Further define presentation, diagnosis, and management of acute to subacute nutritional neuropathy 

A previous series characterized 13 women with acute length-dependent axonal neuropathy secondary to micronutrient deficiencies associated with poor nutritional status including prolonged vomiting and weight loss.

Retrospective review of 14 patients evaluated at our center between January 2017 and September 2021 and diagnosed with acute onset nutritional neuropathy (1–4 weeks) and subacute onset (5–12 weeks).

Thirteen patients were women, and one was a man. Mean age was 49. Nine patients had acute and 5 had subacute presentations. Four patients had a history of alcohol abuse. Five patients had preceding bariatric surgery. Five had a mental health condition. All patients had painful neuropathy with gait ataxia. Seven patients had vomiting. Six patients had at least a 10% weight loss. Three patients had only sensory symptoms. Eleven patients had motor and sensory manifestations. Micronutrient deficiencies identified include pyridoxine (8/11), thiamine (6/12), folate (5/13), B12 (4/14), copper (2/12), and vitamin E (2/12). Nine patients had multiple nutrient deficiencies; 1 patient had 4 deficiencies, 5 had 3 deficiencies, and 3 had 2 deficiencies. CSF protein was elevated in 2 of 11 patients, 95 and 99 mg/dL. NCS/EMG completed in 12 patients showed axonal neuropathy in 6 patients, mixed axonal and demyelinating neuropathy in 2 and was normal in 4. All axonal neuropathy patients had normal CSF protein. Four patients were treated with IVIG or steroids.

We found acute and subacute nutritional neuropathy has a strong female predominance and pyridoxine is the most common deficient nutrient. Most patients had two or more nutrient deficiencies highlighting the diagnostic yield of broader laboratory testing. In patients with acute and subacute axonal neuropathy in the setting of weight loss, vomiting, and demonstrated nutritional deficiencies, CSF testing appears to have limited utility.