Background
The development of peripheral neuropathy, specifically, the formation of primary axonal sensorimotor peripheral polyneuropathy, is a risk for persons who have consumed large quantities of alcoholic beverages over an extended period of time. Symptoms of alcoholic neuropathy, like those of many of the other axonal mixed polyneuropathies, manifest initially in the lower extremities and feet. Sensory symptoms (eg, numbness, paresthesias, dysesthesias, loss of vibration and position sense) generally manifest prior to motor symptoms (eg, weakness). However, patients may present with motor and sensory symptoms at initial presentation.
In most cases of alcoholic neuropathy, the onset of the polyneuropathy is insidious and prolonged, but some cases have been associated with acute, rapidly progressive onset.[1] Symptoms seem to be associated with the lifetime consumption of alcohol, although exceptions are common. Severe cases of alcoholic neuropathy can lead to the development of symptoms in the proximal lower extremities and distal upper extremities.
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Alcohol and Substance Abuse Evaluation
Alcohol (Ethanol) Related Neuropathy
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Pathophysiology
Alcoholic neuropathy is a primary axonal neuropathy characterized by wallerian degeneration of the axons and a reduction in the myelination of neural fibers.[2] Controversy surrounds the pathogenic role of alcohol in development of this neuropathy. Studies on rat models have indicated that alcohol does have a directly neurotoxic effect on spinal cord and neuronal organelles.[3, 4] Acetaldehyde, a metabolite of ethanol, has a direct neurotoxic effect. Ethanol also impairs axonal transport and disturbs cytoskeletal properties. A review of the human literature implicates nutritional deficiencies, most often thiamine deficiency, that are common in alcoholic patients, as the primary causative factor in the development of this neuropathy. Persons with alcoholism may consume smaller amounts of essential nutrients and vitamins and/orexhibitimpaired gastrointestinalabsorption of these nutrients secondary to the direct effects of alcohol.
Protein kinases A and C have also been implicated in the painful symptoms associated with alcoholic neuropathy.[5] Symptoms also have an association with the metabotropic glutamate 5 (mGlu5) receptor in rat models.[6]
Thiamine, also known as the antiberiberi factor or antineuritic factor, is an essential vitamin in the metabolism of pyruvate and has a role in the health of the peripheral nervous system. Thiamine deficiency commonly is found in alcoholic patients, due to decreased absorption and hepatic depletion. Other studies have linked the direct toxic effects of alcohol on peripheral nerves with development of neuropathy. A combination of nutritional deficiency and direct toxicity probably is involved in the pathogenesis of alcoholic neuropathy, and these effects may be additive.[7, 8] Alcohol also has been implicated in the development of cardiac autonomic neuropathy (CAN) and various cranial neuropathies, including optic neuropathy and vagus neuropathy.
Pure alcoholic neuropathy is distinguishable from beriberi (thiamine deficiency). A histopathological review of sural nerve biopsy results revealed small-fiber axonal loss, myelin irregularities, and possibly neural regeneration in chronic cases.[7, 8] A Japanese study found an alcoholic dehydrogenase gene mutation that led to decreased alcohol metabolism and decreased sensory nerve action potentials in the affected group.[9]
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Epidemiology
Frequency
United States
The true incidence of alcoholic neuropathy in the general population is unknown, and figures vary widely, depending on the definition of chronic alcoholism and the criteria used to classify and detect neuropathy. Using the criteria for alcoholism listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), studies employing clinical and electrodiagnostic criteria have estimated that neuropathy is present in 25-66% of defined "chronic alcoholics." The factors most directly associated with the development of alcoholic neuropathy include the duration and amount of total lifetime alcohol consumption.
Mortality/Morbidity
Chronic consumption of alcohol has been implicated in end-organ damage to multiple systems. Damaged structures include the brain (exhibited by development of Wernicke encephalopathy, Korsakoff psychosis, and cerebellar ataxia), heart (as in cardiac myopathy and autonomic neuropathy), pancreas, gallbladder, and liver (cirrhosis), as well as the peripheral nerves. Patients with multisystem damage as a result of alcohol consumption often die of cardiac or liver failure.
Children exposed to greater than 2 oz of alcohol per day in utero exhibit nerve conduction slowing and decreased compound muscle action potential (CMAP) amplitude in comparison with children with no prenatal exposure to alcohol.[10]
Race
Cultural and racial factors involved in the consumption of alcoholic beverages are beyond the scope of this article. The subject has not been well studied in terms of the development of alcoholic neuropathy. However, one noteworthy study suggested that the risk of developing peripheral neuropathy is higher in alcoholic patients whose parents had a history of alcoholism.[11]
Sex
Ammendola and colleagues conducted a study to assess differences between men and women in the development of alcoholic neuropathy.[12] This study used the sural sensory nerve action potential (SNAP) amplitude (ie, nerve conduction study) as the variable measure to detect significant neuropathy in a population of males and females with chronic alcoholism. Although the study provided control for nutritional deficiencies, the female group with chronic alcoholism had a significantly lower sural SNAP amplitude compared with the male group with similar total lifetime dose of ethanol consumption (TLDEC). This study suggested that females may demonstrate increased sensitivity to the toxic effects of alcohol on peripheral nerves.
Age
Increased incidence of alcoholism occurs within the elderly population; however, discussion of this alarming trend is beyond the scope of this article. As mentioned previously, development of alcoholic neuropathy is associated with the duration and extent of total lifetime consumption of alcohol. Elderly persons, because of the natural diminution of postural reflexes and the nerve cell degeneration that occurs with advanced age, may be more at risk for the clinical problems associated with a peripheral neuropathy, such as frequent falls and loss of balance.
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