StyreneFiberglass component, ship building, polyester resin
ThalliumRodenticides, fungicides, mercury and silver alloys, lens manufacturing, photoelectric cells, infrared optical instruments
ToluenePaint, fuel oil, cleaning agents, lacquers, paints and paint thinners
1,1,1



Trichloroethane (methyl chloroform)



Degreaser and propellant
TrichloroethyleneCleaning agent, paint component, decaffeination, rubber solvents, varnish
Vinyl chlorideIntermediate for polyvinyl chloride (PVC) resins for plastics, floor coverings, upholstery, appliances, packaging
XyleneFixative for pathologic specimens, paint, lacquers, varnishes, inks, dyes, adhesives, cements
Table 4. Differential Diagnosis of Peripheral Neuropathy With Selective Lab Testing (Recommended lab tests in bold.)
Inflam-matory Metabolic and Nutritional Infective and Granulo-matous Vasculitic Neoplastic and Para-proteinemic Drug-Induced and Toxic Hereditary
Acute idiopathic polyneuro-pathy (Anti-Gm1, anti-Gd1a, anti-GQ1b)Diabetes ( Fasting blood glucose , 2-hour glucose tolerance test) AIDS ( HIV) Mixed CT disease (ESR)Compression and infiltration ( chest radiograph) AlcoholHMSN
Chronic inflammatory demyelin-ating polyneuro-pathyEndocrino-pathies: hypo-thyroidism, acromegaly ( TSH , Electrolytes, GH) Leprosy, syphilis ( RPR , FTA , MHA-TP) Poly-arteritis nodosaParaneo-plastic syndromes (anti-Hu, anti-RII, etc; CBC)See TableHSN
Uremia ( BUN/CR) Diphtheria, Lyme ( Serology) Rheu-matoid arthritis ( RF) Paraprotein-emias ( SPEP , immuno-fixation , anti-MAG, M protein) Friedreich ataxia
Liver disease ( LFTs) Sarcoidosis ( ACE) SLE ( ANA) Amyloidosis (nerve biopsy)Familial amyloid (nerve biopsy)
Vitamin B-12 deficiency ( B12) Sepsis and multi-organ failure ( ESR) Porphyria (porphobil-inogen, amino-levulinic acid),



meta-chromatic leukodys-trophy, Krabbe, abetalipo-proteinemia, Tangier disease, Refsum disease, Fabry disease



Table 5. Neuropathies With Unusual Features
Small Fiber Neuropathies Facial Nerve Involvement Autonomic Involvement Sensory Ataxia Pure Motor Involvement Skin, Nail, or Hair Manifestation
DiabetesGuillain-BarréParaneo-plasticPolyganglio-nopathiesMotor neuron diseaseVasculitis: purpura, livedo reticularis
AmyloidCIDPGBSParaneo-plasticMultifocal motor neuropathyCryoglo-binemia: purpura
HIV-associatedLyme diseasePorphyriaSjögren syndromeGBsFabry disease: angiokera-tomas
Hereditary sensory and autonomic neuropathySarcoidosisVincristine, vacorCisplatin analogsAcute motor axonal neuropathyLeprosy: skin hypopig-mentation
Fabry diseaseHIVDiabetesVitamin B-6 toxicityPorphyriaOsteo-sclerotic myeloma: skin hyperpig-mentation
Tangier diseaseTangierAmyloidGBS (Miller-Fisher variant) CIDPVariegate porphyria: bullous lesions
Sjögren syndromeHIVIgM monoclonal gammopathy of undetermined significanceOsteosclerotic myelomaRefsum disease: ichthyosis
Hereditary sensory and autonomic neuropathyDiabetic lumbar radiculoplex-opathyArsenic or thallium intoxication: Mees lines
Hereditary motor sensory neuropathy (Charcot-Marie-Tooth)Thallium intoxication: alopecia
LeadGiant axonal neuropathy: curled hair
Table 6. Industrial Agents and Pharmaceuticals Associated With Peripheral Neuropathy
Almitrine (s)“Spanish toxic oil”
Arsenic (s)(d) 2-t-Butylazo- 2- hydroxyl- 5 methylhexane
CapsaicinAcrylamide
Carbamate pesticides (nm) Allyl chloride
Carbon disulfide (m)(d) Amiodaron e (d)
Chloramphenicol (s) Amitriptyline
Cimetidine (m)Carbamates (nm)
Cisplatin (s)Carbon monoxide
CyanateChloroquine
CycloleucineColchicine
CytarabineDichloroacetic acid
Dapsone (m) Disulfiram (m)
Dichloroacetylene (cr)Ethionamide
Didoxynucleosides (s) (ddC, ddI, d4T) Ethyl alcohol
DimethylaminopropionitrileEthylene glycol (cr)
Doxorubicin (m)Ethylene oxide
Ethambutol (s) Germanium dioxide
Etoposide (s)Gold
GlutethimideHexamethylmelamine
HexachloropheneHydrazine
Hydralazine (s) Indomethacin
Hyperinsulinemia/ hypoglycemia (m)Isoniazid
Imipramine (m)Lincomycin (nm)
Interferon alpha (nm)Lithium
Lead (m) L-Tryptophan
LidocaineMercury, inorganic
Methyl n-butyl ketone (m)(d)Mercury, organic
Metronidazole (s) Methaqualone
Misonidazole (s) Methyl bromide
MuzolimineMethyl methacrylate
Nitrous Oxide (s) N hexane (d)
Organophosphates (m) Naproxen
Organophosphorus compounds (nm) Nitrofurantoin (m)
Polychlorinated biphenyls (s)Penicillamine (nm)
Polymyxin (nm)Perhexiline (d)
Pyrethroids (ic) Phenol
Pyridoxine (s) Phenytoin
SarinPyriminil
Succinylcholine (nm)Quinine (nm)
Sulfonamides (m), sulfasalazineStatins
TacrolimusStilbamidine (cr)
Taxanes (paclitaxel, docetaxel) (s) Suramin
Thalidomide (s) Tetrachloroethane
Thallium (s) Tetracyclines (nm)
Trimethaphan (nm) Trithiozine
VidarabineTubocurarine (nm)
Vincristine (m) Vincristine  (m), Vinca alkaloids
ZimeldineVinyl chloride
(s): Predominantly sensory



(m): Predominantly motor



(d): Possibly demyelination with conduction block



(cr): Associated with cranial neuropathy



(nm): Associated with neuromuscular transmission syndromes



(ic): Associated with axon ion channel syndromes



Bold: A rating for common or strong association



Unbolded: B rating for less common or less than strong association



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