Alcohol (Ethanol) Related Neuropathy

Updated: Sep 07, 2021

Author: Danette C Taylor, DO, MS, FACN; Chief Editor: Stephen A Berman, MD, PhD, MBA

Overview

Practice Essentials

Alcoholic neuropathy is common, impacting an average of 44% of chronic alcohol users.[1]

Although commonly seen together, alcoholic neuropathy is separate from other nutritional deficiencies. Treatment is symptomatic; at present, there is no way to completely reverse alcoholic neuropathy.[2, 3]

Identication of alcoholic neuropathy is based on history; there is no specific test that can specifically identify alcoholic neuropathy.

Background

The clinical symptoms of alcoholic peripheral neuropathy (ALN) were first described more than 200 years ago. The descriptions by Lettsom (1787)[4] and Jackson (1822)[5] led to the recognition and association of peripheral nerve disease with excessive ethanol use.

Although patients with alcoholic neuropathy often have associated nutritional deficiencies, it has been identified that these deficiencies are not the cause of the neuropathy. While the exact etiology of the neuropathy hasn't yet been identified, many theories have been raised, ranging from a direct toxic effect of alcohol on peripheral nerves to spinal enzymes or impact of alcohol on the central opioid system.[2]

Pathophysiology

The precise pathogenesis of alcohol neuropathy remains unclear. Many theories have been raised as to the cause of alcohol-related peripheral neuropathy (ALN). While nutritional deficiencies can contribute to progression of ALN, these are not the primary cause leading to neuropathy.

It has been identified that alcohol use can lead to thiamine deficiency, However, animal studies have shown that when thiamine levels are normal, alcohol exposure can still induce neuropathy.[6]

Monforte et al. concluded that alcohol appears to be toxic to autonomic and peripheral nerves in a dose-dependent manner, based on heart rate, blood pressure, and electrophysiologic examination.[7]

Independent of thiamine deficiency, ethanol now appears to have a direct toxic effect on the peripheral nerves. Dina et al suggest that catecholamines in nociceptors are metabolized to neurotoxic products by monoamine oxidase-A (MAO-A). This can cause neuronal dysfunction, which leads to neuropathic pain.[8]

Painful alcoholic polyneuropathy with predominant small-fiber loss and normal thiamine status is well known. The clinicopathologic features of painful symptoms and small axon loss are distinct from those of beriberi neuropathy. This supports the view of direct neurotoxic effect by alcohol or its metabolites.[9]

Axonal transport and cytoskeletal properties are impaired by ethanol exposure. Protein kinase A and protein kinase C may also play a role in the pathogenesis, especially in association with painful symptoms.[10]

In utero alcohol exposure predisposes to a major risk factor for lifelong aberrant neuroimmune function. Behavioral and physiological sequelae occur throughout life and include cognitive developmental disabilities as well as disease susceptibility related to aberrant immune and neuroimmune actions, in particular significant alterations in the neuroimmune axis occur.[11, 12]

Epidemiology

Frequency

Depending on criteria and patient selection, incidence of peripheral neuropathy ranging from 25% to 66% has been reported. These studies included alcoholics hospitalized for other reasons or for detoxification. Neuropathy is more prevalent in frequent, heavy, and continuous drinkers compared to more episodic drinkers.[7]

Mortality/Morbidity

Johnson and Robinson studied the mortality rate of individuals with alcoholism who had autonomic neuropathy.[11]

Their findings suggested that evidence of vagal neuropathy in long-term alcoholics is associated with a significantly higher mortality rate than in the general population (a reported 88% survival rate at 7 years in alcoholics with autonomic neuropathy as compared to 94% in the general population).

Deaths due to cardiovascular disease are a major factor.

Many deaths were attributed to strokes, since heavy alcohol consumption is a significant risk factor for stroke.

Sex

A high incidence of alcoholic polyneuropathy has been observed in women and men. Women, when compared to men, are more predisposed to alcohol-induced damage, and the susceptibility extends to hepatic, cardiac, cerebral, and muscular changes. Also, there appears to be a greater sensitivity of females to the toxic effects of alcohol on peripheral nerve fibers unrelated to malnutrition.[3]

Prognosis

The prognosis of alcoholic neuropathy generally is good, as reported by Hillbom and Wennberg in their series of 10 patients.[13]

Provided that alcohol intake is discontinued and other causes of neuropathy (eg, malignancy, diabetes, nerve trauma) are excluded, clinical and electrophysiologic examinations may return to near normal; however, residual neuropathy may be seen even after years of abstinence.[3]

Prognosis is generally better in patients who are healthy and well nourished. Recovery is presumed to be due to regeneration and collateral sprouting of damaged axons.

Presentation

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.

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.[14]
When proprioception is impacted, gait dysfunction caused by sensory ataxia will occur. This is 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.

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.

DDx

Differential Diagnoses

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 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.[16]
Chronic ethanolism-associated liver involvement[17] 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.[18] 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.

Alcohol-related peripheral neuropathy (ALN) is associated with a small-fiber neuropathy that can be detected with skin biopsy in heavy alcohol drinking individuals with normal thiamine status. Skin biopsy is a useful, minimally invasive biomarker that could extend studies to understand the effect of alcohol on the peripheral nerves and to evaluate potential therapeutic agents in larger clinical trials.[19, 20]

Treatment

Medical Care

Treatment is directed toward stopping further damage to the peripheral nerves and returning to normal functioning. These can be achieved by alcohol abstinence, a nutritionally balanced diet supplemented by all B vitamins, and rehabilitation. However, in the setting of ongoing ethanol use, vitamin supplementation alone has not been convincingly shown to be sufficient for improvement in most patients.

While alcohol-related peripheral neuropathy (ALN) may not be completely reversed, there are many different options to treat the paresthesias and dysesthesias of peripheral neuropathy.

When patients are first diagnosed with ALN, appropriate care to prevent alcohol withdrawl symptoms should be given.

According to Dina et al, adrenal medullectomy and administration of glucocorticoid receptor antagonist mifepristone (RU 38486) prevented and reversed a model of painful peripheral neuropathy in alcohol binge-drinking rats. Their results suggest a convergence of the effects of mediators of the hypothalamic-pituitary-adrenal axis and the sympathoadrenal-stress axis on sensory neurons in the induction and maintenance of alcohol-induced painful peripheral neuropathy.[19]

Author

Danette C Taylor, DO, MS, FACN Medical Director, Movement Disorders, Mercy Health St Mary's; Clinical Assistant Professor, Department of Neurology and Ophthalmology, Michigan State University College of Osteopathic Medicine

Danette C Taylor, DO, MS, FACN is a member of the following medical societies: American Academy of Neurology, American College of Osteopathic Neurologists and Psychiatrists, American Medical Association, American Osteopathic Association, International Parkinson and Movement Disorder Society

Disclosure: Received research grant from: Neurocrine; SCION NeuroStim LLC.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Neil A Busis, MD Chief of Neurology and Director of Neurodiagnostic Laboratory, UPMC Shadyside; Clinical Professor of Neurology and Director of Community Neurology, Department of Neurology, University of Pittsburgh Physicians

Neil A Busis, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: American Academy of Neurology<br/>Serve(d) as a speaker or a member of a speakers bureau for: American Academy of Neurology<br/>Received income in an amount equal to or greater than $250 from: American Academy of Neurology.

Chief Editor

Stephen A Berman, MD, PhD, MBA Professor of Neurology, University of Central Florida College of Medicine

Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Charles Gellido, MD Assistant Professor, Laboratory Director, 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, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Jonathan S Rutchik, MD, MPH, FACOEM Associate Clinical Professor, Division of Occupational Medicine, Department of Medicine, University of California, San Francisco, School of Medicine; Neurology, Environmental and Occupational Medicine Associates (www.neoma.com)

Jonathan S Rutchik, MD, MPH, FACOEM 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, International Parkinson and Movement Disorder Society, Society of Toxicology, Western Occupational and Environmental Medical Association

Disclosure: Nothing to disclose.

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS † Professor Emeritus of Neurology and Psychiatry, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Neuroscience Director, Department of Neurology, Crouse Irving Memorial Hospital

Tarakad S Ramachandran, MBBS, MBA, MPH, FAAN, FACP, FAHA, FRCP, FRCPC, FRS, LRCP, MRCP, MRCS is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners Institute, American College of International Physicians, American College of Physicians, American Heart Association, American Stroke Association, National Association of Managed Care Physicians, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, Royal Society of Medicine

Disclosure: Nothing to disclose.

Julian T, Glascow N, Syeed R, Zis P. Alcohol-related peripheral neuropathy: a systemic review and meta-analysis. J Neurol. 2019 Dec. 266:2907-29919. [QxMD MEDLINE Link]. [Full Text].
Chopra K, Tiwari V. Alcoholic Neuropathy: Possible Mechanisms and Future Treatment Possibilities. Br J Clin Pharmacol. 2011 Oct 11. [QxMD MEDLINE Link].
Dudek I, Hajduga D, Sienko C, Maani A, Sitarz E, Sitarz M, et al. Alcohol-Induced Neuropathy in Chronic Alcoholism: Causes, Pathophysiology, Diagnosis, and Treatment Options. Current Pathobiology Reports. 2020 Oct 23. 8:87-97. [Full Text].
Lettsom JC. Some remarks on the effects of lignum quassiae amarae. Mem Med Soc Lond. 1787. 1:128.
Jackson J. On a peculiar disease resulting from the use of ardent spirits. N Engl J Med Surg. 1822. 11:351.
Bosch EP, Pelham RW, Rasool CG, Chatterjee A, Lash RW, Brown L, et al. Animal models of alcoholic neuropathy: morphologic, electrophysiologic, and biochemical findings. Muscle & Nerve. 1979 Mar-Apr. 2:133-44. [QxMD MEDLINE Link]. [Full Text].
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. 1995 Jan. 52(1):45-51. [QxMD MEDLINE Link].
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. 2008 Sep. 28(6):1180-90. [QxMD MEDLINE Link].
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. 2001 Jun 26. 56(12):1727-32. [QxMD MEDLINE Link].
Koike H, Sobue G. Alcoholic neuropathy. Curr Opin Neurol. 2006 Oct. 19(5):481-6. [QxMD MEDLINE Link].
Johnson RH, Robinson BJ. Mortality in alcoholics with autonomic neuropathy. J Neurol Neurosurg Psychiatry. 1988 Apr. 51(4):476-80. [QxMD MEDLINE Link].
Noor S, Milligan ED. Lifelong Impacts of Moderate Prenatal Alcohol Exposure on Neuroimmune Function. ;9:1107. doi: 10.3389/ fimmu.2018.01107. eCollection 2018. Front Immunol. 2018 May 22. 9:1107. [Full Text].
Hillbom M, Wennberg A. Prognosis of alcoholic peripheral neuropathy. J Neurol Neurosurg Psychiatry. 1984 Jul. 47(7):699-703. [QxMD MEDLINE Link].
Alvarez P, Ferrari LF, Levine JD. Muscle pain in models of chemotherapy-induced and alcohol-induced peripheral neuropathy. Ann Neurol. 2011 Jul. 70(1):101-9. [QxMD MEDLINE Link]. [Full Text].
Behse F, Buchthal F. Alcohol Neuropathy: Clinical, Electrophysiological and Biopsy Findings. Ann Neurol. 1977. 2:95-110.
Avaria Mde L, Mills JL, Kleinsteuber K, et al. Peripheral nerve conduction abnormalities in children exposed to alcohol in utero. J Pediatr. 2004 Mar. 144(3):338-43. [QxMD MEDLINE Link].
Kharbanda PS, Prabhakar S, Chawla YK, Das CP, Syal P. Peripheral neuropathy in liver cirrhosis. J Gastroenterol Hepatol. 2003 Aug. 18(8):922-6. [QxMD MEDLINE Link].
Agelink MW, Malessa R, Weisser U, et al. Alcoholism, peripheral neuropathy (PNP) and cardiovascular autonomic neuropathy (CAN). J Neurol Sci. 1998 Dec 11. 161(2):135-42. [QxMD MEDLINE Link].
Dina OA, Khasar SG, Alessandri-Haber N, Green PG, Messing RO, Levine JD. Alcohol-induced stress in painful alcoholic neuropathy. Eur J Neurosci. 2008 Jan. 27(1):83-92. [QxMD MEDLINE Link].
Mellion ML, Silbermann E, Gilchrist JM, Machan JT, Leggio L, de la Monte S. Small-fiber degeneration in alcohol-related peripheral neuropathy. Alcohol Clin Exp Res. 2014 Jul. 38(7):1965-72. [Full Text].
Shattuck GC. The relation of beri-beri to polyneuritis from other causes. Am J Tropical Med. 1928. 83539-43:
Manji H. Toxic neuropathy. Curr Opin Neurol. 2011 Oct. 24(5):484-90. [QxMD MEDLINE Link].
Mellion M1, Gilchrist JM, de la Monte S. Alcohol-related peripheral neuropathy: nutritional, toxic, or both?. Muscle Nerve. 2011 Mar;. 43(3):309-16.:309-16. [Full Text].
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. 1987 Aug. 80(1):65-71. [QxMD MEDLINE Link].
Adams R, Victor M. Diseases of the nervous system due to nutritional deficiency. Principles of Neurology. McGraw-Hill; 1977. 757.
Brust JCM, Britton C, Chiriboga CA, et al. Mancall EL, ed. Neurological Complications of Substance Abuse. 1997. Vol 3: 89.
Novak DJ, Victor M. The vagus and sympathetic nerves in alcoholic polyneuropathy. Arch Neurol. 1974 Apr. 30(4):273-84. [QxMD MEDLINE Link].
Victor M. Polyneuropathy due to nutritional deficiency and alcoholism. Dyck P, Thomas P, Lambert E, Bunge R, eds. Peripheral Neuropathy. Philadelphia: 1984. 1899.
Windebank AJ. Polyneuropathy due to nutritional deficiency and alcoholism. Dyck P, Thomas P, Lambert E, Bunge R, eds. Peripheral Neuropathy. Philadelphia: 1993. 1310.