Postgastrectomy polyneuropathy with thiamine deficiency

Rapidly developing weakness mimicking Guillain-Barré syndrome in beriberi neuropathy: two case reports

OBJECTIVE

We examined the diagnostic difficulty in thiamine deficiency.

METHODS

We report on two patients with polyneuropathy associated with thiamine deficiency (i.e., beriberi neuropathy) that presented with acute motor symptoms mimicking Guillain-Barré syndrome.

RESULTS

The cause of the thiamine deficiency was associated with gastrectomy to treat cancer in a 46-y-old man and with dietary imbalance in a 33-y-old man. The thiamine deficiency was not related to alcohol intake in either patient. In both patients, the upper and lower extremities showed a rapidly progressive weakness over the course of 1 mo. Muscle weakness in the first patient progressed even after admission to the hospital, and urinary retention, Wernicke's encephalopathy, lactic acidosis, paralytic ileus, and heart failure appeared subsequently. Clinical symptoms in both patients showed improvement after initiation of thiamine administration, although some residual deficit remained.

CONCLUSION

Thiamine deficiency must be actively considered as a possible cause of polyneuropathy, and variability in its clinical features should be taken into consideration.

Nutritional neuropathies

Optimal functioning of the central and peripheral nervous system is dependent on appropriate nutrients. Neurologic consequences of nutritional deficiencies are not restricted to underdeveloped countries. Multiple nutritional deficiencies can coexist. Obesity is of particular concern in the developed world. The rising rate of bariatric surgery are accompanied by neurologic complications related to nutrient deficiencies. Prognosis depends on prompt recognition and institution of appropriate therapy. This review discusses peripheral nervous system manifestations related to the deficiency of key nutrients, neurologic complications associated with bariatric surgery, and conditions that have a geographic significance associated with bariatric surgery and certain conditions that have a geographic predilection.

Alcoholic neuropathy

PURPOSE OF REVIEW

The concept of alcoholic neuropathy has been obscured because of an often undetected or overestimated influence of thiamine deficiency. We describe clinicopathologic features of alcoholic neuropathy, taking the effect of thiamine status into consideration, and recent progress associated with the pathogenesis.

RECENT FINDINGS

Clinical features of alcoholic neuropathy without thiamine deficiency are characterized by slowly progressive, sensory-dominant symptoms. Superficial sensation is predominantly impaired and painful symptoms are the major complaint. Pathologic features are characterized by small-fiber-predominant axonal loss. In contrast, the clinicopathologic features of alcoholic neuropathy with concomitant thiamine deficiency are variable, constituting a spectrum ranging from a picture of a pure form of alcoholic neuropathy to a presentation of nonalcoholic thiamine-deficiency neuropathy. One possible mediator of the direct neurotoxic effects among the metabolites of ethanol is acetaldehyde. 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.

SUMMARY

Nutritional deficiency as well as the direct neurotoxic effects of ethanol or its metabolites can cause alcoholic neuropathy. Although clinicopathologic features of the pure form of alcoholic neuropathy are uniform, they show extensive variation when thiamine deficiency is present.

Myopathy in thiamine deficiency: Analysis of a case

BACKGROUND

Tenderness in the limb muscles has been reported anecdotally in patients with beriberi neuropathy, but clinical effects of thiamine deficiency on skeletal muscle have received little attention.

OBJECTIVE

To describe a patient with thiamine deficiency who manifested myopathic symptoms and responded well to thiamine supplementation.

PATIENT

A 26-year-old woman with neuropathy and heart failure associated with thiamine deficiency also complained of myalgia and weakness, most troublesome in the proximal portions of the limbs.

RESULTS

Serum creatine kinase, myoglobin, and aldolase concentrations were abnormally elevated. Magnetic resonance imaging of lower limb muscles demonstrated areas of high signal intensity in T2-weighted images and showed Gd-DTPA enhancement. A biopsy specimen from the quadriceps muscle showed myopathic changes without neurogenic changes. Abnormalities improved well with thiamine administration.

CONCLUSION

Myopathy may occur in patients with thiamine deficiency.

Wernicke’s Encephalopathy After Gastric Bypass that Masqueraded as Acute Psychosis: A Case Report

Wernicke's encephalopathy was originally described more than a decade ago. It has been reported after many causes of malnutrition. This case presents a patient with thiamine deficiency after gastric bypass, although unusual in itself, further complicating the case was the initial diagnosis of acute psychosis that was scheduled for electroconvulsive therapy. After recognition and intervention, the patient was successfully treated with thiamine replacement and parenteral nutrition.

[Neuropathy with non-alcoholic thiamine deficiency: two cases of bladder disorders]

INTRODUCTION

Neuropathy with non-alcoholic thiamine deficiency is reported in the literature, but bladder disorders are rarely detailed.

CASE REPORTS

We report two cases of bladder disorders in neuropathy with thiamine deficiency. One patient presented with a flaccid bladder and impaired sensation; the postvoid residual volume was raised. The other patient had reduced bladder capacity, with detrusor hyperreflexia and detrusor-sphincter dyssynergia. In both cases, the bladder disorders disappeared with thiamine supplementation.

CONCLUSION

Bladder symptoms may be heterogeneous in nonalcoholic neuropathy. The prognosis is good after vitamin supplementation.

Postgastrectomy polyneuropathy with thiamine deficiency is identical to beriberi neuropathy

OBJECTIVE

We assessed whether postgastrectomy polyneuropathy associated with thiamine deficiency is clinicopathologically identical to beriberi neuropathy, including a biochemical determination of thiamine status.

METHODS

Clinicopathologic features of 17 patients who had postgastrectomy polyneuropathy with thiamine deficiency were compared with those of 11 patients who had thiamine-deficiency neuropathy caused by dietary imbalance.

RESULTS

The typical presentation for the two etiologies was as a symmetric sensorimotor polyneuropathy predominantly involving the lower limbs. A variety of clinical features, including neuropathic symptoms, progression, and coexistence of heart failure or Wernicke's encephalopathy, was seen similarly in both conditions. In both groups, the main electrophysiologic findings were those of axonal neuropathy, most prominently in the lower limbs. Sural nerve biopsy specimens also indicated axonal degeneration in both groups. Subperineurial edema was commonly observed.

CONCLUSION

This study showed that thiamine-deficiency neuropathies due to gastrectomy and dietary imbalance are identical despite variability in their clinicopathologic features and suggested that thiamine deficiency can be a major cause of postgastrectomy polyneuropathy.

Clinical utility of peripheral nerve biopsy

Histopathologic evaluation of nerve biopsy specimens provides important diagnostic information in some patients with peripheral neuropathy. The role of nerve biopsy is more restricted than that of muscle biopsy. Nerve biopsy is utilized mainly for diagnosis of vasculitis and infiltrative neuropathies. It is also utilized in diagnosis of atypical inflammatory demyelinating neuropathies in which the clinical, electrodiagnostic, and laboratory features are inconclusive. In addition, the study of nerve histopathology can also enhance our understanding of disease pathogenesis.

Acquired hypocupremia after gastric surgery

BACKGROUND & AIMS

Copper absorption in humans probably occurs in the stomach and duodenum. Copper is essential for the structure and function of the nervous system and acquired copper deficiency in humans has been recognized to cause a myelopathy that resembles vitamin B12 deficiency. Acquired copper deficiency is not a well-recognized complication of gastric surgery. In Menke's disease a defect in enterocyte transport of absorbed copper results in increased copper content in the duodenal mucosa and hypocupremia.

METHODS

We report 2 patients who developed neurologic deficits with copper deficiency many years after gastric surgery. In 2 other patients with hypocupremic myelopathy but no history of gastric surgery, colonic copper was measured to determine if an absorptive defect similar to that seen in Menke's disease may be responsible for hypocupremia.

RESULTS

In all 4 patients copper deficiency was identified as the cause of the myelopathy. In 2 patients the copper deficiency occurred after gastric surgery. Eight additional patients with copper deficiency after gastric surgery were identified from the literature. Six of these 8 patients also had neurologic manifestations. Colonic mucosa copper content was increased in the 2 patients with hypocupremia without prior gastric surgery.

CONCLUSIONS

Acquired copper deficiency may be a delayed complication of gastric surgery and may result in a myelopathy similar to that seen with vitamin B12 deficiency. In some patients with acquired copper deficiency no cause for the hypocupremia may be evident and a primary absorptive defect should be considered.

Nutrient deficiencies secondary to bariatric surgery

PURPOSE OF REVIEW

The number of adolescent and adult patients submitting to bariatric surgery is increasing rapidly around the world. This review describes the literature published in the last few years concerning nutritional deficiencies after bariatric surgery as well as their etiology, incidence, treatment and prevention.

RECENT FINDINGS

Although bariatric surgery was first introduced in the 1950s, safe and successful surgical management has progressed over the last two decades and longer post-surgical follow-up data are now available. Most of the patients undergoing malabsorptive procedures will develop some nutritional deficiency, justifying mineral and multivitamin supplementation to all postoperatively. Nutrient deficiency is proportional to the length of absorptive area and to the percentage of weight loss. Low levels of iron, vitamin B12, vitamin D and calcium are predominant after Roux-en-Y gastric bypass. Protein and fat-soluble vitamin deficiencies are mainly detected after biliopancreatic diversion. Thiamine deficiency is common in patients with frequent vomiting. As the incidence of these deficiencies progresses with time, the patients should be monitored frequently and regularly to prevent malnutrition.

SUMMARY

Nutritional deficiencies can be prevented if a multidisciplinary team regularly assists the patient. Malnutrition is generally reverted with nutrient supplementation, once it is promptly diagnosed. Especial attention should be given to adolescents, mainly girls at reproductive age who have a substantial risk of developing iron deficiency. Future studies are necessary to detect nutrient abnormalities after new procedures and to evaluate the safety of bariatric surgery in younger obese patients.

Alcoholic neuropathy is clinicopathologically distinct from thiamine-deficiency neuropathy

Characteristics of alcoholic neuropathy have been obscured by difficulty in isolating them from features of thiamine-deficiency neuropathy. We assessed 64 patients with alcoholic neuropathy including subgroups without (ALN) and with (ALN-TD) coexisting thiamine deficiency. Thirty-two patients with nonalcoholic thiamine-deficiency neuropathy (TDN) also were investigated for comparison. In ALN, clinical symptoms were sensory-dominant and slowly progressive, predominantly impairing superficial sensation (especially nociception) with pain or painful burning sensation. In TDN, most cases manifested a motor-dominant and acutely progressive pattern, with impairment of both superficial and deep sensation. Small-fiber-predominant axonal loss in sural nerve specimens was characteristic of ALN, especially with a short history of neuropathy; long history was associated with regenerating small fibers. Large-fiber-predominant axonal loss predominated in TDN. Subperineurial edema was more prominent in TDN, whereas segmental de/remyelination resulting from widening of consecutive nodes of Ranvier was more frequent in ALN. Myelin irregularity was greater in ALN. ALN-TD showed a variable mixture of these features in ALN and TDN. We concluded that pure-form of alcoholic neuropathy (ALN) was distinct from pure-form of thiamine-deficiency neuropathy (TDN), supporting the view that alcoholic neuropathy can be caused by direct toxic effect of ethanol or its metabolites. However, features of alcoholic neuropathy is influenced by concomitant thiamine-deficiency state, having so far caused the obscure clinicopathological entity of alcoholic neuropathy.