Doporu\u010den\u00fd postup pro praktick\u00e9 l\u00e9ka\u0159e<\/p>\n
\u010cesk\u00e1 l\u00e9ka\u0159sk\u00e1 spole\u010dnost Jana Evangelisty Purkyn\u011b<\/p>\n
DOPORU\u010cEN\u00c9 POSTUPY PRO PRAKTICK\u00c9 L\u00c9KA\u0158E Projekt MZ \u010cR zpracovan\u00fd \u010cLS JEP za podpory grantu IGA MZ \u010cR 5390-3 Reg. \u010d. o\/027\/131 Polyneuropatie Autor: Prof. MUDr. Zden\u011bk Ambler, DrSc. Spoluauto\u0159i: Doc. MUDr. Josef Bedna\u0159\u00edk, CSc. Doc. MUDr. Otakar Keller, CSc. Gesce: Neurologick\u00e1 spole\u010dnost \u010cLS JEP Oponenti: MUDr. Karel Linhart MUDr. Blanka \u017di\u017ekov\u00e1 Polyneuropatie (PN) tvo\u0159\u00ed heterogenn\u00ed skupinu poruch perifern\u00edch nerv\u016f. Jde o dif\u00fazn\u00ed nebo v\u00edce\u00ac\u010detn\u00e9 syst\u00e9mov\u00e9, z\u00edskan\u00e9 nebo d\u011bdi\u010dn\u00e9 posti\u017een\u00ed perifern\u00edch nerv\u016f, kter\u00e9 vznik\u00e1 p\u016fsobe\u00acn\u00edm r\u016fzn\u00fdch endogenn\u00edch i exogenn\u00edch vliv\u016f (z\u00e1n\u011btliv\u00e9, metabolick\u00e9, toxick\u00e9, imunopato\u00acgenn\u00ed, vitaminov\u00e9 a nutri\u010dn\u00ed deficience, degenerativn\u00ed i paraneoplastick\u00e9). Posti\u017eeny b\u00fdvaj\u00ed hlavn\u011b dlouh\u00e9 nervy (proto \u010dast\u011bji na doln\u00edch kon\u010detin\u00e1ch) a klinick\u00e9 projevy p\u0159eva\u017euj\u00ed na dist\u00e1ln\u00edch \u010d\u00e1stech kon\u010detin. Klinick\u00fd obraz m\u016f\u017ee b\u00fdt symetrick\u00fd i asymetrick\u00fd, mohou p\u0159eva\u00ac\u017eovat p\u0159\u00ed\u00acznaky senzitivn\u00ed nebo motorick\u00e9. Porucha se m\u016f\u017ee rozvinout akutn\u011b v pr\u016fb\u011bhu dn\u016f a\u017e t\u00fddn\u016f nebo \u010dast\u011bji chronicky b\u011bhem \u0159ady m\u011bs\u00edc\u016f. U PN doch\u00e1z\u00ed ke dv\u011bma typ\u016fm posti\u017een\u00ed perifern\u00edch nerv\u016f, kter\u00e9 se mohou i vz\u00e1jemn\u011b kombinovat: \u2022 axon\u00e1ln\u00ed degenerace – vznik\u00e1 p\u0159i po\u0161kozen\u00ed axonu a axoplazmatick\u00e9ho transportu \u2022 demyelinizace – doch\u00e1z\u00ed k dif\u00fazn\u00edmu nebo segment\u00e1ln\u00edmu po\u0161kozen\u00ed myelinov\u00e9 pochvy. P\u0159i diagnostice neuropati\u00ed vych\u00e1z\u00edme ze t\u0159\u00ed z\u00e1kladn\u00edch krit\u00e9ri\u00ed: \u2022 subjektivn\u00edch p\u0159\u00edznak\u016f \u2022 objektivn\u00edho n\u00e1lezu \u2022 elektrodiagnostiky 1. Subjektivn\u00ed p\u0159\u00edznaky. D\u016fle\u017eit\u00e9 jsou tzv. neuropatick\u00e9 senzitivn\u00ed p\u0159\u00edznaky, kam pat\u0159\u00ed bo\u00aclesti, p\u00e1len\u00ed, brn\u011bn\u00ed, mraven\u010den\u00ed, pocity chladu nebo sn\u00ed\u017een\u00e1 citlivost. Nemocn\u00ed mohou m\u00edt pocit sta\u017een\u00ed kolem kotn\u00edk\u016f nebo pocit ch\u016fze jako po mechu. Obecn\u011b mohou b\u00fdt p\u0159\u00edznaky negativn\u00ed – v\u00fdpadov\u00e9 (sn\u00ed\u017een\u00e9 vn\u00edm\u00e1n\u00ed \u010dit\u00ed) i pozitivn\u00ed – irita\u010dn\u00ed (objevuje se n\u011bco nav\u00edc – bolesti, brn\u011bn\u00ed, p\u00e1len\u00ed, sv\u011bd\u011bn\u00ed apod.). Typ senzitivn\u00edch p\u0159\u00edznak\u016f z\u00e1vis\u00ed na posti\u017een\u00ed jednot\u00acliv\u00fdch druh\u016f vl\u00e1ken. P\u0159i p\u0159eva\u017euj\u00edc\u00edm posti\u017een\u00ed siln\u00fdch vl\u00e1ken (pro vn\u00edm\u00e1n\u00ed vibrace a polohocitu) doch\u00e1z\u00ed k ne\u00acbolestiv\u00fdm parest\u00e9zi\u00edm, zjist\u00ed se porucha vibra\u010dn\u00edho \u010dit\u00ed, pohocitu a pohybocitu, lehk\u00e1 poru\u00accha taktiln\u00edho \u010dit\u00ed a jsou sn\u00ed\u017een\u00e9 nebo vyhasl\u00e9 \u0161lachookosticov\u00e9 reflexy. T\u011b\u017e\u0161\u00ed porucha hlubo\u00ack\u00e9ho \u010dit\u00ed se klinicky projev\u00ed senzitivn\u00ed ataxi\u00ed, kter\u00e1 se manifestuje poruchou rovnov\u00e1hy a atak-tickou ch\u016fz\u00ed hlavn\u011b p\u0159i vylou\u010den\u00ed zrakov\u00e9 kontroly (p\u0159edev\u0161\u00edm za \u0161era, ve tm\u011b a p\u0159i vy\u0161et\u00ac\u0159en\u00ed ch\u016fze se zav\u0159en\u00fdma o\u010dima). Pro posti\u017een\u00ed tenk\u00fdch vl\u00e1ken (pro bolest a teplo) jsou charakteristick\u00e9 bolesti, kter\u00e9 mohou b\u00fdt tup\u00e9, hlubok\u00e9, \u201ebolesti kost\u00ed!\u201e, ale n\u011bkdy i pal\u010div\u00e9, lancinuj\u00edc\u00ed – neuropatick\u00e9 bolesti. P\u0159i vy\u0161et\u0159en\u00ed zjist\u00edme poruchu \u010dit\u00ed pro bolest, teplo, lehkou poruchu taktiln\u00edho \u010dit\u00ed, ale vibra\u010dn\u00ed \u010dit\u00ed i \u0161lachookosticov\u00e9 reflexy jsou norm\u00e1ln\u00ed. Z\u00e1kladn\u00edm motorick\u00fdm projevem je svalov\u00e1 slabost, zv\u00fd\u0161en\u00e1 \u00fanava kon\u010detin a nejist\u00e1 ch\u016fze. Mezi pozitivn\u00ed motorick\u00e9 p\u0159\u00edznaky pat\u0159\u00ed svalov\u00e9 k\u0159e\u010de (krampy) a fascikulace. 2. Objektivn\u00ed n\u00e1lez je charakterizov\u00e1n perifern\u00ed symptomatikou: sn\u00ed\u017een\u00e9 nebo vyhasl\u00e9 \u0161la\u00acchookosticov\u00e9 reflexy, p\u0159edev\u0161\u00edm dist\u00e1ln\u011b (reflex \u0161lachy Achillovy), porucha citlivosti – hyp\u00acest\u00e9zie nebo hyperest\u00e9zie pro r\u016fzn\u00e9 kvality podle posti\u017een\u00ed jednotliv\u00fdch druh\u016f vl\u00e1ken, nebo glob\u00e1ln\u00ed, kdy jde o poruchu pro v\u0161echny kvality \u010dit\u00ed. M\u00edv\u00e1 typick\u00fd pun\u010dochov\u00fd nebo rukavi\u00accov\u00fd charakter (polyneuropatick\u00fd typ). Vy\u0161et\u0159ujeme citlivost taktiln\u00ed, algickou, p\u0159\u00edpadn\u011b i termickou (zkumavkou s teplou a studenou vodou) a v\u017edy tak\u00e9 propriocepci (polohocit a po\u00achybocit akr\u00e1ln\u011b na prstech nohou, p\u0159\u00edpadn\u011b i \u010dit\u00ed vibra\u010dn\u00ed). Svalovou slabost zjist\u00edme sn\u00ed\u017een\u00edm s\u00edly podle svalov\u00e9ho testu. Distribuce svalov\u00e9 slabosti m\u00edv\u00e1 nej\u010dast\u011bji dist\u00e1ln\u00ed p\u0159evahu, co\u017e se projev\u00ed oslaben\u00edm dorz\u00e1ln\u00ed nebo plant\u00e1rn\u00ed flexe nohy (inerva\u010dn\u00ed oblast peroneu b\u00fdv\u00e1 nej\u010dast\u011bji posti\u017eena – v\u00e1zne ch\u016fze po pat\u00e1ch, p\u0159i posti\u017een\u00ed n. tibialis je oslabena ch\u016fze po \u0161pi\u010dk\u00e1ch). P\u0159i proxim\u00e1ln\u00ed p\u0159evaze je v pop\u0159ed\u00ed oslaben\u00ed stehen\u00acn\u00edho svalstva (v\u00e1zne nap\u0159. vst\u00e1v\u00e1n\u00ed ze d\u0159epu nebo ch\u016fze po schodech). Mohou b\u00fdt posti\u017eena i autonomn\u00ed vl\u00e1kna a vznikaj\u00ed projevy dysautonomie, poruchy v\u00e1zo\u00acmotorick\u00e9, sudomotorick\u00e9, ale i kardiovaskul\u00e1rn\u00ed (nap\u0159. postur\u00e1ln\u00ed hypotenze) nebo gastroin\u00actestin\u00e1ln\u00ed poruchy. PN mohou m\u00edt charakter l\u00e9ze symetrick\u00e9, asymetrick\u00e9 i imponovat jako v\u00edce\u010det\u00acn\u00e9 posti\u017een\u00ed jednotliv\u00fdch perifern\u00edch nerv\u016f (mononeuropatia multiplex). Z\u00e1kladn\u00ed ot\u00e1zkou je v\u017edy, zda se skute\u010dn\u011b jedn\u00e1 o PN. Tak nap\u0159. klasick\u00e9 parest\u00e9\u00aczie m\u016f\u017ee zp\u016fsobit jak polyneuropatie tak i lumbosakr\u00e1ln\u00ed radikulopatie, na horn\u00edch kon\u010deti\u00acn\u00e1ch \u00fa\u017eino\u00acv\u00e9 kompresivn\u00ed syndromy, ale m\u016f\u017ee j\u00edt i o centr\u00e1ln\u00ed etiologii, nap\u0159. u m\u00ed\u0161n\u00edch po\u00acruch nebo roztrou\u0161en\u00e9 skler\u00f3zy mozkom\u00ed\u0161n\u00ed. Chybn\u00e1 inici\u00e1ln\u00ed odpov\u011b\u010f m\u016f\u017ee v\u00e9st k dal\u0161\u00edmu sledu zby\u00acte\u010dn\u00fdch vy\u0161et\u0159en\u00ed a posunout diagnostiku jin\u00fdm sm\u011brem. Proto u ka\u017ed\u00e9ho podez\u0159en\u00ed na PN doporu\u010d\u00edme neurologick\u00e9 vy\u0161et\u0159en\u00ed. Sou\u010dasn\u011b je vhodn\u00e9 i prov\u00e9st z\u00e1kladn\u00ed laboratorn\u00ed vy\u0161et\u00ac\u0159en\u00ed \u2013 1. sledu (tab. 1). Z\u00e1kladn\u00ed vy\u0161et\u0159en\u00ed m\u016f\u017ee prov\u00e9st praktick\u00fd l\u00e9ka\u0159 i jak\u00fdkoli specialista. P\u0159i potvrzen\u00ed PN je v\u017edy indikov\u00e1na elektrodiagnostika. 3. Elektrodiagnostika je ji\u017e specializovan\u00e9 vy\u0161et\u0159en\u00ed elektromyografick\u00e9 (EMG) a kon\u00acduk\u010dn\u00ed studie perifern\u00edch nerv\u016f, kter\u00e9 up\u0159esn\u00ed charakter a t\u00ed\u017ei posti\u017een\u00ed. V\u00fdznamn\u00e1 je p\u0159ede\u00acv\u0161\u00edm pro posouzen\u00ed p\u0159evahy l\u00e9ze axon\u00e1ln\u00ed nebo demyeliniza\u010dn\u00ed. U demyeliniza\u010dn\u00edch neuro\u00acpati\u00ed jde p\u0159edev\u0161\u00edm o posti\u017een\u00ed myelinov\u00e9 pochvy, co\u017e se projev\u00ed poruchou veden\u00ed vzruchu (zpomalen\u00edm nebo blokem) a abnormitami p\u0159i konduk\u010dn\u00ed studii. U axon\u00e1ln\u00ed degenerace je veden\u00ed vzruchu v zachovan\u00fdch axonech neporu\u0161eno, ale zjist\u00ed se denerva\u010dn\u00ed (ale i reinerva\u010dn\u00ed) projevy. V\u011bt\u0161i\u00acnou jsou z\u00e1kladn\u00ed typy l\u00e9ze r\u016fzn\u00fdm pom\u011b\u00acrem kombinov\u00e1ny. Axon\u00e1ln\u00ed neuropatie jsou \u010dast\u011bj\u0161\u00ed, zp\u016fsobuj\u00ed je vlivy toxick\u00e9, nutri\u010dn\u00ed deficience, n\u011bkter\u00e9 syst\u00e9mov\u00e9 a metabolick\u00e9 choroby. Doch\u00e1z\u00ed k poru\u0161e axoplazmatick\u00e9ho transportu. \u010cast\u00e9 jsou senzitivn\u00ed pozitivn\u00ed p\u0159\u00edznaky v typick\u00e9 dist\u00e1ln\u00ed lokalizaci, i motorick\u00fd deficit m\u00edv\u00e1 p\u0159evahu dist\u00e1ln\u00ed slabosti. Akutn\u011b vznikaj\u00ed u intoxikac\u00ed a syst\u00e9mov\u00fdch chorob, subakutn\u011b u metabolic\u00ack\u00fdch chorob a n\u011bkter\u00fdch intoxikac\u00ed, chronicky u heredodegenerativn\u00edch a n\u011bkter\u00fdch syst\u00e9mo\u00acv\u00fdch chorob. Obraz mononeuropatia multiplex se vyskytuje u vaskulitid a diabetu. Demyeliniza\u010dn\u00ed neuropatie jsou hlavn\u011b autoimunitn\u00ed a z\u00e1n\u011btliv\u00e9, mohou p\u0159eva\u017eovat moto\u00acrick\u00e9 projevy a posti\u017een\u00ed m\u016f\u017ee m\u00edt dist\u00e1ln\u00ed i proxim\u00e1ln\u00ed p\u0159evahu. Rozv\u00edjej\u00ed se akutn\u011b, sub\u00acakutn\u011b i chronicky. Term\u00edn PN je diagn\u00f3za jen anatomick\u00e1, ale lokalizace chorobn\u00e9ho procesu je v neurologii v\u017edy kl\u00ed\u010dov\u00e1. Elektrodiagnostika up\u0159esn\u00ed charakter patologick\u00e9ho procesu, ale hlavn\u00edm c\u00edlem je v\u017edy objasn\u011bn\u00ed etiologie, \u010demu\u017e mohou pomoci laboratorn\u00ed vy\u0161et\u0159en\u00ed 2. sledu (tab.1). Hlavn\u00ed p\u0159\u00ed\u010diny polyneuropati\u00ed I. Z\u00edskan\u00e9 neuropatie 1) Diabetick\u00e9 neuropatie Diabetes mellitus je nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinou neuropati\u00ed. Symptomatick\u00e1 neuropatie b\u00fdv\u00e1 p\u0159\u00edtomna asi u 10 % diabetik\u016f. Nej\u010dast\u011bji jde o symetrick\u00e9 posti\u017een\u00ed p\u0159ev\u00e1\u017en\u011b senzitivn\u00edch vl\u00e1ken a s dist\u00e1ln\u00ed p\u0159evahou, nej\u010dast\u011bji na doln\u00edch kon\u010detin\u00e1ch. U 20-25 % diabetik\u016f mohou b\u00fdt pro\u00acjevy i fok\u00e1ln\u00edch asymetrick\u00fdch neuropati\u00ed, nap\u0159. proxim\u00e1ln\u00ed diabetick\u00e1 amyotrofie nebo krani\u00ac\u00e1ln\u00ed neuropatie s posti\u017een\u00edm okohybn\u00e9ho nervu. 2) Autoimunitn\u00ed a z\u00e1n\u011btliv\u00e9 polyneuropatie Syndrom Guillain-Barr\u00e9 pat\u0159\u00ed k nej\u010dast\u011bj\u0161\u00edm akutn\u00edm PN, kter\u00e1 se rozv\u00edj\u00ed v pr\u016fb\u011bhu dn\u016f, ma\u00acxim\u00e1ln\u011b t\u00fddn\u016f. M\u00e1 p\u0159evahu motorick\u00e9ho posti\u017een\u00ed. Chronick\u00e1 z\u00e1n\u011btliv\u00e1 demyeliniza\u010dn\u00ed poly\u00acneuropatie se rozv\u00edj\u00ed se mnohem pomaleji, obvykle \u0159adu t\u00fddn\u016f a\u017e m\u011bs\u00edc\u016f. Neuropatie se vys\u00ackytuj\u00ed rovn\u011b\u017e u vaskulitid, Lymesk\u00e9 boreli\u00f3zy a infekce HIV. 3) Neuropatie v d\u016fsledku nutri\u010dn\u00ed deficience. V na\u0161ich podm\u00ednk\u00e1ch jde hlavn\u011b o deficienci vitaminu B1 (thiamin), kter\u00e1 je hlavn\u00ed p\u0159\u00ed\u010dinou alkoholov\u00e9 neuropatie. Dal\u0161\u00ed p\u0159\u00ed\u010dinou neuro\u00acpatie je deficience vitaminu B 12. 4) Neuropatie v souvislosti s chronickou ren\u00e1ln\u00ed insuficienc\u00ed. B\u00fdv\u00e1 p\u0159edev\u0161\u00edm senzitivn\u00ed, u t\u011b\u017e\u0161\u00edch forem ale i s motorick\u00fdm deficitem. 5) Toxick\u00e9 neuropatie. Nej\u010dast\u011bj\u0161\u00ed neuropatie se vyskytuj\u00ed p\u0159i expozici slou\u010denin, kter\u00e9 ob\u00acsahuj\u00ed n-hexan (pou\u017e\u00edv\u00e1 se jako rozpou\u0161t\u011bdlo tuk\u016f, sou\u010d\u00e1st lepidel, lak\u016f, gumov\u00fdch sm\u011bs\u00ed, je obsa\u017een i v pohonn\u00fdch hmot\u00e1ch) a methyl-n-butylketonu (pou\u017e\u00edv\u00e1 se p\u0159i v\u00fdrob\u011b lak\u016f). Neu\u00acrotoxick\u00e9 jsou rovn\u011b\u017e n\u011bkter\u00e9 t\u011b\u017ek\u00e9 kovy (olovo, rtu\u0165). P\u0159\u00edm\u00fd toxick\u00fd vliv na perifern\u00ed nervy m\u00e1 tak\u00e9 alkohol. \u010cast\u011bji se v sou\u010dasn\u00e9 dob\u011b setk\u00e1v\u00e1me s toxick\u00fdmi neuropatiemi po neuroto\u00acxick\u00fdch l\u00e9c\u00edch, jako nap\u0159. po vinkristinu, cisplatin\u011b, paclitaxelu, amiodaronu nebo statinech. 6) Paraneoplastick\u00e9 neuropatie vznikaj\u00ed nep\u0159\u00edm\u00fdm efektem malign\u00edho tumoru a \u010dasto mo\u00achou manifestaci vlastn\u00ed malignity p\u0159edch\u00e1zet. Nej\u010dast\u011bji jde o karcinom plic, prsu, \u017ealudku a st\u0159eva. PN se vyskytuj\u00ed tak\u00e9 u lymfoproliferativn\u00edch poruch a monoklon\u00e1ln\u00edch gamapati\u00ed. 7) Idiopatick\u00e9, kryptogenn\u00ed PN, kde se nepoda\u0159\u00ed zjistit p\u0159\u00ed\u010dinu jsou pom\u011brn\u011b \u010dast\u00e9, dosahuj\u00ed 25-30 %. N\u011bkter\u00e9 p\u0159\u00ed\u010diny (nap\u0159. heredit\u00e1rn\u00ed nebo alkohol) mohou b\u00fdt dlouho skryty. II. Heredit\u00e1rn\u00ed polyneuropatie Nej\u010dast\u011bji jde o heredit\u00e1rn\u00ed senzitivn\u00ed a motorickou neuropatii (HMSN), naz\u00fdvanou tak\u00e9 cho\u00acroba Charcot-Marie-Tooth. L\u00e9\u010dba PN by optim\u00e1ln\u011b m\u011bla ovlivnit z\u00e1kladn\u00ed p\u0159\u00ed\u010dinu, symptomy i podpo\u0159it \u00fapravu. Nap\u0159. u diabetu m\u00e1 nejv\u011bt\u0161\u00ed v\u00fdznam dokonal\u00e1 kompenzace. K ovlivn\u011bn\u00ed bolest\u00ed nebo dysestezi\u00ed u dia\u00acbetick\u00fdch neuropati\u00ed se doporu\u010duje kyselina thioktov\u00e1 – \u03b1-lipoov\u00e1 (Thiocta\u00accid). U deficient\u00acn\u00edch neuropati\u00ed je indikov\u00e1na suplementace vitaminy a samoz\u0159ejm\u00e1 je absti\u00acnence alkoholu. U autoimunitn\u00edch neuropati\u00ed se u\u017e\u00edv\u00e1 r\u016fzn\u00e1 imunoterapie. Symptomatick\u00e1 l\u00e9\u010dba je d\u016fle\u017eit\u00e1 p\u0159e\u00acdev\u0161\u00edm u pozitivn\u00edch senzitivn\u00edch p\u0159\u00edznak\u016f (dysestezi\u00ed nebo neuropatick\u00fdch bolest\u00ed). Z\u00e1kladn\u00ed z\u00e1sady symptomatick\u00e9 l\u00e9\u010dby: \u2022 za\u010d\u00edt l\u00e9\u010dit brzy a \u00fa\u010dinn\u00fdmi medikamenty \u2022 pod\u00e1vat l\u00e9ky v dostate\u010dn\u00e9 d\u00e1vce, pak teprve konstatovat jejich ne\u00fa\u010dinnost a l\u00e9k zm\u011bnit \u2022 pod\u00e1vat l\u00e9ky pravideln\u011b, soustavn\u011b, nikoli jen ad hoc p\u0159i bolesti K symptomatick\u00e9 l\u00e9\u010db\u011b se pou\u017e\u00edvaj\u00ed zejm\u00e9na n\u00e1sleduj\u00edc\u00ed l\u00e9ky: 1) Nesteroidn\u00ed antirevmatika – nap\u0159. ibuprofen, indometacin, naproxen 2) Tricyklick\u00e1 antidepresiva, p\u0159edev\u0161\u00edm amitriptylin. Za\u010d\u00edn\u00e1me v\u017edy mal\u00fdmi d\u00e1vkami 10- 25 mg na noc a pomalu zvy\u0161ujeme podle tolerance 3) Antikonvulziva, p\u0159edev\u0161\u00edm karbamazepin, fenytoin, clonazepam. N\u011bkdy se osv\u011bd\u010duje i kombinace amitriptylinu s deriv\u00e1ty kyseliny valproov\u00e9. Mezi podp\u016frnou l\u00e9\u010dbu pat\u0159\u00ed hlavn\u011b vazodilata\u010dn\u00ed l\u00e9ky a vitaminy (nap\u0159. Milgamma). Pou\u017e\u00ed\u00acvaj\u00ed se v\u011bt\u0161inou jen v kr\u00e1tkodo\u00acb\u00fdch n\u00e1razov\u00fdch d\u00e1vk\u00e1ch, l\u00e9pe v parenter\u00e1ln\u00ed form\u011b a v\u017edy je t\u0159eba objektivn\u011b posoudit jejich skute\u010dn\u00fd efekt. Dlouhodob\u00e1 medikace vazoaktivn\u00edmi l\u00e1tkami nebo vitaminy nem\u00e1 opodstatn\u011bn\u00ed. U PN s motorick\u00fdm deficitem je v\u00fdznamn\u00e1 i l\u00e9\u010dba rehabilita\u010dn\u00ed (v\u010detn\u011b p\u0159\u00edpadn\u00fdch protetic\u00ack\u00fdch pom\u016fcek) a je mo\u017eno vyu\u017e\u00edt i l\u00e9\u010dbu l\u00e1ze\u0148skou (indikace VI\/2). Posudkov\u00e9 hledisko. Akutn\u00ed PN, zejm\u00e9na syndrom Guillain-Barr\u00e9, obvykle nevedou k trval\u00e9 invalidizaci. I chronick\u00e9 PN jsou z\u0159\u00eddka izolovanou p\u0159\u00ed\u010dinou invalidizace, ale mohou k n\u00ed r\u016fznou m\u011brou p\u0159isp\u00edvat (nap\u0159. u diabetick\u00e9 PN). P\u0159i p\u0159etrv\u00e1vaj\u00edc\u00edm motorick\u00e9m deficitu a po\u00acklesu soustavn\u00e9 v\u00fdd\u011ble\u010dn\u00e9 schopnosti se postupuje podle posudkov\u00fdch krit\u00e9ri\u00ed ve Sb. z\u00e1kon\u016f \u010d. 40\/2000. Polyneuropatie jsou uvedeny v kap. VI, odd. B, pol 10. Literatura: 1. Ambler Z. Neuropatie a myopatie. Triton, Praha, 1999:211 2. Ambler Z. Neuropatick\u00e1 bolest a sou\u010dasn\u00e9 mo\u017enosti farmakologick\u00e9 l\u00e9\u010dby. Bolest 3; 2000:17-21 3. Ambler Z. L\u00e9\u010dba polyneuropati\u00ed. Farmakoterapeutick\u00e9 informace, 1997;10:1-3 4. Barohn RJ. Approach to peripheral neuropathy and neuronopathy. Sem Neurol 1998;18:7-18 Tab. 1. Doporu\u010den\u00e9 vy\u0161et\u0159en\u00ed u polyneuropati\u00ed KREV 1. sled: FW, kompletn\u00ed KO, urea, kreatinin, cholesterol, jatern\u00ed testy v\u010detn\u011b GMT, alka\u00aclick\u00e1 fosfat\u00e1za, glyk\u00e9mie, or\u00e1ln\u00ed glukosov\u00fd toleran\u010dn\u00ed test (oGGT), b\u00edlkovina v s\u00e9ru, 2. sled: elektrofor\u00e9za b\u00edlkovin, imunoelektrofor\u00e9za, imunofixace, kvantitativn\u011b imunoglobu\u00acliny, kryoglobuliny, s\u00e9rov\u00e1 hladina B12, antinukle\u00e1rn\u00ed faktor, event. anti DNA, revma\u00actick\u00fd faktor, serologie na Lymeskou boreli\u00f3zu, kompletn\u011b lipidy, event. toxikologie (plazmatick\u00e9 olovo aj.), funkce \u0161t\u00edtn\u00e9 \u017el\u00e1zy, neuron\u00e1ln\u00ed paraneoplastick\u00e9 autoprotil\u00e1tky MO\u010c 1. sled: gluk\u00f3za, b\u00edlkovina 2. porfyriny, DALA (delta-aminolevulov\u00e1 kys.) RTG PLIC dal\u0161\u00ed c\u00edlen\u00e1 vy\u0161et\u0159en\u00ed u susp. paraneoplastick\u00e9 etiologie, n\u00e1dorov\u00e9 markery EMG MOZKOM\u00cd\u0160N\u00cd MOK VY\u0160ET\u0158EN\u00cd RODINN\u00ddCH P\u0158\u00cdSLU\u0160N\u00cdK\u016e, DNA ANAL\u00ddZA NERVOV\u00c1, P\u0158\u00cdPADN\u011a I SVALOV\u00c1 BIOPSIE Z\u00e1kladn\u00ed algoritmus diagnostiky polyneuropati\u00ed<\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"
Doporu\u010den\u00fd postup pro praktick\u00e9 l\u00e9ka\u0159e \u010cesk\u00e1 l\u00e9ka\u0159sk\u00e1 spole\u010dnost Jana Evangelisty Purkyn\u011b DOPORU\u010cEN\u00c9 POSTUPY PRO PRAKTICK\u00c9 L\u00c9KA\u0158E Projekt MZ \u010cR zpracovan\u00fd…<\/p>\n","protected":false},"author":23,"featured_media":0,"parent":3047,"menu_order":169,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_searchwp_excluded":"","kia_subtitle":"","footnotes":""},"class_list":["post-3113","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"\n