Introduction: Neuropathy is a common finding in the ED and differentiating between critical and non-critical causes is an important skill for ED physicians to have. Patients with alcohol abuse disorder can have a myriad of nerve pathologies.

Case presentation: A 51-year-old male with history of CVA and alcohol abuse presented to our ED with three days of bilateral neuropathy distally from his knees and mid-forearms. Physical exam showed lack of sensation light touch and to pinprick in the areas described in his history. He had no motor deficits and CN II-XII were intact. He was not oriented to time or situation and had a broad-based gait. CT head and cervical spine did not show any acute findings. MRI of head, thoracic spine, and lumbar spine did not reveal any pathologies concerning for neuropathic etiologies. Serum studies including cbc, bmp, b12, TSH, and glucose were unremarkable. Lumbar puncture was unremarkable. The patient began attempting to rip out machine coils while in MRI, a serum alcohol was ordered, and resulted at 404.

Final/Working Diagnosis: This patient had an unusual stocking-glove pattern of sensory loss consistent with alcoholic neuropathy. Alcohol appears to be toxic to peripheral nerves in a dose-dependent manner and regardless of nutritional status, age, or other alcohol-related pathologies.

Management: The patient presenting with alcoholic polyneuropathy should be given thiamine because malnutrition can aggravate the disorder, and drinking cessation has shown to improve symptoms. Clinicians should consider alcohol-related causes when presented with distal neuropathies that don’t fit the clinical picture of other known sensory-deficit pathologies.

References and Resources:

1. Peripheral Neuropathy Fact Sheet. NINDS, 2018 Aug; NIH Publication No. 18-NS-4853.
2. Monforte R, Estruch R, Valls-Solé J, Nicolás J, Villalta J, Urbano-Marquez A. Autonomic and peripheral neuropathies in patients with chronic alcoholism. A dose-related toxic effect of alcohol. Arch Neurol. 1995 Jan;52(1):45-51.
3. Koike H, Iijima M, Sugiura M, Mori K, Hattori N, Ito H, Hirayama M, Sobue G. Alcoholic neuropathy is clinicopathologically distinct from thiamine-deficiency neuropathy. Ann Neurol. 2003 Jul;54(1):19-29.
4. Palliyath S, Schwartz BD. Peripheral nerve functions improve in chronic alcoholic patients on abstinence. J Stud Alcohol. 1993 Nov;54(6):684-6.
5. Nishiyama K, Sakuta M. Mexiletine for painful alcoholic neuropathy. Intern Med. 1995 Jun;34(6):577-9.