Download PDF
CC BY-NC-ND 4.0 · Arq Neuropsiquiatr 2018; 76(03): 200-208
DOI: 10.1590/0004-282X20180015
Brazilian Academy of Neurology

Definition and diagnosis of small fiber neuropathy: consensus from the Peripheral Neuropathy Scientific Department of the Brazilian Academy of Neurology

Definição e diagnóstico de neuropatia de fibras finas: consenso do Departamento Científico de Neuropatias Periféricas da Academia Brasileira de Neurologia.
Francisco de Assis Aquino Gondim
1   Universidade Federal do Ceará, Faculdade de Medicina, Hospital Universitário Walter Cantídio, Fortaleza CE, Brasil
,
Amilton Antunes Barreira
2   Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Hospital das Clínicas, Ribeirão Preto SP, Brasil
,
Rinaldo Claudino
3   Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil
,
Márcia Waddington Cruz
4   Universidade Federal do Rio de Janeiro, Departamento de Neurologia, Rio de Janeiro RJ, Brasil
,
Francisco Marcos Bezerra da Cunha
5   Universidade Federal do Cariri, Barbalha CE, Brasil
,
Marcos Raimundo Gomes de Freitas
6   Universidade Federal Fluminense, Faculdade de Medicina, Departamento de Neurologia, Niterói RJ, Brasil
,
Marcondes Cavalcante França Jr
7   Universidade de Campinas, Departamento de Neurologia, Campinas SP, Brasil
,
Marcus Vinícius Magno Gonçalves
8   Universidade da Região de Joinville, Joinville SC, Brasil
,
Wilson Marques Jr
2   Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Hospital das Clínicas, Ribeirão Preto SP, Brasil
,
Osvaldo José Moreira Nascimento
6   Universidade Federal Fluminense, Faculdade de Medicina, Departamento de Neurologia, Niterói RJ, Brasil
,
Acary Souza Bulle Oliveira
9   Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo SP, Brasil
,
Raquel Campos Pereira
10   Universidade Federal de Uberlândia, Faculdade de Medicina, Uberlândia MG, Brasil
,
Camila Pupe
6   Universidade Federal Fluminense, Faculdade de Medicina, Departamento de Neurologia, Niterói RJ, Brasil
,
Francisco Tellechea Rotta
11   Hospital Moinhos de Vento, Porto Alegre RS, Brasil
,
Pedro Schestatsky
11   Hospital Moinhos de Vento, Porto Alegre RS, Brasil
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

ABSTRACT

The aim of this study was to describe the results of a Brazilian Consensus on Small Fiber Neuropathy (SFN). Fifteen neurologists (members of the Brazilian Academy of Neurology) reviewed a preliminary draft. Eleven panelists got together in the city of Fortaleza to discuss and finish the text for the manuscript submission. Small fiber neuropathy can be defined as a subtype of neuropathy characterized by selective involvement of unmyelinated or thinly myelinated sensory fibers. Its clinical picture includes both negative and positive manifestations: sensory (pain/dysesthesias/pruritus) or combined sensory and autonomic complaints, associated with an almost entirely normal neurological examination. Standard electromyography is normal. A growing list of medical conditions is associated with SFN. The classification of SFN may also serve as a useful terminology to uncover minor discrepancies in the normal values from different neurophysiology laboratories. Several techniques may disclose sensory and/or autonomic impairment. Further studies are necessary to refine these techniques and develop specific therapies.

RESUMO

O objetivo deste estudo é descrever os resultados de um Consenso Brasileiro sobre Neuropatia de Fibras Finas (NFF). Quinze neurologistas (membros da Academia Brasileira de Neurologia) revisaram uma versão preliminar do artigo. Onze panelistas se reuniram na cidade de Fortaleza para discutir e terminar o texto para a submissão do manuscrito. NFF pode ser definida como um subtipo de neuropatia caracterizada pelo envolvimento seletivo de fibras sensitivas amielínicas ou pouco mielinizadas. Seu quadro clínico inclui manifestações negativas e positivas: sensitivas (dor/disestesias/prurido) ou queixas sensitivas e autonçmicas combinadas, associadas a exame neurológico quase totalmente normal. A eletromiografia convencional é normal. Uma lista crescente de condições médicas causa NFF. NFF também pode servir como uma terminologia útil para referenciar pequenas discrepâncias nos valores normais de diferentes laboratórios de neurofisiologia. Diferentes técnicas podem evidenciar anormalidades sensitivas e/ou autonçmicas. São necessários mais estudos para refiná-las e para o desenvolvimento de terapias específicas.

Keywords

small fiber neuropathy - unmyelinated nerve fibers

Palavras-chave

neuropatia de pequenas fibras - fibras nervosas amielínicas

*All authors are members, and produced this manuscript on behalf of the Scientific Department of Peripheral Neuropathy, Brazilian Academy of Neurology




Publication History

Received: 19 December 2017

Accepted: 15 January 2018

Article published online:
28 August 2023

© 2023. Academia Brasileira de Neurologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Revinter Publicações Ltda.
Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

 

  • References

  • 1 Gondim FA, Barreira AA, Cruz MW, Cunha FMB, Freitas MRG, França Jr MC, Marques Jr W, Nascimento OJM, Bulle Oliveira AS, Pereira RC, Pupe C, Rotta FT, Schestasky P. Definition and diagnosis of small fiber neuropathy (SFN): recommendations from the Brazilian Academy of Neurology. J Peripher Nerv Syst. 2017;22(3):292-3.
  • 2 Berthold CH, Fraher JP, King RH, Rydmark M. Microscopic anatomy of the peripheral nervous system. In Dyck PJ, Thomas PK. Peripheral neuropathy. 4th ed. Philadelphia: Elsevier Sauders; 2005. Vol 1, p. 35-91.
  • 3 King RH. Unmyelinated nerve fibers. In Dyck PJ, Thomas PK. Peripheral neuropathy. 4th ed. Philadelphia: Elsevier Sauders; 2005. Vol 1, p. 62-7.
  • 4 Chan AC, Wilder-Smith EP. Small fiber neuropathy: getting bigger! Muscle Nerve. 2016 May;53(5):671-82. https://doi.org/10.1002/mus.25082
  • 5 Ochoa J, Mair WG. The normal sural nerve in man. I. Ultrastructure and numbers of fibres and cells. Acta Neuropathol. 1969;13(3):197-216. https://doi.org/10.1007/BF00690642
  • 6 Merkies IS, Faber CG, Lauria G. Advances in diagnostics and outcome measures in peripheral neuropathies. Neurosci Lett. 2015 Jun;596(596):3-13. https://doi.org/10.1016/j.neulet.2015.02.038
  • 7 Stewart JD, Low PA, Fealey RD. Distal small fiber neuropathy: results of tests of sweating and autonomic cardiovascular reflexes. Muscle Nerve. 1992 Jun;15(6):661-5. https://doi.org/10.1002/mus.880150605
  • 8 Pereira MP, Mühl S, Pogatzki-Zahn EM, Agelopoulos K, Ständer S. Intraepidermal nerve fiber density: diagnostic and therapeutic relevance in the management of chronic pruritus: a review. Dermatol Ther (Heidelb). 2016 Dec;6(4):509-17. https://doi.org/10.1007/s13555-016-0146-1
  • 9 Brannagan TH 3rd, Hays AP, Chin SS, Sander HW, Chin RL, Magda P et al. Small-fiber neuropathy/neuronopathy associated with celiac disease: skin biopsy findings. Arch Neurol. 2005 Oct;62(10):1574-8. https://doi.org/10.1001/archneur.62.10.1574
  • 10 Khoshnoodi MA, Truelove S, Burakgazi A, Hoke A, Mammen AL, Polydefkis M. Longitudinal Assessment of Small Fiber Neuropathy: Evidence of a Non-Length-Dependent Distal Axonopathy. JAMA Neurol. 2016 Jun;73(6):684-90. https://doi.org/10.1001/jamaneurol.2016.0057
  • 11 Gibbons CH. Small fiber neuropathies. In: Levin KH, editor. Peripheral nervous system disorders. Riverwoods: Wolters Kluwer Health; 2014. p. 1398-1412.
  • 12 Peters MJ, Bakkers M, Merkies IS, Hoeijmakers JG, van Raak EP, Faber CG. Incidence and prevalence of small-fiber neuropathy: a survey in the Netherlands. Neurology. 2013 Oct;81(15):1356-60. https://doi.org/10.1212/WNL.0b013e3182a8236e PMID:23997150
  • 13 Gondim FA, Brannagan TH 3rd, Sander HW, Chin RL, Latov N. Peripheral neuropathy in patients with inflammatory bowel disease. Brain. 2005 Apr;128(Pt 4):867-79. https://doi.org/10.1093/brain/awh429
  • 14 Gondim FA, de Oliveira GR, Teles BC, Aquino PS, Brasil EF, Carvalho AM et al. Clinical and Electrodiagnostic Findings in Patients with Peripheral Neuropathy and Inflammatory Bowel Disease. Inflamm Bowel Dis. 2015 Sep;21(9):2123-9. https://doi.org/10.1097/MIB.20180015201800150459
  • 15 Thawani SP, Brannagan TH 3rd, Lebwohl B, Green PH, Ludvigsson JF. Risk of Neuropathy Among 28,232 Patients With Biopsy-Verified Celiac Disease. JAMA Neurol. 2015 Jul;72(7):806-11. https://doi.org/10.1001/jamaneurol.2015.0475
  • 16 Pasnoor M, Nascimento OJ, Trivedi J, Wolfe GI, Nations S, Herbelin L et al. North America and South America (NA-SA) neuropathy project. Int J Neurosci. 2013 Aug;123(8):563-7. https://doi.org/10.3109/00207454.2013.782026
  • 17 Gibbons CH, Freeman R. Treatment-induced diabetic neuropathy: a reversible painful autonomic neuropathy. Ann Neurol. 2010 Apr;67(4):534-41. https://doi.org/10.1002/ana.21952
  • 18 Chao CC, Wu VC, Tan CH, Wang YM, Tseng MT, Wu PC et al. Skin denervation and its clinical significance in late-stage chronic kidney disease. Arch Neurol. 2011 Feb;68(2):200-6. https://doi.org/10.1001/archneurol.2010.372
  • 19 Oliveira GR, Teles BC, Brasil EF, Souza MH, Furtado LE, de Castro-Costa CM et al. Peripheral neuropathy and neurological disorders in an unselected Brazilian population-based cohort of IBD patients. Inflamm Bowel Dis. 2008 Mar;14(3):389-95. https://doi.org/10.1002/ibd.20304
  • 20 Ørstavik K, Norheim I, Jørum E. Pain and small-fiber neuropathy in patients with hypothyroidism. Neurology. 2006 Sep;67(5):786-91. https://doi.org/10.1212/01.wnl.0000234035.13779.4a
  • 21 McManis PG, Windebank AJ, Kiziltan M. Neuropathy associated with hyperlipidemia. Neurology. 1994 Nov;44(11):2185-6. https://doi.org/10.1212/WNL.44.11.2185
  • 22 Nascimento OJ. Leprosy neuropathy: clinical presentations. Arq Neuropsiquiatr. 2013 Sep;71 9B:661-6. https://doi.org/10.1590/0004-282X20130146
  • 23 Polydefkis M, Yiannoutsos CT, Cohen BA, Hollander H, Schifitto G, Clifford DB et al. Reduced intraepidermal nerve fiber density in HIV-associated sensory neuropathy. Neurology. 2002 Jan;58(1):115-9. https://doi.org/10.1212/WNL.58.1.115
  • 24 Nascimento OJ, Marques W Jr. Human T-cell leukemia virus (HTLV)-associated neuropathy. Handb Clin Neurol. 2013;115:531-41. https://doi.org/10.1016/B978-0-444-52902-2.00030-8
  • 25 Tembl JI, Ferrer JM, Sevilla MT, Lago A, Mayordomo F, Vilchez JJ. Neurologic complications associated with hepatitis C virus infection. Neurology. 1999 Sep;53(4):861-4. https://doi.org/10.1212/WNL.53.4.861
  • 26 Nolano M, Provitera V, Manganelli F, Pagano A, Perretti A, Santoro L. Small fiber neuropathy in the chronic phase of Chagas disease: a case report. Clin Auton Res. 2013 Jun;23(3):149-53. https://doi.org/10.1007/s10286-013-0189-7
  • 27 Kissel JT, Mendell JR. Neuropathies associated with monoclonal gammopathies. Neuromuscul Disord. 1996 Jan;6(1):3-18. https://doi.org/10.1016/0960-8966(95)00021-6
  • 28 Conceição I, González-Duarte A, Obici L, Schmidt HH, Simoneau D, Ong ML et al. “Red-flag” symptom clusters in transthyretin familial amyloid polyneuropathy. J Peripher Nerv Syst. 2016 Mar;21(1):5-9. https://doi.org/10.1111/jns.12153
  • 29 Indart S, Hugon J, Guillausseau PJ, Gilbert A, Dumurgier J, Paquet C et al. Impact of pain on cognitive functions in primary Sjögren syndrome with small fiber neuropathy: 10 cases and a literature review. Medicine (Baltimore). 2017 Apr;96(16):e6384. https://doi.org/10.1097/MD.20180015201800156384
  • 30 Gøransson LG, Tjensvoll AB, Herigstad A, Mellgren SI, Omdal R. Small-diameter nerve fiber neuropathy in systemic lupus erythematosus. Arch Neurol. 2006 Mar;63(3):401-4. https://doi.org/10.1001/archneur.63.3.401
  • 31 Gøransson LG, Brun JG, Harboe E, Mellgren SI, Omdal R. Intraepidermal nerve fiber densities in chronic inflammatory autoimmune diseases. Arch Neurol. 2006 Oct;63(10):1410-3. https://doi.org/10.1001/archneur.63.10.1410
  • 32 Bakkers M, Merkies IS, Lauria G, Devigili G, Penza P, Lombardi R et al. Intraepidermal nerve fiber density and its application in sarcoidosis. Neurology. 2009 Oct;73(14):1142-8. https://doi.org/10.1212/WNL.0b013e3181bacf05
  • 33 Makonahalli R, Seneviratne J, Seneviratne U. Acute small fiber neuropathy following Mycoplasma infection: a rare variant of Guillain-Barré syndrome. J Clin Neuromuscul Dis. 2014 Jun;15(4):147-51. https://doi.org/10.1097/CND.20180015201800150031
  • 34 Zeng L, Alongkronrusmee D, van Rijn RM. An integrated perspective on diabetic, alcoholic, and drug-induced neuropathy, etiology, and treatment in the US. J Pain Res. 2017 Jan;10:219-28. https://doi.org/10.2147/JPR.S125987
  • 35 Koike H, Iijima M, Sugiura M, Mori K, Hattori N, Ito H et al. Alcoholic neuropathy is clinicopathologically distinct from thiamine-deficiency neuropathy. Ann Neurol. 2003 Jul;54(1):19-29. https://doi.org/10.1002/ana.10550
  • 36 Latov N, Vo ML, Chin RL, Carey BT, Langsdorf JA, Feuer NT. Abnormal Nutritional Factors in Patients Evaluated at a Neuropathy Center. J Clin Neuromuscul Dis. 2016 Jun;17(4):212-4. https://doi.org/10.1097/CND.20180015201800150128
  • 37 Kafaie J, Kim M, Krause E. Small fiber neuropathy following vaccination. J Clin Neuromuscul Dis. 2016 Sep;18(1):37-40. https://doi.org/10.1097/CND.20180015201800150130
  • 38 Santiago S, Espinosa ML, Pérez-Conde MC, Merino M, Ferrer T. [Small fiber dysfunction in peripheral neuropathies]. Rev Neurol. 1999 Mar;28(6):543-54. Spanish.
  • 39 Han C, Hoeijmakers JG, Liu S, Gerrits MM, te Morsche RH, Lauria G et al. Functional profiles of SCN9A variants in dorsal root ganglion neurons and superior cervical ganglion neurons correlate with autonomic symptoms in small fibre neuropathy. Brain. 2012 Sep;135(Pt 9):2613-28. https://doi.org/10.1093/brain/aws187
  • 40 Samuelsson K, Kostulas K, Vrethem M, Rolfs A, Press R. Idiopathic small fiber neuropathy: phenotype, etiologies, and the search for fabry disease. J Clin Neurol. 2014 Apr;10(2):108-18. https://doi.org/10.3988/jcn.2014.10.2.108
  • 41 Gondim FA, Araújo DF, Oliveira IS, Vale OC. Small fiber dysfunction in patients with Wilson's disease. Arq Neuropsiquiatr. 2014 Aug;72(8):592-5. https://doi.org/10.1590/0004-282X20140090
  • 42 Cazzato D, Castori M, Lombardi R, Caravello F, Bella ED, Petrucci A et al. Small fiber neuropathy is a common feature of Ehlers-Danlos syndromes. Neurology. 2016 Jul;87(2):155-9. https://doi.org/10.1212/WNL.20180015201800152847
  • 43 de Araújo DF, de Melo Neto AP, Oliveira ÍS, Brito BS, de Araújo IT, Barros IS et al. Small (autonomic) and large fiber neuropathy in Parkinson disease and parkinsonism. BMC Neurol. 2016 Aug;16(1):139. https://doi.org/10.1186/s12883-016-0667-3
  • 44 Weis J, Katona I, Müller-Newen G, Sommer C, Necula G, Hendrich C et al. Small-fiber neuropathy in patients with ALS. Neurology. 2011 Jun;76(23):2024-9. https://doi.org/10.1212/WNL.0b013e31821e553a
  • 45 Davis MD, Genebriera J, Sandroni P, Fealey RD. Thermoregulatory sweat testing in patients with erythromelalgia. Arch Dermatol. 2006 Dec;142(12):1583-8. https://doi.org/10.1001/archderm.142.12.1583
  • 46 Freeman R, Chase KP, Risk MR. Quantitative sensory testing cannot differentiate simulated sensory loss from sensory neuropathy. Neurology. 2003 Feb;60(3):465-70. https://doi.org/10.1212/WNL.60.3.465
  • 47 Schestatsky P, Stefani LC, Sanches PR, Silva Júnior DP, Torres ILS, Dall-Agnol L et al. Validation of a Brazilian quantitative sensory testing (QST) device for the diagnosis of small fiber neuropathies. Arq Neuropsiquiatr. 2011;69(6):943-8. https://doi.org/10.1590/S0004-282X201100070001
  • 48 Chao CC, Hsieh SC, Tseng MT, Chang YC, Hsieh ST. Patterns of contact heat evoked potentials (CHEP) in neuropathy with skin denervation: correlation of CHEP amplitude with intraepidermal nerve fiber density. Clin Neurophysiol. 2008 Mar;119(3):653-61. https://doi.org/10.1016/j.clinph.2007.11.043
  • 49 Priebe JA, Kunz M, Morcinek C, Rieckmann P, Lautenbacher S. Electrophysiological assessment of nociception in patients with Parkinson's disease: A multi-methods approach. J Neurol Sci. 2016 Sep;368:59-69. https://doi.org/10.1016/j.jns.2016.06.058
  • 50 Schestatsky P, Kumru H, Valls-Solé J, Valldeoriola F, Marti MJ, Tolosa E et al. Neurophysiologic study of central pain in patients with Parkinson disease. Neurology. 2007 Dec;69(23):2162-9. https://doi.org/10.1212/01.wnl.0000295669.12443.d3
  • 51 Schestatsky P, Lladó-Carbó E, Casanova-Molla J, Alvarez-Blanco S, Valls-Solé J. Small fibre function in patients with meralgia paresthetica. Pain. 2008 Oct;139(2):342-8. https://doi.org/10.1016/j.pain.2008.05.001
  • 52 Granovsky Y, Anand P, Nakae A, Nascimento O, Smith B, Sprecher E et al. Normative data for Aδ contact heat evoked potentials in adult population: a multicenter study. Pain. 2016 May;157(5):1156-63. https://doi.org/10.1097/j.pain.20180015201800150495
  • 53 Sletten DM, Weigand SD, Low PA. Relationship of Q-sweat to quantitative sudomotor axon reflex test (QSART) volumes. Muscle Nerve. 2010 Feb;41(2):240-6. https://doi.org/10.1002/mus.21464
  • 54 Berger MJ, Kimpinski K. Test-retest reliability of quantitative sudomotor axon reflex testing. J Clin Neurophysiol. 2013 Jun;30(3):308-12. https://doi.org/10.1097/WNP.0b013e3182873254
  • 55 Teoh HL, Chow A, Wilder-Smith EP. Skin wrinkling for diagnosing small fibre neuropathy: comparison with epidermal nerve density and sympathetic skin response. J Neurol Neurosurg Psychiatry. 2008 Jul;79(7):835-7. https://doi.org/10.1136/jnnp.2007.140947
  • 56 Wilder-Smith EP. Stimulated skin wrinkling as an indicator of limb sympathetic function. Clin Neurophysiol. 2015 Jan;126(1):10-6. https://doi.org/10.1016/j.clinph.2014.08.007
  • 57 Vetrugno R, Liguori R, Cortelli P, Montagna P. Sympathetic skin response: basic mechanisms and clinical applications. Clin Auton Res. 2003 Aug;13(4):256-70. https://doi.org/10.1007/s10286-003-0107-5
  • 58 Low PA, Zimmerman BR, Dyck PJ. Comparison of distal sympathetic with vagal function in diabetic neuropathy. Muscle Nerve. 1986 Sep;9(7):592-6. https://doi.org/10.1002/mus.880090703
  • 59 Low PA, Walsh JC, Huang CY, McLeod JG. The sympathetic nervous system in diabetic neuropathy. A clinical and pathological study. Brain. 1975 Sep;98(3):341-56. https://doi.org/10.1093/brain/98.3.341
  • 60 May O, Arildsen H. Simple function tests for autonomic neuropathy have a higher predictive value on all-cause mortality in diabetes compared to 24-h heart rate variability. J Diabetes Complications. 2012 May-Jun;26(3):246-50. https://doi.org/10.1016/j.jdiacomp.2012.03.004
  • 61 Lauria G, Hsieh ST, Johansson O, Kennedy WR, Leger JM, Mellgren SI et al.; European Federation of Neurological Societies; Peripheral Nerve Society. European Federation of Neurological Societies/Peripheral Nerve Society Guideline on the use of skin biopsy in the diagnosis of small fiber neuropathy. Report of a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society. Eur J Neurol. 2010 Jul;17(7):903-12. https://doi.org/10.1111/j.1468-1331.2010.03023.x
  • 62 Donadio V, Incensi A, Cortelli P, Giannoccaro MP, Jaber MA, Baruzzi A et al. Skin sympathetic fiber α-synuclein deposits: a potential biomarker for pure autonomic failure. Neurology. 2013 Feb;80(8):725-32. https://doi.org/10.1212/WNL.0b013e3182825127
  • 63 Li J, Bai Y, Ghandour K, Qin P, Grandis M, Trostinskaia A et al. Skin biopsies in myelin-related neuropathies: bringing molecular pathology to the bedside. Brain. 2005 May;128(Pt 5):1168-77. https://doi.org/10.1093/brain/awh483
  • 64 Moura L, Oliveira AS, Zanoteli E, Cardoso R, Schmidt B, Gabbai AA. [Normal pattern of intraepidermal nerve fibers in 30 healthy volunteers with PGP 9.5]. Arq Neuropsiquiatr. 2004 Jun;62(2a):271-5. Portuguese. https://doi.org/10.1590/S0004-282X2004000200015
  • 65 Chen X, Graham J, Dabbah MA, Petropoulos IN, Ponirakis G, Asghar O et al. Small nerve fiber quantification in the diagnosis of diabetic sensorimotor polyneuropathy: comparing corneal confocal microscopy with intraepidermal nerve fiber density. Diabetes Care. 2015 Jun;38(6):1138-44. https://doi.org/10.2337/dc14-2422 PMID:25795415
  • 66 Dieckmann G, Pupe C, Nascimento OJ. Corneal confocal microscopy in a healthy Brazilian sample. Arq Neuropsiquiatr. 2016 Jan;74(1):10-7. https://doi.org/10.1590/0004-282X20150178
  • 67 Malik RA, Veves A, Tesfaye S, Smith G, Cameron N, Zochodne D et al.; Toronto Consensus Panel on Diabetic Neuropathy. Small fibre neuropathy: role in the diagnosis of diabetic sensorimotor polyneuropathy. Diabetes Metab Res Rev. 2011 Oct;27(7):678-84. https://doi.org/10.1002/dmrr.1222
  • 68 Tesfaye S, Boulton AJ, Dyck PJ, Freeman R, Horowitz M, Kempler P et al.; Toronto Diabetic Neuropathy Expert Group. Diabetic neuropathies: update on definitions, diagnostic criteria, estimation of severity, and treatments. Diabetes Care. 2010 Oct;33(10):2285-93. https://doi.org/10.2337/dc10-1303