History
Clinical manifestations of alcoholic neuropathy include slowly progressive (over months) abnormalities in sensory, motor, autonomic, and gait function. Early symptoms are often overlooked by patients; medical help is often requested only when significant complications develop. Symptoms are often indistinguishable from other forms of sensory motor axonal neuropathy.
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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.
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Motor manifestations include distal weakness and muscle wasting. [14]
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When proprioception is impacted, gait dysfunction caused by sensory ataxia will occur. This is independent of alcoholic cerebellar degeneration.
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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.
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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.
Physical
Physical examination of patients with alcohol-induced peripheral neuropathy (ALN) 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 are usually decreased or absent.
Stasis dermatitis, glossiness, and thinning of the 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, but may be seen in patients with chronic alcoholism who are nondiabetic.
Rare cases have been reported of severe acute or subacute neuropathy mimicking Guillain-Barré syndrome. Biopsy and electrodiagnostic studies show axonal neuropathy with normal CSF.
Pressure palsies include radial neuropathy (Saturday night palsy), which is a radial nerve compression at the spiral groove that yields wrist drop. Other compression neuropathies at many additional sites can also be seen, including 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 injury.
Symptoms tend to begin slowly, although acute or subacute cases have been described.
Causes
Chronic alcohol exposure, typically greater than 100 g/day, has been identified as a risk of developing alcohol-related peripheral neuropathy (ALN). [15]
Total dose of ethanol over a lifetime increases the risk of developing ALN.
