Symptoms and Signs – Differential Diagnosis of Paresthesia

Symptoms and Signs – Differential Diagnosis of Paresthesia

Paresthesia refers to an atypical sensation or amalgamation of sensations—often characterized as numbness, prickling, or tingling—experienced via peripheral nerve pathways; these sensations are often non-painful. Unpleasant or unpleasant feelings are referred to as dysesthesias.

Paresthesia can manifest abruptly or progressively and may be either transitory or persistent. Paresthesia, a prevalent symptom of various neurological illnesses, may also arise from a systemic condition or specific medication. This may indicate damage or irritation to the parietal lobe, thalamus, spinothalamic tract, or spinal or peripheral nerves, which are integral to the neuronal circuit responsible for transmitting and interpreting sensory stimuli.

Medical History and Physical Assessment
Initially, investigate the paresthesia. When did the odd sensations commence? Request the patient to elucidate their characteristics and distribution. Additionally, inquire about concomitant signs and symptoms, including sensory deficits and paresis or paralysis. Subsequently, obtain a medical history encompassing neurological, cardiovascular, metabolic, renal, and chronic inflammatory conditions, including arthritis and lupus. Has the patient lately experienced a traumatic injury, undergone surgery, or had an invasive procedure that could have compromised peripheral nerves? Concentrate the physical examination on the patient's neurological condition. Evaluate his state of consciousness (LOC) and cranial nerve functionality. Evaluate muscle strength and deep tendon reflexes (DTRs) in limbs exhibiting paresthesia.

Conduct a systematic assessment of light touch, nociception, thermoreception, vibratory sensation, and proprioception. Additionally, observe skin pigmentation and warmth, and assess pulse palpation.

Etiological Factors
Acute arterial occlusion
Acute artery occlusion may result in abrupt paresthesia and coldness in one or both legs due to a saddle embolus. Paresis, intermittent claudication, and resting discomfort are also indicative. The extremities exhibits mottling with a delineation of temperature and color at the site of occlusion. Pulses are nonexistent beneath the occlusion, and the capillary refill time is prolonged.

Obliterative arteriosclerosis
Arteriosclerosis obliterans results in paresthesia, intermittent claudication (the most prevalent symptom), reduced or nonexistent popliteal and pedal pulses, pallor, paresis, and coldness in the affected limb.

Arthritis
Rheumatoid or osteoarthritic alterations in the cervical spine may induce paresthesia in the neck, shoulders, and arms. The lumbar spine may be impacted, resulting in paresthesia in one or both legs and feet.

Neoplasm of the brain
Neoplasms impacting the sensory cortex in the parietal lobe can lead to increasing contralateral paresthesia, along with agnosia, apraxia, agraphia, homonymous hemianopsia, and diminished proprioception.

Buerger's disease
Buerger’s disease, an inflammatory occlusive illness associated with smoking, causes the feet to become cold, cyanotic, and numb upon exposure to cold; subsequently, they redden, warm, and experience tingling sensations. Intermittent claudication, exacerbated by physical activity and alleviated by rest, is also prevalent. Additional findings encompass diminished peripheral pulses, migrating superficial thrombophlebitis, followed by ulceration, muscular atrophy, and gangrene.

Diabetes mellitus
Diabetic neuropathy may induce paresthesia characterized by a burning feeling in the extremities. Additional findings encompass gradual, irreversible anosmia, weariness, polyuria, polydipsia, weight reduction, and polyphagia.

Guillain-Barré syndrome
In Guillain-Barré syndrome, transitory paresthesia may occur prior to the onset of muscle weakness, which often initiates in the legs and progresses to the arms and facial nerves. Weakness may advance to complete paralysis. Additional abnormalities encompass dysarthria, dysphagia, nasal speech, orthostatic hypotension, bladder and bowel incontinence, diaphoresis, tachycardia, and potentially, indications of life-threatening respiratory muscle paralysis.

Cerebral injury
Paresthesia, whether unilateral or bilateral, may arise after head trauma resulting in a concussion or contusion; still, sensory loss is more prevalent. Additional observations encompass varying paresis or paralysis, diminished level of consciousness, headache, blurred or double vision, nausea and vomiting, dizziness, and seizures.

Intervertebral disc herniation
Herniation of a lumbar or cervical disc may result in an immediate or gradual onset of paresthesia along the distribution paths of the afflicted spinal nerves. Additional neuromuscular symptoms encompass intense pain, muscle spasms, and weakness that may advance to atrophy if herniation is not alleviated.

Herpes zoster
Paresthesia, an initial symptom of herpes zoster, manifests in the dermatome innervated by the impacted spinal nerve. Within a few days, this dermatome exhibits a pruritic, erythematous, vesicular rash accompanied by acute, shooting, or scorching pain.

Hyperventilation syndrome
Hyperventilation syndrome, typically induced by severe anxiety, can result in temporary paresthesia in the hands, feet, and perioral region, along with agitation, vertigo, syncope, pallor, muscle twitching and weakening, carpopedal spasm, and cardiac arrhythmias.

Migraine cephalalgia
Paresthesia in the hands, face, and perioral region may indicate an approaching migraine headache. Additional prodromal symptoms encompass scotomas, hemiparesis, disorientation, dizziness, and photophobia. These symptoms may endure throughout the typical pulsating headache and stay even after its resolution.

Multiple sclerosis (MS)
Demyelination of the sensory cortex or spinothalamic tract in multiple sclerosis may result in paresthesia, often one of the initial symptoms. Paresthesia, like to other manifestations of MS, typically fluctuates until the latter stages, at which point it may become permanent. Related results encompass muscular weakness, spasticity, and hyperreflexia. Injury to peripheral nerves. Damage to a significant peripheral nerve can result in paresthesia, sometimes manifesting as dysesthesia, in the region innervated by that nerve. Paresthesia occurs promptly upon trauma and may be enduring.

Additional findings include flaccid paralysis or paresis, hyporeflexia, and varied sensory loss.

Peripheral neuropathy
Peripheral neuropathy may induce increasing paresthesia in all extremities. The patient frequently exhibits muscle weakness, potentially resulting in flaccid paralysis and atrophy, loss of vibration feeling, reduced or absent deep tendon reflexes, neuralgia, and dermatological alterations, including glossy, erythematous skin and anhidrosis.

Rabies
Paresthesia, coldness, and pruritus at the location of an animal bite signify the prodromal phase of rabies. Additional prodromal signs and symptoms include fever, headache, photophobia, hyperesthesia, tachycardia, shallow respirations, and excessive salivation, lacrimation, and perspiration.

Raynaud's phenomenon
Exposure to cold or stress causes the fingers to become pale, chilly, and cyanotic; upon rewarming, they turn red and exhibit paresthesia. Ulceration may manifest in chronic cases.

Epileptic disorders
Seizures originating in the parietal lobe typically induce paresthesia in the lips, fingers, and toes. Paresthesia may serve as auras that precede tonic-clonic seizures.

Spinal cord damage
Paresthesia may manifest following partial spinal cord transection, subsequent to the resolution of spinal shock. It might be unilateral or bilateral, manifesting at or below the lesion level. The associated sensory and motor loss is inconsistent.. Spinal cord abnormalities may be linked to paresthesia during head flexion (Lhermitte’s sign).

Neoplasms of the spinal cord
Tumors of this nature lead to paresthesia, paresis, pain, and sensory loss along the nerve pathways innervated by the impacted spinal cord segment. Paresis may ultimately lead to spastic paralysis accompanied by hyperactive deep tendon reflexes, except when the tumor is located in the cauda equina, which results in hyporeflexia, and potentially causes bladder and bowel incontinence.

Cerebrovascular accident
While contralateral paresthesia can manifest in stroke, sensory loss is more prevalent. Accompanying characteristics differ based on the afflicted artery and may encompass contralateral hemiplegia, diminished level of consciousness, and homonymous hemianopsia.

Systemic lupus erythematosus (SLE)
SLE may induce paresthesia; nevertheless, its principal signs and symptoms encompass nondeforming arthritis (often affecting the hands, feet, and major joints), photosensitivity, and a "butterfly rash" that manifests over the nose and cheeks. Tabes dorsalis. Paresthesia, particularly in the legs, is a prevalent yet late manifestation of tabes dorsalis. Additional findings encompass ataxia, impaired proprioception, altered pain and temperature sensitivity, absent deep tendon reflexes, Charcot's joints, Argyll Robertson pupils, incontinence, and impotence.

Transient ischemic attack (TIA)
Paresthesia generally manifests suddenly during a TIA and is confined to one arm or a specific region of the body. It often endures for approximately 10 minutes and is associated with paralysis or paresis. Related symptoms encompass diminished level of consciousness, vertigo, unilateral visual impairment, nystagmus, aphasia, dysarthria, tinnitus, facial paresis, dysphagia, and ataxic gait.
Additional Causes: Substances. Phenytoin, chemotherapeutic medicines (including vincristine, vinblastine, and procarbazine), isoniazid, nitrofurantoin, chloroquine, and parenteral gold therapy may induce transitory paresthesia that resolves upon cessation of the drug. Radiation treatment. Prolonged radiation therapy may ultimately induce peripheral nerve damage, leading to paresthesia.

Due to the frequent association of paresthesia with localized sensory deficits, instruct the patient on safety precautions. Instruct him to measure the bathwater temperature using a thermometer.

Elucidate safety protocols and inform the patient of the indications and symptoms that necessitate reporting.

While children may have paresthesia due to the same etiologies as adults, many are unable to articulate this symptom. Nonetheless, genetic polyneuropathies are typically initially identified during childhood.