Toxic Neuropathy Treatment & Management
- Author: Jonathan S Rutchik, MD, MPH; Chief Editor: Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS more...
See the list below:
- Advise removal from occupational or environmental exposure.
- Advise discontinuation of medication or recreational drug habit. Also provide information regarding how alcohols affect those with exposures.
- Acute care for those intoxicated with recreational, industrial, or other agents is discussed in other articles on this web site.
- Preventive care and supportive care should include consideration of life stressors, diet, and overall behavior modifications.
- Treatment options also include the following:
- Nonpharmacologic options include cool soaks, heat, massage, elevation or lowering of the limbs, shoe tightness, and/or exercise.
- Pharmacological options include tricyclic antidepressants, anticonvulsants, opiates, or topical capsaicin cream. Other options include intravenous gamma globulin, aldose reductase inhibitors, nerve growth factor, anti–tumor necrosis factor-α; these are mainly research ideas. Three that may be helpful presently include lipoic acid, evening primrose, and vitamin E.
- Alpha lipoic acid is well reviewed by Halat and Dennehy. Thiolic acid is a free radical scavenger and chelator. It is approved for use in Germany for neuropathy. The best studies suggest parenteral use followed by oral use relieves symptoms and improves nerve blood flow. Oral preparations are available in United States. Two studies suggest increased nerve conduction (600/1200 mg for 2 y, oral) and reduced symptoms (1800 mg/d for 3 wk, oral). The mechanism of action includes chelation and, thus, a concern for mineral shortage exists. Monitoring iron levels is suggested, and persons with alcoholism need to take vitamin B.
- Evening primrose is also well summarized by Halat and Dennehy. It includes omega 6 essential fatty acids: gamma linoleic acid (GLA) and linoleic acid. It is an essential component of myelin and the neuronal cell membrane. Dosages ranging from 360-480 mg/d for 6 months to 1 year improved nerve function measurements. It has mild side effects including inhibition of platelet aggregation. Concern also exists for those with seizure disorders.
- Vitamin E is discussed in the article Argyriou et al. Vitamin E has been administered to patients on chemotherapy for prevention of neuropathy at doses of 600 mg/d during treatment and then for 3 months after treatment. A reduced peripheral neuropathy score has been noted. A neuroprotective effect has been described.
See the list below:
- Occupational therapist
- Environmental medicine specialist
Although diet does not play a specific role in reparation of the PNS, a balanced diet is important for various reasons related to general health. Since various B vitamins have been implicated in the development of neuropathies, some physicians suggest supplementation.
Barton A, McLean B. An unusual case of peripheral neuropathy possibly due to arsenic toxicity secondary to excessive intake of dietary supplements. Ann Clin Biochem. 2013 May 29. [Medline].
Hoitsma E, Reulen JP, de Baets M, et al. Small fiber neuropathy: a common and important clinical disorder. J Neurol Sci. 2004 Dec 15. 227(1):119-30. [Medline].
Vegosen L, Davis MF, Silbergeld E, Breysse PN, Agnew J, Gray G, et al. Neurologic symptoms associated with cattle farming in the agricultural health study. J Occup Environ Med. 2012 Oct. 54(10):1253-8. [Medline]. [Full Text].
Samukawa M, Ichihara G, Oka N, Kusunoki S. A case of severe neurotoxicity associated with exposure to 1-bromopropane, an alternative to ozone-depleting or global-warming solvents. Arch Intern Med. 2012 Sep 10. 172(16):1257-60. [Medline].
Kimura J. Polyneuropathies. Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice. 2nd ed. Philadelphia: FA Davis; 1989: 462-81.
Kimura J. Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice. 2nd ed. Philadelphia: FA Davis; 1989. 149-162.
Lowes R. FDA Strengthens Neuropathy Warning for Fluoroquinolones. Medscape Medical News. Aug 15 2013. Available at http://www.medscape.com/viewarticle/809520. Accessed: August 20 2013.
FDA. FDA Drug Safety Communication: FDA requires label changes to warn of risk for possibly permanent nerve damage from antibacterial fluoroquinolone drugs taken by mouth or by injection. US Food and Drug Administration. Aug 15 2013. Available at http://www.fda.gov/Drugs/DrugSafety/ucm365050.htm. Accessed: August 20 2013.
Feldman RG. Occupational and Environmental Neurotoxicology. Philadelphia: Lippincott-Raven; 1999.
Albers J, Bromberg MB. Chemically induced toxic neuropathy. Rosenberg NL, ed. Occupational and Environmental Neurology. Boston: Butterworth-Heinemann; 1995. 175-234.
Schaumberg HH. Human neurotoxic disease. Spencer P, Schaumberg HH, eds. Experimental and Clinical Neurotoxicology. 2nd ed. New York: Oxford University Press; 2000.
Mellion M, Gilchrist JM, de la Monte S. Alcohol-related peripheral neuropathy: nutritional, toxic, or both?. Muscle Nerve. 2011 Mar. 43(3):309-16. [Medline].
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. 1995 Jan. 52(1):45-51. [Medline].
Behse F, Buchthal F. Alcohol Neuropathy: Clinical, Electrophysiological and Biopsy Findings. Ann Neurol. 1977. 2:95-110.
Vittadini G, Buonocore M, Colli G, Terzi M, Fonte R, Biscaldi G. Alcoholic polyneuropathy: a clinical and epidemiological study. Alcohol Alcohol. 2001 Sep-Oct. 36(5):393-400. [Medline].
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.
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. 1990 Sep. 47(9):589-95. [Medline].
Ruijten MW, Salle HJ, Verberk MM. Verification of effects on the nervous system of low level occupational exposure to CS2. Br J Ind Med. 1993 Apr. 50(4):301-7. [Medline].
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].
Gross JA, Haas ML, Swift TR. Ethylene oxide neurotoxicity: report of four cases and review of the literature. Neurology. 1979 Jul. 29(7):978-83. [Medline].
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].
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].
Kuzuhara S, Kanazawa I, Nakanishi T, Egashira T. Ethylene oxide polyneuropathy. Neurology. 1983 Mar. 33(3):377-80. [Medline].
Finelli PF, Morgan TF, Yaar I, Granger CV. Ethylene oxide-induced polyneuropathy. A clinical and electrophysiologic study. Arch Neurol. 1983 Jul. 40(7):419-21. [Medline].
Andersen A, Ellingsen DG, Morland T, Kjuus H. A neurological and neurophysiological study of chloralkali workers previously exposed to mercury vapour. Acta Neurol Scand. 1993 Dec. 88(6):427-33. [Medline].
Barber TE. Inorganic mercury intoxication reminiscent of amyotrophic lateral sclerosis. J Occup Med. 1978 Oct. 20(10):667-9. [Medline].
Adams CR, Ziegler DK, Lin JT. Mercury intoxication simulating amyotrophic lateral sclerosis. JAMA. 1983 Aug 5. 250(5):642-3. [Medline].
Ross AT. Mercuric polyneuropathy with albumino-cytologic dissociation and eosinophilia. JAMA. 1964 Jun 1. 188:830-1. [Medline].
Warkany J, Hubbard DM. Acrodynia and mercury. J Pediatr. 1953. 42:365-386.
Yoshida Y, Kamitsuchibashi H, Hamada R, et al. Truncal hypesthesia in patients with Minamata disease. Intern Med. 1992 Feb. 31(2):204-7. [Medline].
Thomson RM, Parry GJ. Neuropathies associated with excessive exposure to lead. Muscle Nerve. 2006 Jun. 33(6):732-41. [Medline].
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].
Bleeker ML. Clinical presentations of selected neurotoxic compounds. Bleeker ML, Hansen JA, eds. Occupational Neurology and Clinical Neurotoxicology. Baltimore: Williams & Wilkins; 1994. 207-234.
Demers RY, Markell BL, Wabeke R. Peripheral vibratory sense deficits in solvent-exposed painters. J Occup Med. 1991 Oct. 33(10):1051-4. [Medline].
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. 1989 Apr. 31(4):320-5. [Medline].
Padilla SS, Lyerly DP. Effects of p-xylene inhalation on axonal transport in the rat retinal ganglion cells. Toxicol Appl Pharmacol. 1989 Dec. 101(3):390-8. [Medline].
Feldman RG. Effect of toxins and physical agents on the nervous system. Bradley WG et al, eds. Neurology in Clinical Practice. Boston: Butterworth-Heinemann; 1991. 1185-207.
Feldman RG. The recognition and differentiation of neurotoxic and non-neurotoxic syndromes. Chang LW, Slikker W, eds. Neurotoxicology: Approaches and Methods. San Diego: Academic Press; 1995. 689-694.
Juntunen J, Antti-Poika M, Tola S, Partanen T. Clinical prognosis of patients with diagnosed chronic solvent intoxication. Acta Neurol Scand. 1982 May. 65(5):488-503. [Medline].
Antti-Poika M. Overall prognosis of patients with diagnosed chronic organic solvent intoxication. Int Arch Occup Environ Health. 1982. 51(2):127-38. [Medline].
Seppalainen AM, Antti-Poika M. Time course of electrophysiological findings for patients with solvent poisoning. A descriptive study. Scand J Work Environ Health. 1983 Feb. 9(1):15-24. [Medline].
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. 1989 May-Jun. 36(3):180-1. [Medline].
Baker EL. A review of recent research on health effects of human occupational exposure to organic solvents. A critical review. J Occup Med. 1994 Oct. 36(10):1079-92. [Medline].
Orbaek P, Rosen I, Svensson K. Electroneurographic findings in patients with solvent induced central nervous system dysfunction. Br J Ind Med. 1988 Jun. 45(6):409-14. [Medline].
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. 1987 Jan. 44(1):14-25. [Medline].
Feldman RG. Neurotoxic effects of trichloroethylene in drinking water. Isaacson RL, Jensen KF, eds. The Vulnerable Brain and Environmental Risks: Toxins in Air and Water. Plenum Press; Vol 3: 1994.
Smith AG, Howard JR, Kroll R, et al. The reliability of skin biopsy with measurement of intraepidermal nerve fiber density. J Neurol Sci. 2005 Jan 15. 228(1):65-9. [Medline].
Sumner CJ, Sheth S, Griffin JW, et al. The spectrum of neuropathy in diabetes and impaired glucose tolerance. Neurology. 2003 Jan 14. 60(1):108-11. [Medline].
Ohnishi A, Murai Y. Polyneuropathy due to ethylene oxide, propylene oxide, and butylene oxide. Environ Res. 1993 Feb. 60(2):242-7. [Medline].
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. 1992 Jul. 49(7):523-5. [Medline].
Seppalainen AM, Husman K, Martenson C. Neurophysiological effects of long-term exposure to a mixture of organic solvents. Scand J Work Environ Health. 1978 Dec. 4(4):304-14. [Medline].
Seppalainen AM, Lindstrom K, Martelin T. Neurophysiological and psychological picture of solvent poisoning. Am J Ind Med. 1980. 1(1):31-42. [Medline].
Linz DH, de Garmo PL, Morton WE, et al. Organic solvent-induced encephalopathy in industrial painters. J Occup Med. 1986 Feb. 28(2):119-25. [Medline].
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].
Halat KM, Dennehy CE. Botanicals and dietary supplements in diabetic peripheral neuropathy. J Am Board Fam Pract. 2003 Jan-Feb. 16(1):47-57. [Medline].
Argyriou AA, Chroni E, Koutras A, et al. Vitamin E for prophylaxis against chemotherapy-induced neuropathy: a randomized controlled trial. Neurology. 2005 Jan 11. 64(1):26-31. [Medline].
Adams RD, Victor M, Ropper AH. Principles of Neurology. 6th ed. New York: McGraw-Hill; 1997. 1278-1369.
Albers JW, Cavender GD, Levine SP, Langolf GD. Asymptomatic sensorimotor polyneuropathy in workers exposed to elemental mercury. Neurology. 1982 Oct. 32(10):1168-74. [Medline].
Albers JW, Kallenbach LR, Fine LJ, et al. Neurological abnormalities associated with remote occupational elemental mercury exposure. Ann Neurol. 1988 Nov. 24(5):651-9. [Medline].
American Conference of Governmental Industrial Hygienist. Threshold Limit Values and Biological Exposure Indices. 1999.
Angotzi G, Battistini N, Carboncini F, et al. Impairment of nervous system in workers exposed to inorganic mercury. Toxicol Eur Res. 1981 Nov. 3(6):275-8. [Medline].
ATSDR. Toxicological profile for carbon disulphide. US Department of Health and Human Services. 1994.
Berger AR, Schaumberg HH. Disorders of the peripheral nervous system. Rosenstock L, Cullen MR, eds. Textbook of Clinical Occupational and Environmental Medicine. Philadelphia: Saunders; 1994. 482-513.
Bernad PG, Newell S, Spyker DA. Neurotoxicity and behavior abnormalities in a cohort chronologically exposed to trichloroethylene. Vet Hum Toxicol. 1987. 29:475.
Boggs W. IV Calcium, Magnesium Don't Prevent Oxaliplatin Neurotoxicity. Medscape Medical News. Available at http://www.medscape.com/viewarticle/818344. Accessed: December 30, 2013.
Dyck PJ. Diabetic Neuropathy. Philadelphia: WB Saunders Co; 1998.
Dyck PJ. Peripheral Neuropathy. Philadelphia: WB Saunders Co; 1993.
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. 1993 Aug. 50(8):736-44. [Medline].
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. 1980 Dec. 6(4):239-73. [Medline].
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. 1992 Feb-Apr. 16(1-2):171-86. [Medline].
Feldman RG, White RF. Role of the neurologist in hazard identification and risk assessment. Environ Health Perspect. 1996 Apr. 104 Suppl 2:227-37. [Medline].
Gilioli R, et al. Horvath M, ed. Adverse Effects of Environmental Chemicals and Psychotropic Drugs. Amsterdam: Elsevier Science; 1976. Vol 2: 157-164.
Iyer K, Goodgold J, Eberstein A, Berg P. Mercury poisoning in a dentist. Arch Neurol. 1976 Nov. 33(11):788-90. [Medline].
Juntunen J. Neurotoxic syndromes and occupational exposure to solvents. Environ Res. 1993 Jan. 60(1):98-111. [Medline].
Levine SP, Cavender GD, Langolf GD, Albers JW. Elemental mercury exposure: peripheral neurotoxicity. Br J Ind Med. 1982 May. 39(2):136-9. [Medline].
Loprinzi CL, Qin R, Dakhil SR, Fehrenbacher L, Flynn KA, Atherton P, et al. Phase III Randomized, Placebo-Controlled, Double-Blind Study of Intravenous Calcium and Magnesium to Prevent Oxaliplatin-Induced Sensory Neurotoxicity (N08CB/Alliance). J Clin Oncol. 2013 Dec 2. [Medline].
Miller JM, Chaffin DB, Smith RG. Subclinical psychomotor and neuromuscular changes in workers exposed to inorganic mercury. Am Ind Hyg Assoc J. 1975 Oct. 36(10):725-33. [Medline].
National Institute for Occupational Safety and Health (NIOSH). Tetrachloroethylene. Current Intelligence Bulletin; January 1978. number 20.
Occupational Medicine Physician's Guide to Neuropathy in the Workplace Part 3: Case Presentation. J Occup Environ Med. 2009 Jul. 51(7):861-2. [Medline].
Pleasure DE, Schotland DL. Peripheral neuropathies. Rowland LP, ed. Merritt's Textbook of Neurology. 8th ed. Philadelphia: Lea & Febiger; 1989. 601-26.
Rowland LP, ed. Merritt's Textbook of Neurology. 8th ed. Philadelphia: Lea & Febiger; 1989.
Rutchik J. Occupational medicine physician's guide to neuropathy in the workplace, part 2: electromyography and cryptogenic and toxic neuropathy. J Occup Environ Med. 2009 May. 51(5):622-5. [Medline].
Rutchik JS. Occupational medicine physician's guide to neuropathy in the workplace, Part 1. J Occup Environ Med. 2009 Mar. 51(3):390-3. [Medline].
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.
Schaumburg HH, Spencer PS. The neurology and neuropathology of the occupational neuropathies. J Occup Med. 1976 Nov. 18(11):739-42. [Medline].
Shapiro IM, Cornblath DR, Sumner AJ, et al. Neurophysiological and neuropsychological function in mercury-exposed dentists. Lancet. 1982 May 22. 1(8282):1147-50. [Medline].
Singer R, Valciukas JA, Rosenman KD. Peripheral neurotoxicity in workers exposed to inorganic mercury compounds. Arch Environ Health. 1987 Jul-Aug. 42(4):181-4. [Medline].
Somjen S, Mercury. Schaumberg HH and Spencer PS, eds. Clinical Neurotoxicology. Baltimore: Lippincott Williams & Wilkins; 1980.
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. 2001 Dec. 50(6):773-9. [Medline].
Zampollo A, Baruffini A, Cirla AM, et al. Subclinical inorganic mercury neuropathy: neurophysiological investigations in 17 occupationally exposed subjects. Ital J Neurol Sci. 1987 Jun. 8(3):249-54. [Medline].
- Table 1. Exposure Limits, Common Organic Solvents and Metals
- Table 2. Agency for Toxic Substances and Disease Registry Biological Exposure Indices
- Table 3. Industrial Uses of Common Organic Solvents and Metals
- Table 4. Differential Diagnosis of Peripheral Neuropathy With Selective Lab Testing (Recommended lab tests in bold.)
- Table 5. Neuropathies With Unusual Features
- Table 6. Industrial Agents and Pharmaceuticals Associated With Peripheral Neuropathy
TWA: ppm (mg/m3),
ppm (mg/m3) TLV,
|Acrylamide||(0.3)||(0.03), 60 Ca|
|Arsenic, inorganic||(0.01)||C (0.002)||(0.01), -|
|Arsenic, organic||0.5 mg/m3|
|Carbon disulfide||20, 30, 100 for 30 min||1 (3),|
10 STEL (30),
|Ethylene oxide||1 < 0.1,|
< 0.18, 5 C,
|n -hexane||500 (1800)||50 (180), 1100||50, (176)|
|Lead||0.05 mg/m3||0.100 mg/m3||(0.05), -|
|Mercury, inorganic||C 0.1 mg/m3||0.05 mg/m3,|
C 0.01 mg/m3,
|Mercury, organic||0.01 mg/m3,|
C 0.04 mg/m3
ST 0.03 mg/m3,
|Methyl n -butyl|
|100 (410)||5 (20)|
|Perchloroethylene||100, 200 C,|
300 for 5 min
in 3 h
|150 Ca||25 (170),|
|Styrene||100, 200 C,|
600 for 5 min
in 3 h
100 ST (425), 700
|Thallium||0.1 mg/m3 skin||0.1 mg/m3,|
|Toluene||200, 300, 500 for 10 min||100 (375),|
150 ST (560),
|350 (1900)||C 350(1900)|
for 15 min,
|Trichloroethylene||100, 200 C,|
300 for 5 min
in 2 h
|1000 Ca||50 (269),|
|Vinyl chloride||1, 5 for 15 min||ND|
|Xylene||100 (435)||100 (435),|
150 ST (655)
|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|
|Arsenic||Inorganic arsenic: end of work week, 50 µg/g|
monomethyl-arsonic acid, cacodylic acid (days)
|Hair (ingestion chronic)|
|Carbon disulfide||2-TTCA* 5 mg/g||Carbon disulfide||Carbon disulfide|
|n -hexane||2-5 hexanediol: end of shift, 5 mg/g|
2 hexanol, total metabolites
|n -hexane||n -hexane|
|Lead||Lead||Lead 30 μg/100 mL||Erythrocyte protopor-phyrin|
|Mercury, inorganic||Mercury: start of shift, 35 µg/g||Mercury: end of shift at end of work week, 15 µg/L|
|Methyl n -butyl ketone||2,5 hexane dione|
|Perchloro-ethylene||Perchloro-ethylene, trichloroacetic acid||Perchloroethylene 1 mg/L||Perchloro-ethylene: before last shift of week, 10 ppm†|
|Styrene||Mandelic 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|
|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
|Methyl chloroform: prior to last shift of work week, 40 ppm†|
|Trichloro-ethylene||Trichloroethylene, trichloroacetic acid: end of work week, 100 mg/g or trichloroacetic acid plus trichloroethanol, 300 mg/g||Trichloroethylene: end of work week, 4 mg/L||Trichloro-|
|Xylene||Methylhippuric acid: end of shift, 1.5 mg/g||Xylene||Xylene|
|*2-TTCA - 2-thiothiazolidine-4-carboxylic acid|
† ppm - parts per million
|Acrylamide||Mining and tunneling, adhesives, waste treatment, ore processing, paper, pulp industry, photography, dyes|
|Arsenic||Pesticides, pigments, antifouling paint, electroplating, seafood, smelters, semiconductors, logging|
|Carbon disulfide||Viscose rayon, explosives, paints, preservatives, textiles, rubber cement, varnishes, electroplating|
|Ethylene oxide||Instrument sterilization, chemical precursor|
|n -hexane||Glues and vegetable extraction, components of naphtha, lacquers, metal-cleaning compounds|
|Lead||Solder, lead shot, illicit whiskey, insecticides, auto body shops, storage batteries, foundries, smelters, lead-based paint, lead stained glass, lead pipes|
|Mercury||Scientific instruments, electrical equipment, amalgams, electroplating, photography, felt making, taxidermy, textiles, pigments, chloroalkali industry|
|Methyl n -butyl ketone||Paints, varnishes, quick-drying inks, lacquers, metal-cleaning compounds, paint removers|
|Perchloroethylene||Dry cleaning, degreaser, textile industry|
|Styrene||Fiberglass component, ship building, polyester resin|
|Thallium||Rodenticides, fungicides, mercury and silver alloys, lens manufacturing, photoelectric cells, infrared optical instruments|
|Toluene||Paint, fuel oil, cleaning agents, lacquers, paints and paint thinners|
Trichloroethane (methyl chloroform)
|Degreaser and propellant|
|Trichloroethylene||Cleaning agent, paint component, decaffeination, rubber solvents, varnish|
|Vinyl chloride||Intermediate for polyvinyl chloride (PVC) resins for plastics, floor coverings, upholstery, appliances, packaging|
|Xylene||Fixative for pathologic specimens, paint, lacquers, varnishes, inks, dyes, adhesives, cements|
|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)||Alcohol||HMSN|
|Chronic inflammatory demyelin-ating polyneuro-pathy||Endocrino-pathies: hypo-thyroidism, acromegaly ( TSH , Electrolytes, GH)||Leprosy, syphilis ( RPR , FTA , MHA-TP)||Poly-arteritis nodosa||Paraneo-plastic syndromes (anti-Hu, anti-RII, etc; CBC)||See Table||HSN|
|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
|Small Fiber Neuropathies||Facial Nerve Involvement||Autonomic Involvement||Sensory Ataxia||Pure Motor Involvement||Skin, Nail, or Hair Manifestation|
|Diabetes||Guillain-Barré||Paraneo-plastic||Polyganglio-nopathies||Motor neuron disease||Vasculitis: purpura, livedo reticularis|
|Amyloid||CIDP||GBS||Paraneo-plastic||Multifocal motor neuropathy||Cryoglo-binemia: purpura|
|HIV-associated||Lyme disease||Porphyria||Sjögren syndrome||GBs||Fabry disease: angiokera-tomas|
|Hereditary sensory and autonomic neuropathy||Sarcoidosis||Vincristine, vacor||Cisplatin analogs||Acute motor axonal neuropathy||Leprosy: skin hypopig-mentation|
|Fabry disease||HIV||Diabetes||Vitamin B-6 toxicity||Porphyria||Osteo-sclerotic myeloma: skin hyperpig-mentation|
|Tangier disease||Tangier||Amyloid||GBS (Miller-Fisher variant)||CIDP||Variegate porphyria: bullous lesions|
|Sjögren syndrome||HIV||IgM monoclonal gammopathy of undetermined significance||Osteosclerotic myeloma||Refsum disease: ichthyosis|
|Hereditary sensory and autonomic neuropathy||Diabetic lumbar radiculoplex-opathy||Arsenic or thallium intoxication: Mees lines|
|Hereditary motor sensory neuropathy (Charcot-Marie-Tooth)||Thallium intoxication: alopecia|
|Lead||Giant axonal neuropathy: curled hair|
|Almitrine (s)||“Spanish toxic oil”|
|Arsenic (s)(d)||2-t-Butylazo- 2- hydroxyl- 5 methylhexane|
|Carbamate pesticides (nm)||Allyl chloride|
|Carbon disulfide (m)(d)||Amiodaron e (d)|
|Cimetidine (m)||Carbamates (nm)|
|Cisplatin (s)||Carbon monoxide|
|Dapsone (m)||Disulfiram (m)|
|Didoxynucleosides (s) (ddC, ddI, d4T)||Ethyl alcohol|
|Dimethylaminopropionitrile||Ethylene glycol (cr)|
|Doxorubicin (m)||Ethylene oxide|
|Ethambutol (s)||Germanium dioxide|
|Hyperinsulinemia/ hypoglycemia (m)||Isoniazid|
|Imipramine (m)||Lincomycin (nm)|
|Interferon alpha (nm)||Lithium|
|Methyl n-butyl ketone (m)(d)||Mercury, organic|
|Misonidazole (s)||Methyl bromide|
|Nitrous Oxide (s)||N hexane (d)|
|Organophosphorus compounds (nm)||Nitrofurantoin (m)|
|Polychlorinated biphenyls (s)||Penicillamine (nm)|
|Polymyxin (nm)||Perhexiline (d)|
|Succinylcholine (nm)||Quinine (nm)|
|Sulfonamides (m), sulfasalazine||Statins|
|Taxanes (paclitaxel, docetaxel) (s)||Suramin|
|Thallium (s)||Tetracyclines (nm)|
|Vincristine (m)||Vincristine (m), Vinca alkaloids|
|(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