Acute nutritional axonal neuropathy

Abstract

Introduction: This study describes clinical, laboratory, and electrodiagnostic features of a severe acute axonal polyneuropathy common to patients with acute nutritional deficiency in the setting of alcoholism, bariatric surgery (BS), or anorexia. Methods: Retrospective analysis of clinical, electrodiagnostic, and laboratory data of patients with acute axonal neuropathy. Results: Thirteen patients were identified with a severe, painful, sensory or sensorimotor axonal polyneuropathy that developed over 2-12 weeks with sensory ataxia, areflexia, variable muscle weakness, poor nutritional status, and weight loss, often with prolonged vomiting and normal cerebrospinal fluid protein. Vitamin B6 was low in half and thiamine was low in all patients when obtained before supplementation. Patients improved with weight gain and vitamin supplementation, with motor greater than sensory recovery. Discussion: We suggest that acute or subacute axonal neuropathy in patients with weight loss or vomiting associated with alcohol abuse, BS, or dietary deficiency is one syndrome, caused by micronutrient deficiencies.Muscle Nerve 57: [33][34][35][36][37][38][39] 2018 The differential diagnosis of acute neuropathies is limited and includes immune, toxic, infectious, and metabolic causes. While the diagnosis of acute inflammatory demyelinating polyneuropathy (e.g., classical Guillain-Barr e syndrome [GBS]) can be established with relative certainty on clinical and electrodiagnostic grounds, the differential diagnosis of acute symmetric axonal polyneuropathy, particularly when accompanied by normal cerebrospinal fluid (CSF) protein, extends beyond axonal GBS variants. Severe acute axonal neuropathy with a GBS-like pattern has been described with alcohol abuse, 1-3 after bariatric surgery (BS) 3 and gastrectomy, 4,5 and in anorexia. 6 Vomiting and weight loss have been described as risk factors. The etiology has been unclear, but multifactorial nutritional deficiencies have been postulated. The differentiation from GBS variants such as acute motor and sensory axonal neuropathy (AMSAN) or MillerFisher syndrome, toxic (arsenic) or metabolic (porphyria) neuropathies is important, as treatment differs. In a retrospective search of our electromyography (EMG) database, we identified 13 patients with this condition. MATERIALS AND METHODSOne of us (E.L.L.) collected the first 5 patients in this series between 2009 and 2015 from his EMG practice at our center. With approval from our local institutional review board, we systematically studied this neuropathy using a computerized search of the University of Rochester EMG database and electronic medical record from August 1999 to December 2015 including the original 5 patients. Search terms were "vomiting" or "alcoholism," and "axonal neuropathy." Inclusion criteria were presence of an axonal neuropathy and vomiting or alcoholism as well as an acute to subacute onset of symptoms. Exclusion criteria were known neuropathy or underlying conditions known to be associated with neuropathy (dia...

Acute flaccid paralysis: Do not forget beriberi neuropathy

“…While sub‐acute evolution may suggest CIDP, most of our patients showed a predominantly or exclusively axonal, sensorimotor pattern on NCS, similar to that reported in previous studies . However, asymmetric neuropathy was noted in three of our patients, and prompted the initial consideration of vasculitic neuropathy.…”

“…Thus, patients with BB need not have obvious signs of malnutrition. Case reports from resource‐rich countries report BB in the setting of chronic alcohol abuse, recurrent vomiting, long‐term total parenteral nutrition, and bariatric surgery . Previous reports of BB outbreaks among prisoners and under‐privileged have identified severe malnutrition, severe penalties, and cholera infection as significant risk factors .…”

Diabetic Peripheral Neuropathy: Epidemiology, Diagnosis, and Pharmacotherapy

“…46 In a study of bariatric surgery in patients with and without diabetes, there were improvements in body mass index, systemic inflammation, metabolic parameters, and small nerve fibers, as measured by corneal confocal microscopy (CCM). 47 Micronutrient deficiencies after bariatric surgery are associated with an acute neuropathy, 48,49 and longer longitudinal studies that accurately phenotype neuropathy are required to delineate potential risk factors for this condition.…”

Neuropathy of Connective Tissue Diseases and Other Systemic Diseases

“…Most patients in the series improved with vitamin supplementation, weight gain, resolution of diarrhea and vomiting, and abstinence from alcohol. 104…”