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of sweating in areas of sensory loss, but otherwise the autonomic nervous system is unaffected In distinction to other polyneuropathies, tendon re exes are usually preserved in leprosy despite widespread sensory loss Probably this is the result of sparing of most of the muscular and larger sensory nerves Because of widespread anesthesia, injuries may pass unrecognized, with resultant infections, trophic changes, and loss of tissue Variations in host immunity result in patterns of disease having both tuberculoid and lepromatous characteristics (dimorphous leprosy) Erythema nodosum occurs in a few cases The diagnosis can be made from a skin scraping or biopsy but often, multiple samples are required Treatment All forms of leprosy require long-term treatment with sulfones (dapsone being the most commonly used), rifampin, and clofazimine The skin lesions of lepromatous leprosy are responsive to thalidomide, which itself may cause a sensory neuropathy (page 1041; Barnhill and McDougall) Reactivation of disease, or a conversion from the tuberculoid to the lepromatous pattern, may occur during times of reduced immunity Polyneuropathy with Hypothyroidism Although characteristic disturbances of skeletal muscle are known to complicate hypothyroidism (see Chap 51), the demonstration of a de nite polyneuropathy has been infrequent However, a number of elderly myxedematous patients complain of weakness and numbness of the feet, legs, and, to a lesser extent, hands, for which no other explanation can be found Loss of re exes, diminution in vibratory, jointposition, and touch-pressure sensations, and weakness in the distal parts of the limbs are the usual ndings The neuropathic manifestations are seldom severe Nerve conduction velocities are slowed, and the protein content of the CSF is usually increased to more than 100 mg/dL Possibly the latter nding is a re ection of the increased protein content of the serum in the hypothyroid state The subjective improvement and complete or near-complete reversibility of neuropathic signs following treatment with thyroid hormones provides convincing evidence of a hypothyroid etiology In biopsies of nerve, an edematous protein in ltration of the endoneurium and perineurium, a kind of metachromatic mucoid material, has been seen Dyck and Lambert (who should be credited for drawing attention to this neuropathy) noted segmental demyelination in teased ber preparations In electron-microscopic sections, a slight increase in glycogen, acid mucopolysaccharides, and aggregates of glycogen and cytoplasmic laminar bodies in Schwann cells have been observed by others Polyneuropathy of sensorimotor type has also been observed in association with a syndrome of chronic lymphocytic thyroiditis and alopecia (Hart et al) Chronic Mild Sensory Polyneuropathy of the Elderly (Burning Feet Syndrome) All neurologists have observed numerous cases of a relatively nonprogressive sensory polyneuropathy in elderly patients Tingling paresthesias of feet and lower legs, sensory loss, and absent ankle re exes are the usual ndings The hands may be mildly affected but leg weakness and imbalance are absent or tri ing A painful variety is also known (see later) Laboratory studies may be normal or reveal minimally altered sensory conduction, but the evaluation has often not been extensive, and therefore it is dif cult to say if Sjogren syndrome, glucose intolerance, or another underlying disease is responsible Usually this chronic condition progresses little The most common variant of this form of chronic sensory polyneuropathy is one that affects mainly elderly women, who.

Table 46-5 Causes of painful sensory neuropathy (Adapted from Mendell and Sahenk) Common Idiopathic in the elderly Diabetes Vasculitis Residue of Guillain-Barre syndrome Renal failure Connective tissue disease, especially Sjogren disease Human immune de ciency virus Less Common Amyloidosis, familial and primary Paraneoplastic Sarcoidosis Toxic neuropathy, esp arsenic poisoning Fabry disease Perineuritis

More than 30 statistics relating to the use of the Exadata Smart Flash Cache are available You can also use the FLASHCACHECONTENT object with CellCLI commands, described later in this chapter, to determine whether an object is currently being kept in the Exadata Smart Flash Cache The following code shows an example of the type of information you can get about an object Please note that you have to get the objectNumber for an object by querying the DBA_OBJECTS view for the object_id of the object

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complain of slowly progressive (over years) painful burning and numbness of the feet, ascending to the ankles or midcalves There are few ndings on examination; often only a mild or moderate loss of pinprick and thermal sensation, and ankle re exes that may or may not be reduced Again, there is little or no progression over the years Most of these cases are idiopathic but there is a broad differential diagnosis including the diseases mentioned earlier, as outlined by Mendell and Sahenk (Table 46-5 is adapted from their discussion) Identi able causes for painful sensory neuropathy in elderly include mainly diabetes, alcoholic-nutritional de ciency states, connective tissue disease, amyloidosis, and vasculitis Electrophysiologic tests are likewise normal or virtually so; a few show diminished sural nerve potentials and minor changes of motor amplitudes When these changes cannot be ascribed to diabetes, malnutrition, medications, or the other causes listed in the table, a substantial group of patients is left and are in need of symptomatic relief Some have been helped by gabapentin or by antidepressants (amitriptyline, desipramine, or sertraline) and analgesic cream applied nightly to the soles and toes Surprisingly, a few of the more severe cases have apparently responded to gamma globulin infusions but these observations require corroboration (Gorson and Ropper, 1995) In a number of cases of burning feet, the intradermal sensory nerves in skin biopsy specimens are said to be depleted of bers but the meaning of this nding is not certain (Periquet et al) Multiple Symmetrical Lipomas with Sensorimotor Polyneuropathy Whereas the usual cutaneous lipomas have no neurologic accompaniments, this clinical curiosity, known as LannoisBensaude disease, consists of symmetrical lipomas of the neck and shoulders that are associated with polyneuropathy and sometimes deafness A mitochondrial disorder is suspected Details can be found in the review by Neumann

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