eMedicine Specialties > Neurology > Neuromuscular Diseases

Nutritional Neuropathy: Follow-up

Author: R Andrew Sewell, MD, Clinical Instructor in Psychiatry and Mental Illness Research, Education, and Clinical Center (MIRECC) Fellow, Veterans Affairs Connecticut Health Care System, Yale University School of Medicine
Coauthor(s): Lawrence D Recht, MD, Professor of Neurology and Neurosurgery, Department of Neurology and Clinical Neurosciences, Stanford University Medical School
Contributor Information and Disclosures

Updated: Nov 30, 2009

Follow-up

Further Outpatient Care

After the diagnosis is made and treatment is initiated, the primary care physician can follow up with the patient.

Deterrence/Prevention

  • Pyridoxine (vitamin B6) deficiency
    • Patients receiving isoniazid should receive pyridoxine 30 mg/d as prophylaxis.
    • Those receiving penicillamine should receive pyridoxine 100 mg/d.
    • Doses of more than 0.2 g/d have been associated with chronic sensory neuropathy.
    • The recommended daily allowance for men is 2 mg/d.
  • Alpha-tocopherol (vitamin E)
    • In patients with cystic fibrosis, short-bowel syndrome, or deficiency of vitamin E transporter, monitor the serum a-tocopherol level.
    • In those with cholestatic disease, monitor the ratio of serum a-tocopherol level to total serum lipid level.
    • For those with abetalipoproteinemia, use the adipose tissue percentage or results of erythrocyte hydrogen peroxide assay. (Serum a-tocopherol measurements are inaccurate in this disorder.)
  • Bariatric surgery
    • The chance of developing peripheral neuropathy is less in those who have surgery performed at the Mayo Clinic, do not have a jejunoileal bypass, take vitamin and calcium supplements, and attend nutritional clinics postoperatively.
    • Increased risk is associated with greater and faster weight loss; lower postsurgery BMI; lower serum albumin and transferrin; prolonged postoperative nausea, vomiting, diarrhea, and dumping; postoperative complications requiring rehospitalization; inadequate vitamin and calcium supplementation; and poor compliance. Accentuated and rapid weight loss appears to be the crucial risk factor.
    • Unrelated factors appear to be age, weight and BMI, diabetes, HgA1C, cholesterol, triglycerides, and length of hospitalization.
    • In the absence of a deficit, monitoring every 6 months for the first 2 years then annually after that is appropriate, giving oral B 12 supplementation when it is in the low-normal range.
    • In the presence of a deficit, give 0.5 mg/d oral B 12 supplementation, switching to 1.0 g/mo IM if the deficits are not corrected in 3 months or if anemia is also present.
    • Copper deficiency can present decades following surgery, so should be considered as a potential cause for neuropathy in anyone with even a remote history of bariatric surgery.

Prognosis

  • An acute decrease in vitamin levels causes acute symptoms of vitamin deficiency but few morphologic changes. However, as the deficiency becomes chronic over months to years, such changes eventually take place.
    • In severe chronic deficiency states, response to pharmacologic treatment may be partial or nonexistent, as axonal degeneration can be halted but sometimes not reversed.
    • Improvement is always slow and, although peripheral nerves regenerate at a rate of 1 mm/d, full recovery cannot occur if the neuronal cell body or proximal neuron is damaged or if central pathways have been damaged.
  • Thiamine (vitamin B 1 ) deficiency: Recovery is slow, often leaving residual muscular weakness and atrophy. In areas of endemic deficiency, the mortality rate from cardiac causes if untreated is 25-70%.
  • Cyanocobalamin (vitamin B 12 ) deficiency: Rapid improvement occurs almost immediately after treatment is begun. Gradual improvement occurs over the next 4-6 months.
  • Alcohol neuropathy: Slow incomplete recovery occurs in weeks to months.
  • Vitamin E neuropathy: Recovery is incomplete.
  • Pyridoxine (vitamin B 6 ) excess: Most patients improve with discontinuation; few cases resolve entirely.
  • Malnutrition neuropathy: About 5% of patients have permanent and symptomatic neurologic damage because of extensive degeneration in the distal ends of posterior column fibers. Another 5% have deficiencies, as noted on physical examination.
  • Bariatric surgery: Only about 15% can expect complete resolution of their symptoms, although most respond to treatment.

Patient Education

  • Dietary information on nutrition should be provided.
  • Patients who use nutritional supplements should be warned that, although pyridoxine is water soluble and excreted in the urine, they still should not take too much.
 


More on Nutritional Neuropathy

Overview: Nutritional Neuropathy
Differential Diagnoses & Workup: Nutritional Neuropathy
Treatment & Medication: Nutritional Neuropathy
Follow-up: Nutritional Neuropathy
Multimedia: Nutritional Neuropathy
References
[ CLOSE WINDOW ]

References

  1. Poitou Bernert C, Ciangura C, Coupaye M, Czernichow S, Bouillot JL, Basdevant A. Nutritional deficiency after gastric bypass: diagnosis, prevention and treatment. Diabetes Metab. Feb 2007;33(1):13-24. [Medline].

  2. Prodan CI, Bottomley SS, Vincent AS, Cowan LD, Greenwood-Van Meerveld B, Holland NR. Copper deficiency after gastric surgery: a reason for caution. Am J Med Sci. Apr 2009;337(4):256-8. [Medline].

  3. Menezes MS, Harada KO, Alvarez G. Painful peripheral polyneuropathy after bariatric surgery. Case reports. Rev Bras Anestesiol. May-Jun 2008;58(3):252-9. [Medline].

  4. Thaisetthawatkul P, Collazo-Clavell ML, Sarr MG, Norell JE, Dyck PJ. A controlled study of peripheral neuropathy after bariatric surgery. Neurology. Oct 26 2004;63(8):1462-70. [Medline].

  5. Gill GV, Bell DR. Persisting nutritional neuropathy amongst former war prisoners. J Neurol Neurosurg Psychiatry. Oct 1982;45(10):861-5. [Medline].

  6. Thaisetthawatkul P, Collazo-Clavell ML, Sarr MG, Norell JE, Dyck PJ. A controlled study of peripheral neuropathy after bariatric surgery. Neurology. Oct 26 2004;63(8):1462-70. [Medline].

  7. Kesler A, Pianka P. Toxic optic neuropathy. Curr Neurol Neurosci Rep. Sep 2003;3(5):410-4. [Medline].

  8. Tanyel MC, Mancano LD. Neurologic findings in vitamin E deficiency. Am Fam Physician. Jan 1997;55(1):197-201. [Medline].

  9. Tanyel MC, Mancano LD. Neurologic findings in vitamin E deficiency. Am Fam Physician. Jan 1997;55(1):197-201. [Medline].

  10. Kesler A, Pianka P. Toxic optic neuropathy. Curr Neurol Neurosci Rep. Sep 2003;3(5):410-4. [Medline].

  11. Chang CG, Adams-Huet B, Provost DA. Acute post-gastric reduction surgery (APGARS) neuropathy. Obes Surg. Feb 2004;14(2):182-9. [Medline].

  12. Diamond I, Messing RO. Neurologic effects of alcoholism. West J Med. Sep 1994;161(3):279-87. [Medline].

  13. Erbsloh F, Abel M. Deficiency neuropathies. In: Bruyn GW, Vinken PJ, eds. Handbook of Clinical Neurology. Vol 7: Diseases of Nerves, Part I. New York: Wiley Interscience Division; 1970:558-638.

  14. Forbes CD, Jackson WF. A Colour Atlas and Text of Clinical Medicine. 1993. Aylesbury: Hazell Books Ltd; 428.

  15. Gill GV, Bell DR. Persisting nutritional neuropathy amongst former war prisoners. J Neurol Neurosurg Psychiatry. Oct 1982;45(10):861-5. [Medline].

  16. Hattori N, Koike H, Sobue G. [Metabolic and nutritional neuropathy]. Rinsho Shinkeigaku. Nov 2008;48(11):1026-7. [Medline].

  17. Koike H, Sobue G. Alcoholic neuropathy. Curr Opin Neurol. Oct 2006;19(5):481-6. [Medline].

  18. Kumar N. Copper deficiency myelopathy (human swayback). Mayo Clin Proc. Oct 2006;81(10):1371-84. [Medline].

  19. Le Quesne PM. Persisting nutritional neuropathy in former war prisoners. Br Med J (Clin Res Ed). Mar 19 1983;286(6369):917-8. [Medline].

  20. Li K, McKay G. Images in clinical medicine. Ischemic retinopathy caused by severe megaloblastic anemia. N Engl J Med. Mar 23 2000;342(12):860. [Medline].

  21. Pallis CA. Neurological manifestations of nutritional disorders. Practitioner. Apr 1974;212(1270 Spec No):509-17. [Medline].

  22. Theodoropoulos DS. Optic neuropathy in vitamin B12 deficiency [letter; comment]. Lancet. Jul 11 1998;352(9122):146-7. [Medline].

  23. Weber GA, Sloan P, Davies D. Nutritionally-induced peripheral neuropathies. Clin Podiatr Med Surg. Jan 1990;7(1):107-28. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

malabsorption neuropathy, alcohol neuropathy, Strachan syndrome, Jamaican neuritis, camp foot, dry beriberi, wet beriberi, deficiency amblyopia, nutritional optic amblyopia, tobacco-alcohol amblyopia, pellagra, subacute combined degeneration, vitamin deficiency, nutritional deficiency, peripheral neuropathies

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

R Andrew Sewell, MD, Clinical Instructor in Psychiatry and Mental Illness Research, Education, and Clinical Center (MIRECC) Fellow, Veterans Affairs Connecticut Health Care System, Yale University School of Medicine
R Andrew Sewell, MD is a member of the following medical societies: American Academy of Neurology, American Headache Society, American Pain Society, and American Psychiatric Association
Disclosure: Nothing to disclose.

Coauthor(s)

Lawrence D Recht, MD, Professor of Neurology and Neurosurgery, Department of Neurology and Clinical Neurosciences, Stanford University Medical School
Lawrence D Recht, MD is a member of the following medical societies: American Academy of Neurology, American Association for Cancer Research, American Neurological Association, and Society for Neuroscience
Disclosure: Nothing to disclose.

Medical Editor

Milind J Kothari, DO, Professor and Vice-Chair, Department of Neurology, Pennsylvania State University College of Medicine; Consulting Staff, Department of Neurology, Penn State Milton S Hershey Medical Center
Milind J Kothari, DO is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Glenn Lopate, MD, Associate Professor, Department of Neurology, Division of Neuromuscular Diseases, Washington University School of Medicine; Chief of Neurology, St Louis ConnectCare, Consulting Staff, Barnes Jewish Hospital
Glenn Lopate, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.