A Case of Significant Malnutrition Presenting as Acute Sensorimotor Axonal Neuropathy

Nutritional status is an important, but often overlooked, component of care for patients being seen in any number of subspecialty clinics. The neurologic ramifications of nutritional deficiencies tend to present in the later stages of prolonged malnutrition. A 34 year-old woman with a history of alcoholism presented to the emergency department with two weeks of worsening gait imbalance, diffuse paresthesia, allodynia, and weakness of all extremities. The physical examination yielded diffuse loss of sensation to all sensory modalities in a length-dependent manner and complete lack of deep tendon reflexes in all extremities. There was also mild 4/5 weakness of proximal musculature of upper and lower extremities. Nerve conduction studies showed a diffuse sensorimotor axonal neuropathy that was worse in the lower extremities compared to the upper extremities. Laboratory evaluation yielded significant deficiencies that included calcium, pyridoxine, vitamin E, folate, borderline low thiamine, and elevated homocysteine levels. This was a unique case of severe malnutrition manifesting as an acute diffuse axonal neuropathy. Lower socioeconomic status with concurrent alcohol use can lead to a bevy of neurologic conditions as seen in our patient.