Patient Presentation
A 20-year-old right-handed male came to clinic with complaints of numbness and tingling in the right lower part of his forearm, 4th and 5th digit and lateral hand. The problem had been increasing over the past month. In particular it increased over the day and was best in the morning. It also got worse day to day over the work week and was better on the weekends. He also complained of some general shoulder and neck muscle pain that he described as cramping, which also improved with rest. He had started a new summer job about 5 weeks previous where he did extensive computer work. He said that the keyboard and mousepad were on top of a solid desk with the monitor in front of the keyboard. He showed the examiner how he had to place the lateral aspect of his right lower forearm across the edge of the desk. He used other computers at home but said that he had a separate tray for his keyboard and mouse that were lower in height than the edge of the desk he worked on, and the edges of the tray were padded. He also played a variety of videogames with hand or lap controllers. He denies any new medications or toxin exposure. The past medical history was non-contributory. The family history revealed no neurological or genetic abnormalities.
The pertinent physical exam showed a healthy male with normal vital signs and growth parameters. His musculoskeletal examination showed very tight muscles of the neck and shoulder girdle bilaterally. His neurological examination was normal except for pain and numbness in the ulnar nerve distribution of the right lower forearm and hand. Strength was normal. The diagnosis of an acute, focal peripheral neuropathy secondary to ulnar nerve compression along with general muscle spasm of the neck and shoulders was made. He was instructed to suspend all computer work until he had normal sensation. He was given an information prescription of Internet resources on how to properly set-up a computer workstation so that it would be ergonomically appropriate for him. He was also instructed to take frequent short breaks, and to do intermittent stretching of his body. He was to return to clinic if the symptoms persisted or changed. At his next health supervision visit, he reported no problems after he had changed his workstation.
Discussion
Peripheral neuropathy is simply a disease of the peripheral nerves. They can be acute (30%) or chronic (about 67%). About 70% of chronic neuropathy in children is hereditary, 20% is indeterminant and 10% is acquired. Peripheral neuropathies are often present with predominantly distal involvement that is bilateral and symmetric. Sensory symptoms can include numbness, dysesthesia or ataxia. Motor symptoms often include weakness. The autonomic nervous system can also be affected with arrhythmias, hypotension, bowel or bladder problems or abnormal sweating.
Learning Point
The differential diagnosis of peripheral neuropathy includes:
- Neurologic
- Abetaliporteinemia
- Charcot-Marie Tooth Disease
- Chronic Inflammatory Demyelinating Polyneuropathy
- Dejerine-Sottas
- Giant Axonal Neuropathy
- Guillian-Barre Syndrome
- Hereditary Sensory Neuropathies – Familial Dysautonomia
- Ischemic Monomelic Neuropathy
- Mononeuritis Multiplex
- Metachromatic Leukodystrophy
- Refsum Disease
- Infectious Disease
- Chagas Disease
- Diphtheria
- Leprosy
- Lyme Disease
- Rabies
- Tick Paralysis
- Rheumatic/Inflammatory
- Churg-Strauss Syndrome
- Henoch-Schonlein Purpura
- Inflammatory Bowel Disease
- Juvenile Rheumatoid Arthritis
- Polyarteritis Nodosa
- Sarcoidosis
- Sjogren’s Syndrome
- Systemic Lupus Erythematosus
- Wegener’s Granulomatosis
- Specific Diseases
- Celiac Disease
- Chronic Illness Polyneuropathy
- Cystic Fibrosis
- Diabetes Mellitis
- Hypothyroidism
- Porphyria
- Malignancy
- Renal Failure/Uremia
- Transplantation – Bone Marrow, Liver
- Vitamin Deficiency – B1, B2, B6, B12, E
- Drugs
- Alcohol
- Anti-retroviral medications
- Antibiotics – chloramphenicol, isoniazid, metronidazole, nitrofurantoin, penicillin, sulfonamide,
- Chemotherapy
- Phenytoin
- Thalidomide
- Toxins
- Arsenic
- Lead
- Mercury
- n-Hexane
- Organophosphates
- Thallium
- Other
- Epidemic neuropathy
- Factitious
- Idiopathic – Bell’s palsy
- Mechanical – brachial plexus injury, injections, pressure,
Questions for Further Discussion
1. What types of evaluation can be considered for peripheral neuropathy?
2. What are indications for evaluation by a neurologist?
3. What are common health problems associated with using computers?
Related Cases
- Disease: Peripheral Nerve Disorders
- Symptom/Presentation: Pain
- Specialty: Neurology / Neurosurgery
- Age: Young Adult
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Peripheral Nerve Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:2280-2285.
Cruse, RP. Overview of Acquired Peripheral Neuropathy in Children. Up To Date.
Available from the Internet at http://www.uptodate.com (rev. 1/13/2010, cited 8/13/2010).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 