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Toxic Neuropathy Follow-up

  • Author: Jonathan S Rutchik, MD, MPH; Chief Editor: Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS  more...
 
Updated: Feb 03, 2016
 

Further Outpatient Care

See the list below:

  • Consistent follow-up care with a neurologist is necessary to monitor the progress of neurological findings.
  • Follow-up with an occupational medicine specialist may be important to assist with return to work and reduction of exposure. This clinician may be able to work with the company supervisors or management to improve the work environment. This may occur if the company chooses to substitute the neuropathy-causing agent with a less-toxic agent in the workplace, to change the schedules of workers so that their exposure is less during a period of time, or to promote safer personal protective equipment. Communication between health care provider and management is essential for this individual's health as well as his or her status for disability or ability return to work.
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Prognosis

Each patient's prognosis depends on the severity of the neuropathy when exposure is ceased or reduced to levels that will not affect health negatively.

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Patient Education

See the list below:

  • Inform patients about aspects of dose, diet, and nutrition that may increase risk of toxicity when taking a medication. Since many solvents are metabolized in the liver, concomitant use of medications with similar metabolism may lead to increased toxicity.
  • Workers, by law, need to be informed of chemicals in the workplace and their potential health hazards. Material safety data sheets (MSDS), per order of Occupational Safety and Health Administration (OSHA), are available to all workers in the workplace.
  • The Emergency Planning and Community Right to Know Act (EPCRA) requires that facilities using, storing, or manufacturing hazardous chemicals make public inventory and report every release to public officials and health personnel. These facilities must cooperate with health personnel who are treating victims of exposure.
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Contributor Information and Disclosures
Author

Jonathan S Rutchik, MD, MPH Associate Clinical Professor, Division of Occupational Medicine, Department of Medicine, University of California, San Francisco, School of Medicine; Neurology, Environmental and Occupational Medicine Associates (www.neoma.com)

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Glenn Lopate, MD Associate Professor, Department of Neurology, Division of Neuromuscular Diseases, Washington University School of Medicine; 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, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS Professor Emeritus of Neurology and Psychiatry, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Neuroscience Director, Department of Neurology, Crouse Irving Memorial Hospital

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS is a member of the following medical societies: American College of International Physicians, American Heart Association, American Stroke Association, American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners Institute, National Association of Managed Care Physicians, American College of Physicians, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, Royal Society of Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Milind J Kothari, DO Professor, 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 Neurological Association, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

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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 oxide 1 < 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 μg/100 mL Erythrocyte protopor-phyrin
Mercury, inorganicMercury: start of shift, 35 µg/gMercury: end of shift at end of work week, 15 µg/L  
Methyl n -butyl ketone 2,5 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 syndrome HIVIgM monoclonal gammopathy of undetermined significanceOsteosclerotic myelomaRefsum disease: ichthyosis
  Hereditary sensory and autonomic neuropathy Diabetic 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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