Alcohol (Ethanol) Related Neuropathy Clinical Presentation

Clinical manifestations of alcoholic neuropathy can be summarized as slowly progressive (over months) abnormalities in sensory, motor, autonomic, and gait function. Patients might ignore early symptoms, and seek help only when significant complications develop. Symptoms are often indistinguishable from other forms of sensory motor axonal neuropathy.

• Sensory symptoms include early numbness of the soles, followed by dysesthesias of feet and legs, especially at night. "Pins and needles" sensation, which is reported commonly, progresses to severe pain that is described as burning or lancinating. Symptoms typically start distally and progress slowly to proximal involvement (dying-back neuropathy). When symptoms extend above the ankle level, the fingertips often get similarly affected, giving rise to the well-known stocking and glove pattern. Paresthesia might become unpleasant, even painful.
• Motor manifestations include distal weakness and muscle wasting.^[13]
• When proprioception becomes involved, sensory ataxia will occur giving rise to gait difficulty, independent of alcoholic cerebellar degeneration.
• Autonomic disturbances are seen less commonly than in other neuropathic conditions (eg, diabetes).

  • Dysphagia and dysphonia are prominent secondary to degeneration of the vagus nerve. Other parasympathetic abnormalities include depressed reflex heart rate responses, abnormal pupillary function, sexual impotence, and sleep apnea.
  • Sympathetic dysfunction is rare but if present can produce orthostatic hypotension and hypothermia.
• Frequent falls and accidents are common. These are secondary to gait unsteadiness and ataxia that are caused by cerebellar degeneration, sensory ataxia, or distal weakness.

• Examination shows distal sensory loss in the lower extremities. In severe cases, the hands may be involved.
• In addition to distal atrophy and weakness, deep tendon reflexes usually are decreased or absent.
• Stasis dermatitis, glossiness, and thinness of skin of the lower legs are common findings.
• Hyperesthesia and hyperalgesia may be seen along with hyperpathia.
• Excessive sweating of the soles and dorsal aspects of the feet and of the palms and fingers is a common manifestation of alcoholic neuropathy and is indicative of involvement of the peripheral (postganglionic) sympathetic nerve fibers.
• Occurrence of trophic ulcers is rare.
• Charcot arthropathy, also known as neuroarthropathy, is most commonly associated with diabetes mellitus, despite a variety of other etiologies. It has also been associated with chronic alcoholism in nondiabetic individuals.
• Rare cases have been reported of severe acute or subacute neuropathy mimicking Guillain-Barré syndrome.
• Pressure palsies include radial neuropathy (Saturday night palsy), which is radial nerve compression at the spiral groove that yields wrist drop, in addition to compression neuropathy at many additional sites. Ulnar neuropathy at the elbow, radial or axillary nerve injury in the axilla (crutch-type compression), peroneal neuropathy at the fibular head, and superficial radial nerve are just a few of the potential sites of nerve injury.

• Variants

  • Rare cases of acute or subacute alcoholic peripheral neuropathy have been described. They mimic Guillain-Barré syndrome, although biopsy and electrodiagnostic studies have revealed an axonal neuropathy, with normal CSF parameters. A causal association with ethanol has been proposed.
  • Pressure palsies: Alcoholics with generalized axonal peripheral neuropathy are prone to pressure palsies at multiple sites. Associated nutritional deficiency and weight loss might potentiate the same. Neurapraxia is more common than axonotmesis, and recovery is often the rule, although elderly patients do poorly.