eMedicine Specialties > Physical Medicine and Rehabilitation > Peripheral Neuropathy

Alcoholic Neuropathy: Differential Diagnoses & Workup

Author: Scott R Laker, MD, Staff Physician, Department of Rehabilitation, University of Colorado Health Sciences Center
Coauthor(s): William J Sullivan, MD, Assistant Professor, Pain Medicine Fellowship Director, Director of Medical Student Education, Department of Physical Medicine and Rehabilitation, University of Colorado at Denver Health Sciences Center
Contributor Information and Disclosures

Updated: Sep 5, 2008

Differential Diagnoses

Amyotrophic Lateral Sclerosis
Mononeuritis Multiplex
Beriberi (Thiamine Deficiency)
Postpolio Syndrome
Charcot-Marie-Tooth Disease
Diabetic Lumbosacral Plexopathy
Diabetic Neuropathy

Other Problems to Be Considered

Age-related neuropathy
Drug-induced paraneoplastic syndromes
Heavy metal neuropathy
Heavy metal toxicity
Nutritional paraneoplastic syndromes

Workup

Laboratory Studies

  • Chemistry profile - Chronic alcohol consumption may cause an increase in liver enzyme levels (eg, aspartate aminotransferase, alanine aminotransferase, gamma glutamyltransferase).
  • Diabetes testing - Peripheral neuropathy may be among the first presenting symptoms associated with diabetes mellitus (DM); however, patients who present with diabetes-related polyneuropathy have been diagnosed with DM several years previously. Hemoglobin A1C can be used to estimate average blood glucose levels over the course of previous months.
  • Creatinine level - Renal insufficiency indicated by elevated blood creatinine levels also may be a cause for peripheral neuropathy.
  • Thiamine, vitamin B-12, and folic acid levels - These essential vitamins play an important role in the proper functioning of the peripheral and central nervous systems and should be the among the first laboratory tests ordered on a patient with polyneuropathy. Nutritional deficiencies associated with alcoholism are common and may contribute to the development of neuropathy in alcoholic patients (see Pathophysiology).12
  • The following laboratory tests are ordered once more common diagnoses are essentially excluded:
    • Screen for heavy metal toxicity. The toxicity of lead and other heavy metals is a well-known cause of neuropathy.
    • Determine the erythrocyte sedimentation rate. It may be elevated in patients with symptoms of a peripheral polyneuropathy, owing to an inflammatory condition (eg, paraneoplastic syndrome).
    • Test for human immunodeficiency virus (HIV) infection and venereal disease. Symptoms of peripheral neuropathy can be an early manifestation of HIV.13 Syphilis also should be considered as a cause of neuropathy.

Imaging Studies

In the appropriate presentation of alcoholic neuropathy, imaging may be required to evaluate the etiology of nerve dysfunction.

Other Tests

  • Nerve conduction studies (NCSs) - Although not specific for alcoholic neuropathy, NCSs can help to clarify the diagnosis and can to some extent quantify the amount of peripheral neuropathy present, when comparisons are made with age-adjusted normal values. However, nerve conduction velocities (NCVs) are generally normal or mildly slowed in patients with alcoholic neuropathy. Some fast-conducting axons can be spared, preserving measured velocity until axon loss has severely progressed. Demyelinating neuropathies show a greater loss of conduction velocity.
    • Sural/superficial peroneal SNAP - In ethanol (ETOH) neuropathy, the response may be absent or the amplitude may be significantly reduced. The superficial peroneal SNAP generally is more difficult to obtain than is the sural in average patients, including elderly individuals; therefore, it is less specific for pathology. The sural SNAP should be readily obtainable in most patients, including those of advanced age.
    • Tibial/peroneal compound motor action potential (CMAP) and NCV to intrinsic foot muscle - In ETOH neuropathy, test results may show significantly reduced amplitude. Results may demonstrate slowing of NCV below the reference range.
    • Ulnar/median SNAP - Consider performing this test to evaluate the extent of neuropathy if lower extremity sensory studies suggest abnormalities.
    • Ulnar/median CMAP - Consider performing this test to evaluate the extent of neuropathy if lower extremity motor studies suggest abnormalities.
    • Tibial H-reflex - In ETOH neuropathy, the patient may have an absent response or may have symmetrically reduced amplitude or increased latency. Typically, this is thought to be the most sensitive of electrophysiologic tests, with some studies quoting rates as high as 50%.
    • T-wave - One study found that the T-wave is somewhat more sensitive for alcoholic neuropathy.14
  • Needle electromyography (EMG)
    • Needle EMG is based on presentation.  A typical peripheral neuropathy screen will involve a proximal muscle and a distal one in the lower and upper extremities. 
    • A more extensive screen also may be useful in evaluating for the presence of a concomitant lumbosacral radiculopathy.
    • Significant abnormalities seen in patients with ETOH neuropathy include the presence of positive sharp waves and/or fibrillation potentials. Complex, repetitive discharges also may be observed. However, if the NCSs are normal, the presence of positive sharp waves in 1 intrinsic foot muscle is not necessarily indicative of neuropathic pathology. Occasionally, intrinsic foot muscles display abnormal electromyographic potentials in asymptomatic people.
    • If lower extremity muscle abnormalities are detected, a sampling of upper extremity muscles is indicated to estimate extent of disease.
  • Vibrometer testing - Results may be useful in detecting early signs of subclinical neuropathic disease.

More on Alcoholic Neuropathy

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

References

  1. Yerdelen D, Koc F, Uysal H. Strength-duration properties of sensory and motor axons in alcoholic polyneuropathy. Neurol Res. May 16 2008;[Medline].

  2. Corsetti G, Rezzani R, Rodella L, et al. Ultrastructural study of the alterations in spinal ganglion cells of rats chronically fed on ethanol. Ultrastruct Pathol. Jul-Aug 1998;22(4):309-19. [Medline].

  3. Narita M, Miyoshi K, Narita M, et al. Involvement of microglia in the ethanol-induced neuropathic pain-like state in the rat. Neurosci Lett. Feb 27 2007;414(1):21-5. [Medline].

  4. Chen X, Levine JD. Mechanically-evoked C-fiber activity in painful alcohol and AIDS therapy neuropathy in the rat. Mol Pain. 2007;3:5. [Medline]. [Full Text].

  5. Miyoshi K, Narita M, Takatsu M, et al. mGlu5 receptor and protein kinase C implicated in the development and induction of neuropathic pain following chronic ethanol consumption. Eur J Pharmacol. May 21 2007;562(3):208-11. [Medline].

  6. Koike H, Iijima M, Sugiura M, et al. Alcoholic neuropathy is clinicopathologically distinct from thiamine-deficiency neuropathy. Ann Neurol. Jul 2003;54(1):19-29. [Medline].

  7. Koike H, Mori K, Misu K, et al. Painful alcoholic polyneuropathy with predominant small-fiber loss and normal thiamine status. Neurology. Jun 26 2001;56(12):1727-32. [Medline].

  8. Masaki T, Mochizuki H, Matsushita S, et al. Association of aldehyde dehydrogenase-2 polymorphism with alcoholic polyneuropathy in humans. Neurosci Lett. Jun 17 2004;363(3):288-90. [Medline].

  9. 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].

  10. Pessione F, Gerchstein JL, Rueff B. Parental history of alcoholism: a risk factor for alcohol-related peripheral neuropathies. Alcohol Alcohol. Nov 1995;30(6):749-54. [Medline].

  11. Ammendola A, Gemini D, Iannaccone S, et al. Gender and peripheral neuropathy in chronic alcoholism: a clinical-electroneurographic study. Alcohol Alcohol. Jul-Aug 2000;35(4):368-71. [Medline]. [Full Text].

  12. Peters TJ, Kotowicz J, Nyka W, et al. Treatment of alcoholic polyneuropathy with vitamin B complex: a randomised controlled trial. Alcohol Alcohol. Nov-Dec 2006;41(6):636-42. [Medline]. [Full Text].

  13. Fama R, Eisen JC, Rosenbloom MJ, et al. Upper and lower limb motor impairments in alcoholism, HIV infection, and their comorbidity. Alcohol Clin Exp Res. Jun 2007;31(6):1038-44. [Medline].

  14. Schott K, Schäfer G, Günthner A, et al. T-wave response: a sensitive test for latent alcoholic polyneuropathy. Addict Biol. Jul 2002;7(3):315-9. [Medline].

  15. Gane E, Bergman R, Hutchinson D. Resolution of alcoholic neuropathy following liver transplantation. Liver Transpl. Dec 2004;10(12):1545-8. [Medline]. [Full Text].

  16. Dell PC, Guzewicz RM. Atypical peripheral neuropathies. Hand Clin. May 1992;8(2):275-83. [Medline].

  17. 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].

  18. Bushbacher L. Rehabilitation of patients with peripheral neuropathies. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: Saunders; 1995:984.

  19. Hilz MJ, Zimmermann P, Rösl G, et al. Vibrameter testing facilitates the diagnosis of uremic and alcoholic polyneuropathy. Acta Neurol Scand. Dec 1995;92(6):486-90. [Medline].

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

  21. 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].

  22. Nishiyama K, Sakuta M. Mexiletine for painful alcoholic neuropathy. Internal Medicine. 1995, June;34(6):577-9. [Medline]. [Full Text].

  23. Oishi M, Mochizuki Y, Suzuki Y, et al. Current perception threshold and sympathetic skin response in diabetic and alcoholic polyneuropathies. Intern Med. Oct 2002;41(10):819-22. [Medline]. [Full Text].

  24. Scholz E, Diener HC, Dichgans J, et al. Incidence of peripheral neuropathy and cerebellar ataxia in chronic alcoholics. J Neurol. Aug 1986;233(4):212-7. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

alcoholic neuropathy, alcohol neuropathy, peripheral neuropathy, alcoholism-induced neuropathy, alcohol-related neuropathy, primary axonal sensorimotor peripheral polyneuropathy, neuropathy treatment, axonal neuropathy, neuropathy pain, symptoms of neuropathy, nutritional axonal sensorimotor polyneuropathy, nutritional neuropathy, toxic axonal sensorimotor polyneuropathy, alcoholism, alcohol addiction

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Scott R Laker, MD, Staff Physician, Department of Rehabilitation, University of Colorado Health Sciences Center
Scott R Laker, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Coauthor(s)

William J Sullivan, MD, Assistant Professor, Pain Medicine Fellowship Director, Director of Medical Student Education, Department of Physical Medicine and Rehabilitation, University of Colorado at Denver Health Sciences Center
William J Sullivan, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, International Spine Intervention Society, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Daniel D Scott, MD, MA, BS, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Colorado at Denver and Health Sciences Center
Daniel D Scott, MD, MA, BS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, National Multiple Sclerosis Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching

CME Editor

Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center
Disclosure: Nothing to disclose.

Chief Editor

Robert H Meier III, MD, Director, Amputee Services of America; Active Medical Staff, Presbyterian/St Luke's Hospital, Spalding Rehabilitation Hospital, Select Specialty Hospital; Consulting Staff, Kindred Hospital
Robert H Meier III, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

RELATED EMEDICINE ARTICLES
 
 
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.