eMedicine Specialties > Neurology > Neurotoxicology

Alcohol (Ethanol) Related Neuropathy: Differential Diagnoses & Workup

Author: Tarakad S Ramachandran, MBBS, FRCP(C), FACP, Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital
Coauthor(s): Charles Gellido, MD, Laboratory Director, Assistant Professor, Department of Neurology, Jacobi Medical Center, Albert Einstein College of Medicine
Contributor Information and Disclosures

Updated: Jun 15, 2009

Differential Diagnoses

Amyotrophic Lateral Sclerosis
Neuropathy of Leprosy
Chronic Inflammatory Demyelinating Polyradiculoneuropathy
Organophosphates
Diabetic Neuropathy
Paraneoplastic Autonomic Neuropathy
Femoral Mononeuropathy
Paraneoplastic Encephalomyelitis
HIV-1 Associated Acute/Chronic Inflammatory Demyelinating Polyneuropathy
Peroneal Mononeuropathy
HIV-1 Associated Distal Painful Sensorimotor Polyneuropathy
Primary Lateral Sclerosis
HIV-1 Associated Neuromuscular Complications (Overview)
Sarcoidosis and Neuropathy
HIV-1 Associated Vacuolar Myelopathy
Syringomyelia
Lambert-Eaton Myasthenic Syndrome
Tropical Myeloneuropathies
Leptomeningeal Carcinomatosis
Vitamin B-12 Associated Neurological Diseases
Median Neuropathy
Meralgia Paresthetica

Other Problems to Be Considered

Amyloidosis
Cryoglobulinemia
Selected nutritional deficiencies
Porphyria
Lumbosacral disk syndromes
Neuromuscular diseases
Paraneoplastic neuropathy

Workup

Laboratory Studies

The diagnosis is based on accurate history of prolonged and excessive alcohol intake, clinical signs and symptoms, and electrophysiologic testing. Behse and Buchtal suggested that a minimum of 100 mL of ethyl alcohol (3 L of beer or 300 mL of spirits) per day for 3 years will precipitate the neuropathy.

Other Tests

  • Electrophysiologic findings primarily reveal evidence of primary axonal sensory motor polyneuropathy. Electrodiagnosis might detect a subclinical peripheral neuropathy.
    • Sensory conduction studies may be abnormal even before the advent of clinical symptoms.
      • Sural nerve sensory action potentials (SNAP) are reduced slightly to moderately in conduction velocity and SNAP amplitudes also are reduced.
      • As the condition worsens, the sensory potentials may become unobtainable. The median, radial, and ulnar nerves show the same response as the disease progresses.
    • Motor conduction studies of the lower extremities (tibial and peroneal nerves) may reveal a slight reduction in conduction velocity (not to exceed 70-80% of the lower limit of normal), with diminution of the compound muscle action potential (CMAP) amplitude with a slight prolongation in distal latency. The upper extremity nerves follow the same pattern as time progresses.
    • The tibial H reflex latency is prolonged and becomes unobtainable if the condition continues to progress. The F waves are obtained more easily but reveal slight to moderate prolongation of latency.
  • Needle electromyography (EMG) examination of the distal muscles of the lower extremities shows active denervation as well as chronic changes in the form of re-innervation patterns.
    • Spontaneous activity (positive sharp waves and fibrillation) is seen in the tibialis anterior and gastrocnemius.
    • The motor unit action potentials are reduced in recruitment pattern, with high-amplitude, long-duration, and polyphasic motor units.
  • Avaria et al have demonstrated that prenatal alcohol exposure is associated with abnormalities in nerve electrical properties and that the pattern is different from that seen in adults, showing conduction slowing and decrease in proximal and distal amplitude.11
  • Chronic ethanolism-associated liver involvement12 and nutritional deficiency may be inferred by abnormal liver function test results and macrocytic anemia. Thiamine levels are not consistently reduced, but the thiamine-mediated enzyme transketolase estimation is often abnormal.
  • Cerebrospinal fluid (CSF) is typically normal or might show a mildly elevated total protein level.
  • Patients have an increased risk of compression neuropathy, and electrodiagnostic findings can be complicated by superimposed mononeuropathies that are present. Recent methods of demonstrating small-diameter fiber neuropathy, such as quantitative sensory testing and intraepidermal nerve fiber density, have been applied but need to be applied in large scale.
  • Sural nerve biopsy often shows evidence of generalized distal axonal loss affecting both large and small fibers but without distinctive pathologic features.
  • Autonomic testing of parasympathetic and sympathetic reflexes is often abnormal (25% in one study), including analysis of heart rate variability, Valsalva maneuver, handgrip, tilt table, and standing maneuvers.13 The pattern of abnormalities often resembles the changes in diabetes and other causes of autonomic failure.

Histologic Findings

Pathologic findings of the peripheral nerve in alcoholic neuropathy generally are agreed to consist of axonal degeneration with secondary segmental demyelination.

More on Alcohol (Ethanol) Related Neuropathy

Overview: Alcohol (Ethanol) Related Neuropathy
Differential Diagnoses & Workup: Alcohol (Ethanol) Related Neuropathy
Treatment & Medication: Alcohol (Ethanol) Related Neuropathy
Follow-up: Alcohol (Ethanol) Related Neuropathy
References
[ CLOSE WINDOW ]

References

  1. Lettsom JC. Some remarks on the effects of lignum quassiae amarae. Mem Med Soc Lond. 1787;1:128.

  2. Jackson J. On a peculiar disease resulting from the use of ardent spirits. N Engl J Med Surg. 1822;11:351.

  3. Shattuck GC. The relation of beri-beri to polyneuritis from other causes. Am J Tropical Med. 1928;83539-43.

  4. Behse F, Buchthal F. Alcohol Neuropathy: Clinical, Electrophysiological and Biopsy Findings. Ann Neurol. 1977;2:95-110.

  5. Monforte R, Estruch R, Valls-Sole J, et al. Autonomic and peripheral neuropathies in patients with chronic alcoholism. A dose-related toxic effect of alcohol. Arch Neurol. Jan 1995;52(1):45-51. [Medline].

  6. Hallett M, Fox JG, Rogers AE, et al. Controlled studies on the effects of alcohol ingestion on peripheral nerves of macaque monkeys. J Neurol Sci. Aug 1987;80(1):65-71. [Medline].

  7. Dina OA, Khasar SG, Alessandri-Haber N, Bogen O, Chen X, Green PG. Neurotoxic catecholamine metabolite in nociceptors contributes to painful peripheral neuropathy. Eur J Neurosci. Sep 2008;28(6):1180-90. [Medline].

  8. Koike H, Mori K, Misu K, Hattori N, Ito H, Hirayama M. Painful alcoholic polyneuropathy with predominant small-fiber loss and normal thiamine status. Neurology. Jun 26 2001;56(12):1727-32. [Medline].

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

  10. Johnson RH, Robinson BJ. Mortality in alcoholics with autonomic neuropathy. J Neurol Neurosurg Psychiatry. Apr 1988;51(4):476-80. [Medline].

  11. Avaria Mde L, Mills JL, Kleinsteuber K, et al. Peripheral nerve conduction abnormalities in children exposed to alcohol in utero. J Pediatr. Mar 2004;144(3):338-43. [Medline].

  12. Kharbanda PS, Prabhakar S, Chawla YK, Das CP, Syal P. Peripheral neuropathy in liver cirrhosis. J Gastroenterol Hepatol. Aug 2003;18(8):922-6. [Medline].

  13. Agelink MW, Malessa R, Weisser U, et al. Alcoholism, peripheral neuropathy (PNP) and cardiovascular autonomic neuropathy (CAN). J Neurol Sci. Dec 11 1998;161(2):135-42. [Medline].

  14. Dina OA, Khasar SG, Alessandri-Haber N, Green PG, Messing RO, Levine JD. Alcohol-induced stress in painful alcoholic neuropathy. Eur J Neurosci. Jan 2008;27(1):83-92. [Medline].

  15. Hillbom M, Wennberg A. Prognosis of alcoholic peripheral neuropathy. J Neurol Neurosurg Psychiatry. Jul 1984;47(7):699-703. [Medline].

  16. Adams R, Victor M. Diseases of the nervous system due to nutritional deficiency. In: Principles of Neurology. McGraw-Hill; 1977:757.

  17. Brust JCM, Britton C, Chiriboga CA, et al. Mancall EL, ed. Neurological Complications of Substance Abuse. Vol 3. 1997:89.

  18. Novak DJ, Victor M. The vagus and sympathetic nerves in alcoholic polyneuropathy. Arch Neurol. Apr 1974;30(4):273-84. [Medline].

  19. Victor M. Polyneuropathy due to nutritional deficiency and alcoholism. In: Dyck P, Thomas P, Lambert E, Bunge R, eds. Peripheral Neuropathy. Philadelphia: 1984:1899.

  20. Windebank AJ. Polyneuropathy due to nutritional deficiency and alcoholism. In: Dyck P, Thomas P, Lambert E, Bunge R, eds. Peripheral Neuropathy. Philadelphia: 1993:1310.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

alcoholic neuritis, neuritic beriberi, neuropathic beriberi, alcohol-related neuropathy, ethanol neuropathy, alcohol neuropathy, alcoholic peripheral neuropathy, ethanol-related neuropathy, peripheral nerve disease

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Tarakad S Ramachandran, MBBS, FRCP(C), FACP, Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital
Tarakad S Ramachandran, MBBS, FRCP(C), FACP is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners, American College of International Physicians, American College of Managed Care Medicine, American College of Physicians, American Heart Association, American Stroke Association, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, and Royal Society of Medicine
Disclosure: Abbott Labs  Honoraria Consulting; Teva Marion Honoraria Consulting; Boeringer-Ingelheim Honoraria Speaking and teaching

Coauthor(s)

Charles Gellido, MD, Laboratory Director, Assistant Professor, Department of Neurology, Jacobi Medical Center, Albert Einstein College of Medicine
Charles Gellido, MD is a member of the following medical societies: American Academy of Neurology and American Association of Neuromuscular and Electrodiagnostic Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jonathan S Rutchik, MD, MPH, Assistant Professor, Department of Occupational and Environmental Medicine, University of California at San Francisco
Jonathan S Rutchik, MD, MPH is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Occupational and Environmental Medicine, and Society of Toxicology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Neil A Busis, MD, Chief, Division of Neurology, Department of Medicine, Head, Clinical Neurophysiology Laboratory, University of Pittsburgh Medical Center-Shadyside
Neil A Busis, MD is a member of the following medical societies: American Academy of Neurology and American Association of Neuromuscular and Electrodiagnostic Medicine
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

Stephen A Berman, MD, PhD, Professor, Department of Internal Medicine, Section of Neurology, Dartmouth Medical School; Chief, Neurology Service, White River Junction Veterans Medical Center
Stephen A Berman, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, and Phi Beta Kappa
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.