Possible Alcoholic Neuropthy?
 

Hello all,

I'm at a bit of a loss. About 2 months ago I woke up one morning and my entire left side was numb and tingly. It came out of nowhere. Later on I started getting some tingling in my face and shortly after it spread everywhere. Now it is completely random depending on the day. The most common thing is tingling in my left leg from my knee down to my foot. But, both arms and legs have had both numbness and tingling at some point. The numbness is more common in my arms while the tingling is most common in my feet. The burning is more common when I'm indoors and the AC is running but after laying in bed for a while it eventually goes away. They do feel cold to touch. Sometimes my hands will be similar but not nearly as bad. There really is no rhyme or reason to where the symptoms are honestly. They tend to not be as noticeable if I'm active like doing work around the house or in the gym. When I'm sitting it's far more noticeable. I've been to the ER twice first the only thing they found was low potassium. The second time I got dizzy and lightheaded while driving and went in but I ended up testing positive for covid 2 days later and the dizziness is mostly gone a few weeks later.

So far I've had a ton of bloodwork done and a brain MRI and everything has come back clean. No diabetes, liver and kidney function are normal, no inflammatory markers or abnormal proteins. Things like B1/12, thiamine, etc. have all been checked and they are high but I have started supplementing more consistently lately so they might be artificially elevated. Only thing is my blood pressure has been slightly high for a few years now but not high enough to take medicine for according to my dr. Plus with no drinking right now it should lower to a normal level but the anxiety isn't helping that. My EMG is scheduled this month so that should tell me more. But in the meantime any ideas what this could be? I've asked both my PCP and a neurologist that I had an initial appointment with and they are both unsure. They don't think it's from my drinking but it could be possible. For the past 10 years I've probably averaged around 15 drinks spread over 1-3 days on the weekend. It could be anywhere from 2 beers 1 day only to ~20 drinks spread over 3-4 days. It's higher than I should be drinking but from what I've read people have drank far more than that before they got any damage from alcohol. Plus, my bloodwork has never shown any issues. Here is what the neurologist said after my appointment. He did mention that he was encouraged by the exam so it appears that went well. No strength or weakness issues and everything appeared mostly normal.

Differential diagnosis include electrolyte, metabolic abnormalities, increased alcohol intake related symptoms, nonspecific paresthesias, neuropathy, nerve injury. Central nervous system process such as MS or demyelinating disorder cannot be ruled out, especially given it does have relapsing and remitting type of symptom pattern .

Any ideas? Alcohol is the only thing I can think of but the way the symptoms came on make no sense. Usually they would start in the feet and work up not on one side and spread rapidly from there despite stopping alcohol. Plus I stopped entirely drinking 2 months ago except last month I had a bit over a weekend. Nothing since. I have another appointment once my EMG is done but that's a month+ away and the anxiety is driving me crazy. Thankfully I've learned how to keep it under control enough to not go back to the ER because the anxiety is messing with me too badly.

Here's my neuro exam notes if it helps:

Vital Signs:
BP (!) 144/97 (BP Location: Left arm, Patient Position: Sitting, BP Cuff Size: Adult) Comment: 2nd reading | Pulse 81 | Temp 36.6 °C (97.8 °F) (Temporal) | Resp 18 | Ht 188 cm (6' 2") | Wt 86.2 kg (190 lb) | BMI 24.39 kg/m² | Pain Score: 0-No pain

Neurologic Exam

Mental Status
Oriented to person, place, and time.
Level of consciousness: alert
Knowledge: good.

Cranial Nerves
Cranial nerves II through XII intact.

Motor Exam
Muscle bulk: normal
Overall muscle tone: normal

Strength
Strength 5/5 throughout.

Sensory Exam
Light touch normal.
Vibration normal.
Pinprick normal.

Specifically no abnormalities in sensory modalities. He does report feeling tingling in the left lateral leg above the ankle and going down to his dorsal aspect of the foot. However no deficits when touching the leg.

Gait, Coordination, and Reflexes

Gait
Gait: normal (Arises from chair unaided. Good cadence, normal stride length. Narrow base. Normal arm swing bialaterally.)

Coordination
Romberg: negative
Finger to nose coordination: normal
Heel to shin coordination: normal
Tandem walking coordination: normal

Tremor
Resting tremor: absent
Intention tremor: absent
Action tremor: absent

Reflexes
Reflexes 2+ except as noted.
Right brachioradialis: 0
Left brachioradialis: 0
Right biceps: 1+
Left biceps: 1+
Right triceps: 1+
Left triceps: 1+
Right patellar: 0
Left patellar: 0
Right plantar: normal
Left plantar: normal
Right ankle clonus: absent
Left pendular knee jerk: absent

Forgot to include some other bloodwork that may or may not be relevant:

Taken on 6/16
Sodium 140 mmol/L
135 - 145 mmol/L
Potassium 3.9 mmol/L
3.5 - 5.0 mmol/L
Chloride 105 mmol/L
99 - 109 mmol/L
Carbon Dioxide 27 mmol/L
23 - 33 mmol/L
Anion Gap 8 mmol/L
5 - 16 mmol/L
Blood Urea Nitrogen 12 mg/dL
8 - 25 mg/dL
Creatinine 1.03 mg/dL
0.70 - 1.30 mg/dL
Blood Urea Nitrogen Creatinine Ratio 11.7 ratio
10.0 - 24.0 ratio
Estimated Glomerular Filtration Rate 84
>60
eGFR units = mL/min/1.73 meters squared

If the patient is African American multiply the Estimated Glomerular Filtration Rate result by 1.21.
Glucose 112 mg/dL
65 - 110 mg/dL H
Calcium 10.0 mg/dL
8.7 - 10.4 mg/dL
Albumin 5.0 g/dL
3.5 - 5.0 g/dL
Protein, Total 7.4 g/dL
6.2 - 8.2 g/dL
Globulin 2.4 g/dL
2.2 - 4.2 g/dL
Albumin Globulin Ratio 2.1 ratio
1.0 - 1.9 ratio H
Bilirubin, Total 0.80 mg/dL
0.10 - 1.50 mg/dL
Aspartate Aminotransferase 20 U/L
10 - 45 U/L
Alanine Aminotransferase 18 U/L
10 - 65 U/L
Alkaline Phosphatase 65 U/L
35 - 115 U/L

Taken on 6/9

Calcium 9.9 mg/dL
8.7 - 10.2 mg/dL
ALT 16 IU/L
0 - 44 IU/L
Glucose 99 mg/dL
65 - 99 mg/dL
Sodium 139 mmol/L
134 - 144 mmol/L
Potassium 4.4 mmol/L
3.5 - 5.2 mmol/L
Chloride 100 mmol/L
96 - 106 mmol/L
CO2 24 mmol/L
20 - 29 mmol/L
Albumin 4.7 g/dL
4.0 - 5.0 g/dL
Bilirubin, Total 0.8 mg/dL
0.0 - 1.2 mg/dL
BUN 13 mg/dL
6 - 20 mg/dL
Creatinine 1.23 mg/dL
0.76 - 1.27 mg/dL
EGFR (Calc) 80 mL/min/1.73
>59 mL/min/1.73
BUN/Creatinine Ratio 11
9 - 20
Protein, Total, Serum 6.9 g/dL
6.0 - 8.5 g/dL
Globulin 2.2 g/dL
1.5 - 4.5 g/dL
Albumin/Globulin Ratio 2.1
1.2 - 2.2
Alkaline Phosphatase 75 IU/L
44 - 121 IU/L
AST 13 IU/L
0 - 40 IU/L

White Blood Cells 10.5 Thousand/mcL
3.8 - 11.0 Thousand/mcL
Red Blood Cells 5.22 Million/mcL
4.20 - 5.70 Million/mcL
Hemoglobin 15.7 g/dL
13.2 - 17.0 g/dL
Hematocrit 45.0 %
39.0 - 50.0 %
Mean Cell Volume (MCV) 86.2 fL
80.0 - 100.0 fL
Mean Corpuscular Hemoglobin (MCH) 30.1 pg
27.0 - 34.0 pg
Mean Cell Hemoglobin Concentration (MCHC) 34.9 g/dL
32.0 - 37.0 g/dL
Red Cell Distribution Width (RDW) 12.1 %
11.0 - 15.5 %
Platelets 294 Thousand/mcL
150 - 400 Thousand/mcL
Nucleated Red Blood Cells 0.0 /100 WBCs
0.0 - 0.9 /100 WBCs
Differential Type Automated
Neutrophils % 82.0 %
40.0 - 75.0 % H
Immature Granulocytes % 0.3 %
0.0 - 1.0 %
Lymphocytes % 11.8 %
15.0 - 48.0 % L
Monocytes % 5.5 %
0.0 - 12.0 %
Eosinophils % 0.1 %
0.0 - 7.0 %
Basophils % 0.3 %
0.0 - 2.0 %
Neutrophils, absolute 8.65 Thousand/mcL
1.90 - 7.40 Thousand/mcL H
Immature Granulocytes, absolute 0.03 Thousand/mcL
0.00 - 0.05 Thousand/mcL
Lymphocytes, absolute 1.24 Thousand/mcL
1.00 - 3.90 Thousand/mcL
Monocytes, absolute 0.58 Thousand/mcL
0.00 - 0.80 Thousand/mcL
Eosinophils, absolute 0.01 Thousand/mcL
0.00 - 0.50 Thousand/mcL
Basophils, absolute 0.03 Thousand/mcL
0.00 - 0.10 Thousand/mcL

Vitamin B12 988 pg/mL
247 - 911 pg/mL H

Welcome gooilers18. :welcome_sign: Someone will be along.

research neutrophils % divided by lymphocyte% ratio. anything over 3 indicates inflamation. yours is 7 . i use that ratio to keep track of how my sarcoidosis is doing. it may have implications for the issues you are having also.
that is pretty high.

your sugar levels are also borderline or high, which could have caused a problem long term.

That was taken 2 days before I tested positive for Covid so that might explain it. I had just started to get my first symptoms. Earlier in the day I got dizzy while driving which was likely Covid related since it’s better now. At least I hope thats the case.

i didnt mean i think you have sarcoidosis. i use the ratio to keep track of inflammation which for me means if sarcoidosis is active, flaring or not.
That ratio is an indication of inflammation, no matter what the cause of it.

check out those numbers again in a few months.

I will. I have a follow up after my EMG probably in a month or so. I was just offering a possible explanation for the inflammation. I did find it surprising that a higher ratio was present for people that had worse outcomes with covid. Found that interesting but thankfully Covid is done with me for now. Definitely explained the weird crappy symptoms I got.

yes, i think you got lucky there with your covid outcome with that ratio being as high as it was. without a doubt that raised your ratio. it will be interesting to see what it goes down to now. i would ask for a c reactive protein test the next time they take blood for you also.

it sounds like you might have small fiber neuropathy, due to your symptoms and that it moves around to different areas of your body. if it is, it won't show up on an emg/ncs, so don't get discouraged if that testing proves to be negative , get a skin punch biopsy to test for small fiber neuropathy.

you also may not have one cause for your symptoms. There could be a synergy effect with long term alcohol use, lack of proper nutrition if you werent eating correctly while you were drinking at higher levels, and possible pre diabetes from long term high normal sugar levels.

Something intersting here. I had a previous ER visit where they only found low potassium. They treated that and they sent me on my way. That was 2 weeks before the reading and they did some blood work there as well. During that time my WBC was high at 14.37 and my neut was at 9.43. However, the % was 65.6/26 which is only 2.5 No idea what caused my WBC to be raised during that visit. I'm not sure if low K can cause that. But with the readings I posted my WBC was within normal range even though my neut was high.

There's a company online I've used to test for some vitamins that my doctors didn't test for and they have tests available at pretty cheap prices. I'm going to order some for Wednesday. Besides the c reactive protein and CBC is there anything else I should look into testing? At a minimum those would see if there's still some inflammation going on. If the increase was caused by covid it should be better by now.

i would see how your emg/ncs comes out and if you have a skin punch biopsy to detect small fiber neuropathy, which i highly recommend, and then to go from there depending on the results of those tests.

Ok yeah I’ll do that. It’s only a bit over a week out so it’s not long to wait.

EMG came out clean which was kind of expected. I'll probably get a call from the neuro early next week about possible next steps. Been having some dizziness that came back lately that is likely covid related but I'm not sure. It was hard to take a shower for a while without getting super dizzy but started improving once my symptoms reduced especially once the congestion eased up. I was fine for a week or so but now it came back. Could be related to everything that's going on with me and covid just exasperated it but who knows. Reading online looks like it's not that uncommon. Trying to not google symptoms of anything and just see what the doctors say to try to give the anxiety a bit of a break. Thankfully my yearly physical with my primary doctor is in about 10 days so I can bring it up then if it's still happening and if I don't see my neuro by then.

Figure I’d post an update. Neuro got back to me and said there is no sign of nerve or muscle damage which is good but I wasn’t tested for small fiber. I did have some extra blood work done. Everything was normal including my ESR and CRP so no signs of inflammation. My b12 was down to 750 which is strange it dropped so much with me supplementing daily. Used to be around 1100. So unless I’m having absorption issues I’m good there.

Not quite sure what the next steps will be but I’m going to keep on my neuro to see what the plan is instead of just letting him say everything is fine.

This same thing happened to me 3 years ago. Neuro said the sensory tests (heat, vibration, touch, etc) on your feet would show something if small fiber were impaired. For what it's worth.

I went on my way for 3 years, drinking about like you described (after taking 3 months off), maybe a bit more. Just came off a bender vacation with some buddies and it is all back.....stinks.

For what it’s worth I did drink a bit last weekend for the first time in months and the symptoms did seem to come on a little harder. But it’s so hard to tell with how up and down they’ve been. Guess my only option is to cut it entirely for a while and see if things improve. My neuro exam seemed relatively normal but with the emg coming up clean not sure what other type of nerve damage it could be.

Recently I also had a 2 hour glucose test and testing for celiac and neither came up with anything. I’ve done blood work for just about every known cause and so far nothing. Maybe I did just get the short end of the stick and it’s idiopathic or alcohol caused it at a lesser amount than others. Who knows.

Edit: I just found out my insurance doesn’t require a referral for specialists. There’s a few neurology clinics near me so I’m going to try to find another one that’s open. With the testing and visits I’ve already hit my out of pocket max so they might as well throw everything at me testing wise.

it could be small fiber nerve dmage.

That's what I expect at this point but I can't seem to get a confirmation. Hell I can't even get a diagnosis on what is causing this. I got a differential diagnosis when all of this started and now it's turned into "you don't have any of the bad stuff so here's some gabapentin to go away."

if you are in the US go to a peripheral neuropathy center. you can get a skin punch biopsy to test for small fiber peripheral neuropathy. you have to be your own advocate.

Just a quick update. On a whim I decided to get my B6 tested and it was at 61 ng/mL with the normal range 2.1-21.7. Sounds like B6 toxicity which can cause neuropathy. Good news is that once stopping B6 it should improve. So for now no energy drinks, multivitamin, cereal, or anything else that has b6. Sucks but at least I may have an answer.