Among the multitude of odd neurologic manifestations attributed to this disease, the best known ones are cerebellar ataxia and myoclonus. In addition, Hadjivassiliou and colleagues have reported patients with a range of neuromuscular disorders in whom the neurologic symptoms antedated the diagnosis of the bowel disorder. A nondescript sensorimotor neuropathy was the most frequent, but one patient had mononeuropathy multiplex and Chin and colleagues have reported a multifocal neuropathy pattern. In a small prospective survey of treated celiac disease, Luostarinen and colleagues found 23 percent with evidence of a polyneuropathy by nerve conduction testing, but the clinical findings were scant. Antigliadin antibodies (simple antibodies directed against gluten), as well as more specific anti-transglutaminase antibodies and histologic examination of a duodenal biopsy are confirmatory of the diagnosis. Luostarinen and colleagues suggested that a search be made for these antibodies in patients with polyneuropathies of obscure origin. It is not clear how many of their cases could be attributed to nutritional deficiency. We have not encountered a definite instance despite attempts to detect the special sprue antibodies in the evaluation of over 200 cases of otherwise obscure polyneuropathy.
Neuropathies Associated With HIV (See Also Chap. 32)
Patients infected with HIV are prone to several types of neuropathies, including a predominantly sensory type that may be painful, a lumbosacral polyradiculopathy, cranial (mainly facial nerve) and limb mononeuropathies, CIDP, GBS, and a vasculitic mononeuritis multiplex—none of which differs from the idiopathic or conventional varieties except that there is often a pleocytosis in the spinal fluid. Almost unique and common patterns in this group are the CMV cauda equina neuritis syndrome and an acute or subacute painful infiltrative lymphocytic neuropathy—the diffuse infiltrative lymphocytosis syndrome (DILS; Moulingier et al). Polyneuropathy may also be induced by antiviral agents that are used in the treatment of HIV infection, as discussed in Chap. 32.
These are among the most clinically complex diseases of the peripheral nerves. Involvement of multiple spinal nerve roots produces a distinctive or sometimes confusing constellation of findings, usually quite different from those of polyneuropathy and from multiple mononeuropathies. As described earlier, muscle weakness caused by polyradiculopathy is characteristically asymmetrical and variably distributed in proximal and distal parts of the limbs, reflecting a pattern of muscles that share common root innervations (e.g., the combination of weakness in hamstring and gastrocnemius, or of iliopsoas, quadriceps, and obturator). However, muscles with similar innervation are not necessarily affected to the same degree because of the disproportionate contribution of a given root to each muscle. Sensory loss tends also to be patchy and to involve both the proximal and distal aspects of a dermatome. Pain is common in a radicular pattern, but sometimes only in the distal distribution of the root or in the back. The sensory findings tend to be less prominent than the motor ones. In keeping with nerve root pattern, certain tendon reflexes may be spared; a normal ankle jerk combined with an absent knee jerk, or the opposite, are particularly suggestive of a polyradiculopathy (or a lumbar plexopathy). Pain often takes the form of sharp jabs projected into the innervated zone of the involved root. As with mononeuritis multiplex, the cumulative effect of multiple root lesions can simulate a polyneuropathy in which case the tendency for polyradiculopathy to involve proximal muscles is the most helpful distinguishing feature.