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Bell DSH. Diabetic Mononeuropathies and Diabetic Amyotrophy. Diabetes Ther 2022; 13:1715-1722. [PMID: 35969368 PMCID: PMC9500121 DOI: 10.1007/s13300-022-01308-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/27/2022] [Indexed: 01/12/2023] Open
Abstract
This brief review describes the etiology, pathophysiology, clinical features, therapy and prognosis of the diabetic mononeuropathies and diabetic amyotrophy and neuropathic cachexia. Mononeuropathies include cranial neuropathies, of which the oculomotor nerve is most commonly affected, and are thought to be due to microvascular occlusion. Peripherally, entrapment neuropathies occur in both the upper and lower limbs and are due to compression of an already damaged nerve in anatomically restricted channels. Diabetic radiculopathies occur in the dermatones of the thorax and abdomen, mimicking intraabdominal or intrathoracic pathology. I also describe the features of the rare but very distinctive diabetic amyotrophy and neuropathic cachexia. Overall, the prognosis from these conditions is excellent with residual pain or muscle weakness being rare with the exception of diabetic amyotrophy where the prognosis is dependent upon cooperation with intensive rehabilitation. Therapies include "watchful waiting," physical therapy and rarely surgical intervention, which may be urgently needed for nerve decompression and reversal of motor defects.
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Affiliation(s)
- David S H Bell
- Southside Endocrinology, 1900 Crestwood Blvd, Suite 201, Irondale, AL, 35210, USA.
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Breiner A, Nguyen TB, Purgina B, Bourque PR. Vertebral Ischemic Necrosis in Diabetic Lumbosacral Radiculoplexus Neuropathy. Diabetes Care 2021; 44:e53-e54. [PMID: 33479158 DOI: 10.2337/dc20-2787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 12/11/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Ari Breiner
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada .,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Thanh B Nguyen
- Division of Neuroradiology, Department of Radiology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Bibianna Purgina
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Pierre R Bourque
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Ng PS, Dyck PJ, Laughlin RS, Thapa P, Pinto MV, Dyck PJB. Lumbosacral radiculoplexus neuropathy: Incidence and the association with diabetes mellitus. Neurology 2019; 92:e1188-e1194. [PMID: 30760636 DOI: 10.1212/wnl.0000000000007020] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/01/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the previously unknown incidence of lumbosacral radiculoplexus neuropathy (LRPN) and its association with diabetes mellitus (DM). METHODS LRPN defined by clinical and electrophysiologic criteria was identified among Olmsted County, Minnesota, residents during a 16-year period (2000-2015) using the unique facilities of the Rochester Epidemiology Project. DM was ascertained using American Diabetes Association criteria. RESULTS Of 1,892 medical records reviewed, 59 patients (33 men, 26 women) were identified as having LRPN. The median age was 70 years (range 24-88 years) and the median time of onset of symptoms to diagnosis was 2 months (range 1-72 months). DM was more frequent in patients with LRPN than in controls (39/59 vs 35/177, p < 0.001) but not in those with pre-DM (10/20 vs 55/142, p = 0.336). LRPN recurred in 3 patients with DM resulting in 62 LRPN episodes during the study period. The overall incidence of LRPN was 4.16/100,000/y (95% confidence interval [CI] 3.13-5.18). The incidences of LRPN among DM and non-DM groups were 2.79/100,000/y (95% CI 1.94-3.64) and 1.27/100,000/y (95% CI 0.71-1.83), respectively. The odds of LRPN among patients with DM and pre-DM was 7.91 (95% CI 4.11-15.21) and 1.006 (95% CI 1.004-1.012), respectively. CONCLUSIONS LRPN incidence in Olmsted County of 4.16/100,000/y makes LRPN a common inflammatory neuropathy and is higher than that of other immune-mediated neuropathies (acute or chronic inflammatory demyelinating polyradiculoneuropathy, brachial plexus neuropathy) assessed within the same population. DM is a major risk factor for LRPN and thus justifies the continued classification of LRPN into diabetic and nondiabetic forms.
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Affiliation(s)
- Peng Soon Ng
- From the Department of Neurology (P.S.N.), National Neuroscience Institute, Singapore; Department of Neurology (P.S.N., P.J.D., R.S.L., M.V.P., P.J.B.D.), and Division of Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN
| | - Peter J Dyck
- From the Department of Neurology (P.S.N.), National Neuroscience Institute, Singapore; Department of Neurology (P.S.N., P.J.D., R.S.L., M.V.P., P.J.B.D.), and Division of Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN
| | - Ruple S Laughlin
- From the Department of Neurology (P.S.N.), National Neuroscience Institute, Singapore; Department of Neurology (P.S.N., P.J.D., R.S.L., M.V.P., P.J.B.D.), and Division of Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN
| | - Prabin Thapa
- From the Department of Neurology (P.S.N.), National Neuroscience Institute, Singapore; Department of Neurology (P.S.N., P.J.D., R.S.L., M.V.P., P.J.B.D.), and Division of Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN
| | - Marcus V Pinto
- From the Department of Neurology (P.S.N.), National Neuroscience Institute, Singapore; Department of Neurology (P.S.N., P.J.D., R.S.L., M.V.P., P.J.B.D.), and Division of Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN
| | - P James B Dyck
- From the Department of Neurology (P.S.N.), National Neuroscience Institute, Singapore; Department of Neurology (P.S.N., P.J.D., R.S.L., M.V.P., P.J.B.D.), and Division of Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN.
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Concomitance of diabetic neuropathic amyotrophy and cachexia: a case report with review of the literature. North Clin Istanb 2015; 2:165-170. [PMID: 28058361 PMCID: PMC5175098 DOI: 10.14744/nci.2015.52523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 03/23/2015] [Indexed: 11/20/2022] Open
Abstract
Diabetic amyotrophy is a rare condition in which patients develop severe aching or burning pain in hips and thighs. This is followed by weakness and wasting of the muscles of proximal lower extremities, which often occur asymmetrically. Diabetic neuropathic cachexia is a different type of diabetic neuropathies. It leads to intense pain in affected extremities accompained by anorexia, weight loss as well as mood and sleep disturbances. A 42-year-old type 2 diabetic woman with a known poor glycemic control presented with loss of appetite, and weight (approximately 15 kg), severe burning sensation over her lower limbs, depression and sleep disturbances for 3 months. Symmetric wasting was noted in her proximal lower extremities with bilateral muscle weakness. Her patella and Achilles reflexes were absent with decrease in her upper extremity reflexes. We evaluated the patient as diabetic amyotrophy associated with diabetic neuropathic cachexia based on clinical signs, electrophysiological and radiological examination findings. Physicians should take into consideration these rare complications of diabetes mellitus showing characteristics different from other types of neuropathies.
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Abstract
Diabetic radiculoplexus neuropathies (DRPN) are neuropathies clinically and pathologically distinct from the neuropathy typically associated with diabetes (DPN). DRPN are usually subacute in onset, painful, and often demonstrate a monophasic course with incomplete recovery. Pathologically, these neuropathies are due to ischemic injury from altered immunity and often have features suggestive or diagnostic of microvasculitis. Unlike DPN, immune therapy may be helpful in treatment of these conditions given their pathological substrate and therefore are important to identify early and distinguish from other neuropathies that occur in patient with diabetes.
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Affiliation(s)
- Ruple S Laughlin
- Department of Neurology, Mayo Clinic Rochester, Rochester, MN, USA.
| | - P James B Dyck
- Department of Neurology, Mayo Clinic Rochester, Rochester, MN, USA; Peripheral Neuropathy Research Laboratory, Mayo Clinic Rochester, Rochester, MN, USA
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Abstract
Diabetic neuropathies consist of a variety of syndromes resulting from different types of damage to peripheral or cranial nerves. Although distal symmetric polyneuropathy is the most common type of diabetic neuropathy, many other subtypes have been defined since the 1800s, including proximal diabetic, truncal, cranial, median, and ulnar neuropathies. Various theories have been proposed for the pathogenesis of these neuropathies. The treatment of most requires tight and stable glycemic control. Spontaneous recovery is seen in most of these conditions with diabetic control. Immunotherapies have been tried in some of these conditions however are controversial.
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Affiliation(s)
- Mamatha Pasnoor
- Department of Neurology, University of Kansas Medical Center, 3599 Rainbow Boulevard, Mail-Stop 2012, Kansas City, KS 66160, USA.
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Abstract
Diabetes is the most common cause of peripheral neuropathy in the world. Both type 1 (insulin-dependent) and type 2 diabetes are commonly complicated by peripheral nerve disorders. Two main types of neuropathy are observed: the most common is a nerve fiber length-dependent, distal symmetrical sensory polyneuropathy with little motor involvement but frequent, and potentially life threatening, autonomic dysfunction. Alteration of temperature and pain sensations in the feet is an early manifestation of diabetic polyneuropathy. The second pattern is a focal neuropathy, which more commonly complicates or reveals type 2 diabetes. Poor diabetic control increases the risk of neuropathy with subsequent neuropathic pains and trophic changes in the feet, which can be prevented by education of patients.
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Affiliation(s)
- Gérard Said
- Department of Neurology, Hôpital de la Salpêtrière, Paris, France.
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Morales-Vidal S, Morgan C, McCoyd M, Hornik A. Diabetic peripheral neuropathy and the management of diabetic peripheral neuropathic pain. Postgrad Med 2012; 124:145-53. [PMID: 22913903 DOI: 10.3810/pgm.2012.07.2576] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Diabetic peripheral neuropathy (DPN) affects approximately half of patients with diabetes. Neuropathic pain is a major complaint of patients with diabetic polyneuropathy. Diabetic peripheral neuropathy can also lead to autonomic dysfunction. This article provides an outline of the clinical subtypes, pathophysiological features, and diagnosis of DPN. Disease-modifying treatments are reviewed, with particular attention paid to DPN pain management.
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Affiliation(s)
- Sarkis Morales-Vidal
- Department of Neurology, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL 60153, USA.
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11
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Laughlin RS, Dyck PJB. Electrodiagnostic testing in lumbosacral plexopathies. Phys Med Rehabil Clin N Am 2012. [PMID: 23177033 DOI: 10.1016/j.pmr.2012.08.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Patients presumed to have lower limb symptoms localizing to the lumbar or lumbosacral plexus require rigorous electrophysiological evaluation. Entities that cause lumbosacral plexopathies may be patchy, asymmetrical and more diffuse than initially suspected. As a result, bilateral nerve conduction studies and needle examination outside those routinely tested and clinically affected may be needed to document the extent of involvement including needle examination of the thoracic paraspinals and consideration of upper limb studies. This article outlines the lumbar and lumbosacral plexus anatomy, and discusses a differential diagnosis and electrophysiological approach in assessing patients with presumed lumbosacral plexopathies.
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Affiliation(s)
- Ruple S Laughlin
- Department of Neurology, Mayo Clinic Rochester, Rochester, MN 55905, USA.
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12
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Abstract
The prevalence of diabetic polyneuropathy (DPN) can approach 50% in subjects with longer-duration diabetes. The most common neuropathies are generalized symmetrical chronic sensorimotor polyneuropathy and autonomic neuropathy. It is important to recognize that 50% of subjects with DPN may have no symptoms and only careful clinical examination may reveal the diagnosis. DPN, especially painful diabetic peripheral neuropathy, is associated with poor quality of life. Although there is a better understanding of the pathophysiology of DPN and the mechanisms of pain, treatment remains challenging and is limited by variable efficacy and side effects of therapies. Intensification of glycemic control remains the cornerstone for the prevention or delay of DPN but optimization of other traditional cardiovascular risk factors may also be of benefit. The management of DPN relies on its early recognition and needs to be individually based on comorbidities and tolerability to medications. To date, most pharmacological strategies focus upon symptom control. In the management of pain, tricyclic antidepressants, selective serotonin noradrenaline reuptake inhibitors, and anticonvulsants alone or in combination are current first-line therapies followed by use of opiates. Topical agents may offer symptomatic relief in some patients. Disease-modifying agents are still in development and to date, antioxidant α-lipoic acid has shown the most promising effect. Further development and testing of therapies based upon improved understanding of the complex pathophysiology of this common and disabling complication is urgently required.
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Affiliation(s)
| | - Martin J Stevens
- Heart of England NHS Foundation Trust, Birmingham, UK
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
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Garces-Sanchez M, Laughlin RS, Dyck PJ, Engelstad JK, Norell JE, Dyck PJB. Painless diabetic motor neuropathy: a variant of diabetic lumbosacral radiculoplexus Neuropathy? Ann Neurol 2011; 69:1043-54. [PMID: 21425185 DOI: 10.1002/ana.22334] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Revised: 11/01/2010] [Accepted: 11/08/2010] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Occasionally, diabetic patients develop painless, lower-limb, motor predominant neuropathy. Whether this is a variant of diabetic lumbosacral radiculoplexus neuropathy (DLRPN) (a painful disorder from ischemic injury and microvasculitis), a variant of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) or another disorder is unsettled. Here, we characterize the clinical and pathological features of painless diabetic motor predominant neuropathy. METHODS We identified patients with this syndrome who underwent nerve biopsy. We compared pathological features to 33 DLRPN and 25 CIDP biopsies. RESULTS 23 patients were identified (22 had type 2 diabetes mellitus); 12 men; median age 62.2 years (range 36-78); median weight loss 30 pounds (range 0-100). Overall, the clinical features were similar to DLRPN except painless patients had more symmetrical and upper limb involvement, with slower progression and more severe impairment. Physiological testing demonstrated pan-modality sensory loss, autonomic abnormalities and axonal polyradiculoneuropathies. Nerve biopsies were similar to DLPRN showing ischemic injury (multifocal fiber loss [11/23], perineural thickening [18/23], injury neuroma [11/23], neovascularization [17/23]) and evidence of altered immunity and microvasculitis (epineurial perivascular inflammation [23/23], prior bleeding [11/23], vessel wall inflammation [15/23], and microvasculitis [3/23]). In contrast, CIDP biopsies did not show ischemic injury or microvasculitis but revealed demyelination and onion-bulbs. INTERPRETATION 1) Painless diabetic motor neuropathy is painless DLRPN and not CIDP and is caused by ischemic injury and microvasculitis. 2) The clinical features of painless DLRPN are different from typical DLPRN being more insidious and symmetrical with slower evolution. 3) The slower evolution may explain the lack of pain.
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Abrams BM. Femoral and Saphenous Neuropathies. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00109-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Said G. Neuropatie diabetiche. Neurologia 2010. [DOI: 10.1016/s1634-7072(10)70501-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
Diabetic neuropathy (DN) is the most frequent among peripheral neuropathies. Since its pathophysiology is so complicated, neither classification nor therapeutic management of DN has been established. Sensory/autonomic polyneuropathy (DP) is the main type of DN. Since diabetic patients occasionally have one or more subtypes of DN and/or other polyneuropathy including treatable neuropathy like CIDP, the treatment for DP has to be conducted after excluding the possibility of other conditions. Glycemic control is most essential to prevent the development of DP. However, it is practically difficult to keep HbA1c under 6.5% so that drinking and smoking better be restricted and blood pressure be properly maintained to retard the progression of DP. Aldose reductase inhibitor is only one commercially available drug for DP and its efficacy must be evaluated by nerve function tests along with subjective symptoms. More vigorous therapeutic procedure is expected by obtaining not only more potential drugs based on pathogenic mechanisms but also the technique targeting of DNA/siRNA of given peptides at dorsal root ganglion neurons.
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Said G. Focal and multifocal diabetic neuropathies. ARQUIVOS DE NEURO-PSIQUIATRIA 2008; 65:1272-8. [PMID: 18345446 DOI: 10.1590/s0004-282x2007000700037] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2007] [Accepted: 10/22/2007] [Indexed: 12/13/2022]
Abstract
Diabetic neuropathy is the most common neuropathy in industrialized countries, with a remarkable range of clinical manifestations. The vast majority of the patients with clinical diabetic neuropathy have a distal symmetrical form that progress following a fiber-length dependent pattern, with predominant sensory and autonomic manifestations. This pattern of neuropathy is associated with a progressive distal axonopathy. Patients are exposed to trophic changes in the feet, pains and autonomic disturbances. Less often, diabetic patients may develop focal and multifocal neuropathy that includes cranial nerve involvement, limb and truncal neuropathies. This neuropathic pattern tends to occur after 50 years of age, mostly in patients with longstanding diabetes mellitus. The LDDP does not show any trend to improvement and either relentlessly progresses or remain relatively stable over years. Conversely the focal diabetic neuropathies, which are often associated with inflammatory vasculopathy on nerve biopsies, remain self limited, sometimes after a relapsing course.
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Kawamura N, Dyck PJB, Schmeichel AM, Engelstad JK, Low PA, Dyck PJ. Inflammatory mediators in diabetic and non-diabetic lumbosacral radiculoplexus neuropathy. Acta Neuropathol 2008; 115:231-9. [PMID: 18064475 DOI: 10.1007/s00401-007-0326-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Revised: 11/19/2007] [Accepted: 11/21/2007] [Indexed: 10/22/2022]
Abstract
Nerve microvasculitis and ischemic injury appear to be the primary and important pathogenic alterations in lumbosacral radiculoplexus neuropathy of patients with (DLRPN) and without (LRPN) diabetes mellitus (DM). Here, we examine the involvement of inflammatory mediators in DLRPN and LRPN. Paraffin sections of sural nerves from 19 patients with DLRPN, 13 patients with LRPN, and 20 disease control patients were immunostained for intercellular adhesion molecule-1 (ICAM-1), tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and nuclear factor kappaB (NF-kappaB). The findings were correlated with histopathology. The pathologic and immunohistochemical alterations of DLRPN and LRPN nerves were indistinguishable. The nerves of both types of LRPN had a significantly greater number of ICAM-1 positive vessels than did the controls (P < 0.01). TNF-alpha expression was seen in Schwann cells and some macrophages of DLRPN and LRPN nerves, whereas IL-6 expression was minimal. There was greater NF-kappaB immunoreactivity in vessels and endoneurial cells of DLRPN and LRPN nerves than of the controls (P < 0.001). NF-kappaB expression correlated with the number of empty nerve strands (P < 0.01) and the frequency of axonal degeneration (P < 0.05), whereas TNF-alpha expression correlated inversely with the number of empty nerve strands of teased fibers (P < 0.05). Our findings suggest that up-regulation of inflammatory mediators target different cells at different disease stages and that these mediators may be sequentially involved in an immune-mediated inflammatory process that is shared by both DLRPN and LRPN. Up-regulated inflammatory mediators may be immunotherapeutic targets in these two conditions.
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Abrams BM. Femoral and Saphenous Neuropathies. Pain Manag 2007. [DOI: 10.1016/b978-0-7216-0334-6.50104-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
Diabetic neuropathy (DN) refers to symptoms and signs of neuropathy in a patient with diabetes in whom other causes of neuropathy have been excluded. Distal symmetrical neuropathy is the commonest accounting for 75% DN. Asymmetrical neuropathies may involve cranial nerves, thoracic or limb nerves; are of acute onset resulting from ischaemic infarction of vasa nervosa. Asymmetric neuropathies in diabetic patients should be investigated for entrapment neuropathy. Diabetic amyotrophy, initially considered to result from metabolic changes, and later ischaemia, is now attributed to immunological changes. For diagnosis of DN, symptoms, signs, quantitative sensory testing, nerve conduction study, and autonomic testing are used; and two of these five are recommended for clinical diagnosis. Management of DN includes control of hyperglycaemia, other cardiovascular risk factors; alpha lipoic acid and L carnitine. For neuropathic pain, analgesics, non-steroidal anti-inflammatory drugs, antidepressants, and anticonvulsants are recommended. The treatment of autonomic neuropathy is symptomatic.
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Affiliation(s)
- V Bansal
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareilly Road, Lucknow 226014, India
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Abstract
Diabetes mellitus is associated with a wide spectrum of neuropathy syndromes, ranging from a mild asymptomatic distal sensory neuropathy to a severe disabling radiculoplexus neuropathy. As the pathophysiology of these separate conditions is better understood, classification of the various phenotypes becomes important because of treatment implications. Here we provide a short summary of the history of the classification of diabetic neuropathies and try to describe the most common forms classified according to their presumed pathophysiology. We have tried to include epidemiological data where available, as well as histopathology of nerve in several diabetic neuropathies.
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Affiliation(s)
- Michael Sinnreich
- Department of Neurology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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Affiliation(s)
- Andrew J M Boulton
- Division of Endocrinology, University of Miami School of Medicine, P.O. Box 016960 (D-110), Miami, Florida, USA.
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Abstract
The focal and multifocal neuropathies affect only a minority of patients with diabetes; however, they form a major clinical problem in terms of diagnosis, development of significant symptoms and signs, and often inadequate therapy. Diagnosis requires accurate and detailed clinical history and neurologic examination combined with targeted neurophysiologic tests, which differ considerably from those carried out in day-to-day practice. Because of their relatively infrequent occurrence, treatment is not evidence based.
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Affiliation(s)
- Rayaz A Malik
- Department of Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK.
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Dyck PJB, Windebank AJ. Diabetic and nondiabetic lumbosacral radiculoplexus neuropathies: new insights into pathophysiology and treatment. Muscle Nerve 2002; 25:477-91. [PMID: 11932965 DOI: 10.1002/mus.10080] [Citation(s) in RCA: 194] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Diabetic lumbosacral radiculoplexus neuropathy (DLRPN) (also called diabetic amyotrophy) is a well-recognized subacute, painful, asymmetric lower-limb neuropathy that is associated with weight loss and type II diabetes mellitus. Nondiabetic lumbosacral radiculoplexus neuropathy (LRPN) has received less attention. Comparison of large cohorts with DLRPN and LRPN demonstrated that age at onset, course, type and distribution of symptoms and impairments, laboratory findings, and outcomes are similar. Both conditions are lumbosacral radiculoplexus neuropathies that are associated with weight loss and begin focally with pain but that evolve into widespread, bilateral paralytic disorders. Although both are monophasic illnesses, patients have prolonged morbidity from pain and weakness, and many patients become wheelchair-dependent. Although motor-predominant, there is unequivocal evidence that autonomic and sensory nerves are also involved. Cutaneous nerves from patients with DLRPN and LRPN show pathological evidence of ischemic injury (multifocal fiber loss, perineurial thickening and degeneration, neovascularization, microfasciculation, and swollen axons with accumulated organelles) and microvasculitis (mural and perivascular inflammation, separation and fragmentation of mural smooth muscle layers of microvessels and hemosiderin-laden macrophages). Controlled trials with immune-modulating therapies in DLRPN are in progress, and preliminary data suggest that such therapy may be beneficial in LRPN. It is likely that DLRPN and LRPN are immune-mediated neuropathies that should be separated from chronic inflammatory demyelinating polyneuropathy and from systemic necrotizing vasculitis.
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Affiliation(s)
- P James B Dyck
- Peripheral Neuropathy Research Laboratory, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA.
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Ogawa K, Sasaki H, Kishi Y, Yamasaki H, Okamoto K, Yamamoto N, Hanabusa T, Nakao T, Nishi M, Nanjo K. A suspected case of proximal diabetic neuropathy predominantly presenting with scapulohumeral muscle weakness and deep aching pain. Diabetes Res Clin Pract 2001; 54:57-64. [PMID: 11532331 DOI: 10.1016/s0168-8227(01)00249-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 48-year-old man with a 14-year history of type 2 diabetes with proliferative diabetic retinopathy and distal symmetrical diabetic polyneuropathy visited our hospital. Eight months later, he subacutely developed difficulty in both shoulder movement and trouble standing up from a squatting position. This was accompanied by severe bilateral shoulder and thigh pain. Magnetic resonance imaging of the brain, cervical and lumbar spine, computed tomography of the shoulder and X-ray films of the cervical spine and shoulder revealed no abnormality. Cerebrospinal fluid showed a mild elevation of protein (0.93 g/l) without cell infiltration. Antiganglioside antibodies and point mutation of mitochondrial DNA at position 3243 were not found. Neuropathology of the sural nerve showed a moderate myelinated fiber loss, active axonal degeneration, but onion-bulb formation, endoneurial or epineurial vasculitis were not observed. Electromyography revealed neurogenic changes in the proximal upper limb muscles. Nerve conduction studies revealed mild bilateral slowing in nerve conduction velocity in both of the upper and lower limbs. The diagnosis of this patients was suspected to be a proximal diabetic neuropathy (diabetic amyotrophy). The pain and muscle weakness had persisted more severely in the shoulder than in the thigh throughout the clinical course. His unbearable symptoms could be partially alleviated by an administration of a selective serotonin reuptake inhibitor, fluvoxamine maleate. Proximal diabetic neuropathy is a rare disabling type of neuropathy, which is characterized with subacute bilateral muscle weakness and wasting in the proximal part of the lower limbs. The involvement of the scapulohumeral region observed in this case is very unusual in proximal diabetic neuropathy.
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Affiliation(s)
- K Ogawa
- The First Department of Medicine, Wakayama University of Medical Science, 811-1 Kimiidera, Wakayama 641-8509, Japan
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Abstract
The pathogenic basis and treatment of diabetic polyradiculoneuropathy is a source of recent controversy as there may be two or more distinct forms of diabetic polyradiculoplexopathy. We believe that the following two categories of diabetic polyradiculoneuropathy can be made on the basis of clinically differences: 1) the more common asymmetric, painful polyradiculoneuropathy; and 2) the rare symmetric, painless, polyradiculoneuropathy. The asymmetric, painful form (also known as diabetic amyotrophy) may have an autoimmune basis, but the etiology is not clear. The natural history for diabetic amyotrophy is spontaneous improvement. Nevertheless, various immunotherapies (eg, corticosteroids and intravenous immunoglobulin (IVIg) have been tried with subsequent improvement in symptoms. Treatment is reserved only for patients with severe ongoing pain, given the significant side effects of these medications in those patients with diabetes. Prednisone and IVIg may help alleviate the pain associated with diabetic amyotrophy. Relief of pain can help patients begin physical therapy earlier, however, there are no prospective, blinded, controlled studies that demonstrate that these treatments lead to an earlier and better recovery of muscle strength compared with the natural history of the disorder. The symmetric, painless form of diabetic polyradiculoneuropathy may in fact represent chronic inflammatory demyelinating polyneuropathy (CIDP) occurring in a patient with diabetes mellitus (DM). Patients with idiopathic CIDP may improve various immunomodulating therapies, including corticosteroid treatment, plasma exchange (PE), and IVIg. In this regard, patients with the symmetric, painless, proximal diabetic polyradiculoneuropathy may also respond to corticosteroids, plasma exchange, IVIg, azathioprine, or cyclophosphamide. However, as with diabetic amyotrophy, some patients improve spontaneously without treatment. In still other patients, the neuropathy appears unresponsive to immunotherapy. In such patients, this polyradiculoneuropathy might be caused by metabolic dysfunction associated with DM. Unfortunately, from a clinical, laboratory, and electrophysiologic standpoint, it is impossible to distinguish the patients with a symmetric, painless diabetic polyradiculoneuropathy who might respond to therapy. A trial of PE can be useful in identifying patients who might have a polyradiculoplexopathy that is responsive to immunotherapy. If patients respond to PE, they may continue to receive intermittent exchanges or be switched over to prednisone or IVIg.
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Affiliation(s)
- Anthony A. Amato
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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29
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Dyck PJ, Engelstad J, Norell J, Dyck PJ. Microvasculitis in non-diabetic lumbosacral radiculoplexus neuropathy (LSRPN): similarity to the diabetic variety (DLSRPN). J Neuropathol Exp Neurol 2000; 59:525-38. [PMID: 10850865 DOI: 10.1093/jnen/59.6.525] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Diabetic lumbosacral radiculoplexus neuropathy (DLSRPN) has been shown to be due to ischemic injury from microvasculitis. The present study tests whether ischemic injury and microvasculitis are the pathologic cause of non-diabetic lumbosacral radiculoplexus neuropathy (LSRPN), and whether the pathologic alterations are different between LSRPN and DLSRPN. We studied distal cutaneous nerve biopsies of 47 patients with LSRPN and compared findings with those of 14 age-matched healthy controls and 33 DLSRPN patients. In both disease conditions, we found evidence of ischemic injury (multifocal fiber degeneration and loss, perineurial degeneration and scarring, characteristic fiber alterations, neovascularization, and injury neuroma) that we attribute to microvasculitis (mural and perivascular mononuclear inflammation of microvessels, inflammatory separation, fragmentation and destruction of mural smooth muscle, and previous microscopic bleeding [hemosiderin]). Teased nerve fibers in LSRPN showed significantly increased frequencies of axonal degeneration, segmental demyelination, and empty nerve strands. The segmental demyelination appeared to be clustered on fibers with axonal dystrophy. The nerves with abnormal frequencies of demyelination were significantly associated with nerves showing multifocal fiber loss. We reached the following conclusions: 1) LSRPN is a serious condition with much morbidity that mirrors DLSRPN. 2) Ischemic injury from microvasculitis appears to be the cause of LSRPN. 3) Axonal degeneration and segmental demyelination appear to be linked and due to ischemia. 4) The pathologic alterations in LSRPN and DLSRPN are indistinguishable, raising the question whether these 2 conditions have a common underlying mechanism, and whether diabetes mellitus contributes to the pathology or is a risk factor in DLSRPN. 5) Both LSRPN and DLSRPN are potentially treatable conditions.
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Affiliation(s)
- P J Dyck
- Peripheral Neuropathy Research Laboratory, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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30
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Cirak B, Guven MB. Catamenial mononeuropathy and radiculopathy. J Neurosurg 1999; 90:374. [PMID: 9950514 DOI: 10.3171/jns.1999.90.2.0374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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31
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Abstract
Amongst the focal and multifocal neuropathies that are associated with diabetes mellitus one of the most common is a proximal predominantly motor lower limb neuropathy. Recent evidence has indicated that, at least in a proportion of cases, this may have an inflammatory basis. We have examined a consecutive series of 15 cases of proximal diabetic neuropathy (diabetic amyotrophy). These were characterized by proximal pain and asymmetric proximal or generalized lower limb muscle weakness, associated in some cases with radicular sensory involvement. Two-thirds of the patients had an accompanying distal symmetric sensory polyneuropathy. Biopsy of the intermediate cutaneous nerve of the thigh, a sensory branch of the femoral nerve, showed epineurial microvasculitis in 3 patients and nonvasculitic epineurial inflammatory infiltrates in another case. In a further case, microvasculitis was found in both in the sural nerve and a quadriceps muscle biopsy specimen. The detection of inflammatory changes appeared to be correlated with the occurrence of sensory radicular involvement. Whether similar changes are present in muscle nerves in this predominantly motor syndrome requires further study. Nevertheless, the present observations confirm the view that secondary vasculitic or other inflammatory reactions may contribute to some forms of diabetic neuropathy.
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Affiliation(s)
- J G Llewelyn
- Royal Free Hospital School of Medicine, London, UK
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32
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Abstract
Recent work has shown that inflammatory vasculopathy is commonly seen in biopsies of diabetic patients with neuropathy. Most of these patients have had syndromes consistent with proximal diabetic neuropathy or amyotrophy. This suggests that inflammatory vasculopathy is important in the pathogenesis of these disorders. Immunosuppressive therapy may benefit many of these patients.
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Affiliation(s)
- D A Krendel
- Department of Pathology and Neurology, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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33
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Perkins AT, Morgenlander JC. Endocrinologic causes of peripheral neuropathy. Pins and needles in a stocking-and-glove pattern and other symptoms. Postgrad Med 1997; 102:81-2, 90-2, 102-6. [PMID: 9300020 DOI: 10.3810/pgm.1997.09.318] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In the Western world, diabetes is the biggest cause of peripheral neuropathy, usually distal symmetric polyneuropathy but some times another polyneuropathy or a focal neuropathy. In addition, hypothyroidism and acromegaly can cause carpal tunnel syndrome and other sensory complaints. A complete blood cell count, nerve-conduction tests, thyroid-function tests (needed in all patients with carpal tunnel syndrome), and when necessary, needle electromyography can help confirm the diagnosis. Treatment of underlying disease is the most successful management approach: Tight glucose control in diabetic patients, thyroid hormone replacement therapy in patients with hypothyroidism, and removal of the pituitary adenoma in patients with acromegaly are of proven benefit. Significant symptomatic relief of dysesthesias can be obtained with use of capsaicin cream, tricyclic antidepresants, anticonvulsant agents, or an antiarrhythmic drug.
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Affiliation(s)
- A T Perkins
- Department of Medicine (neurology), Duke University Medical Center, Durham, North Carolina, USA
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34
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Abstract
The most common form of diabetic neuropathy is chronic, distal symmetrical sensorimotor, or predominantly sensory neuropathy; the latter is invariably associated with some degree of autonomic dysfunction. There are, however, other neuropathic patterns in diabetes mellitus that are uncommon but are important to recognize, since they may mimic many other non-neurologic diseases. This article discusses a variety of forms of mononeuropathies and diabetic proximal motor neuropathy, commonly known as diabetic amyotropy.
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Affiliation(s)
- R Pourmand
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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35
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Lindner A, Zierz S. [Differential sciatica pain diagnosis from the neurologic viewpoint]. MEDIZINISCHE KLINIK (MUNICH, GERMANY : 1983) 1997; 92:335-43. [PMID: 9297065 DOI: 10.1007/bf03044774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Low back pain and sciatica with or without neurological deficits represent frequent disorders in clinical practice. Both, history and neurological examination are essential for localizing underlying lesions and initiating appropriate investigations. Pain location, sensory symptoms, motor signs and reflexes are extremely reliable in indicating which motor root(s) or peripheral nerve(s) are affected. Sometimes, pain and/or paraesthesia are the only presenting symptoms. Therefore differential diagnosis of low back pain and sciatica is various. This article summarizes the differential diagnosis of low back pain and sciatica according to the site of the lesion as follows: 1. lesions of the spinal cord, 2. lesions of the nerve roots (L4, L5, S1-S3), 3. lesions of the lumbosacral plexus, 4. peripheral nerve lesions (sciatic nerve, peroneal nerve), 5. low back pain and sciatica due to neuropathies, and 6. low back pain and sciatica as a symptom of other neurological disorders. Additionally, the status of neuroradiological procedures in establishing diagnosis is discussed.
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Affiliation(s)
- A Lindner
- Neurologische Klinik und Poliklinik, Martin-Luther-Universität Halle-Wittenberg
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36
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Abstract
A case fulfilling the criteria for the diagnosis of diabetic amyotrophy is reported. Based on the clinical and electrodiagnostic features, it is concluded that diabetic amyotrophy is a recognizable clinical entity that can be differentiated from other diabetic neuropathies. The site of the lesion and the pathogenesis in diabetic amyotrophy remain controversial. The course of the illness is variable with gradual, but often incomplete, improvement.
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Affiliation(s)
- S Chokroverty
- Department of Neurology, St. Vincent's Hospital and Medical Center of New York, New York, USA
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37
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Abstract
Diabetic neuropathy is the most common neuropathy in industrialized countries, with a remarkable range of clinical manifestations. The usual pattern is a distal symmetrical sensory polyneuropathy, associated with autonomic disturbances. Less often, diabetes is responsible for a focal or multifocal neuropathy affecting cranial nerves, especially oculomotor nerves, and roots and nerves innervating proximal muscles of the lower limbs. Metabolic abnormalities due to hyperglycaemia, lack of insulin and their consequences and ischaemic phenomena secondary to diabetic microangiopathy account for nerve lesions.
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Affiliation(s)
- G Said
- Service de Neurologie, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
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38
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Diabetic polyneuropathy in controlled clinical trials: Consensus Report of the Peripheral Nerve Society. Ann Neurol 1995; 38:478-82. [PMID: 7668839 DOI: 10.1002/ana.410380323] [Citation(s) in RCA: 81] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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39
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Knowledge-based expert systems. Clin Neurophysiol 1995. [DOI: 10.1016/b978-0-7506-1183-1.50021-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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40
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Said G, Goulon-Goeau C, Lacroix C, Moulonguet A. Nerve biopsy findings in different patterns of proximal diabetic neuropathy. Ann Neurol 1994; 35:559-69. [PMID: 8179302 DOI: 10.1002/ana.410350509] [Citation(s) in RCA: 199] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Besides distal symmetrical sensory polyneuropathy (DSSP), middle-aged diabetic patients may present with focal or multifocal neuropathies, including proximal neuropathy of the lower limbs, the pathophysiological features of which are uncertain. We studied 10 non-insulin-dependent diabetic patients, 45 to 72 years of age, who developed a painful proximal neuropathy of the lower limbs for which other causes of neuropathy were carefully excluded. The proximal neuropathy was asymmetrical in all patients, sensory in 4, motor and sensory in the others. Signs of DSSP were present in all. A sample of the intermediate cutaneous nerve of the thigh, a sensory branch of the femoral nerve, was taken by biopsy and examined by light and electron microscopy. Examination of the nerve specimens revealed ischemic nerve lesions in 3 patients. Nerve ischemia was associated with vasculitis and inflammatory infiltration in 2 of them. In the other patients the lesions of the cutaneous nerve of the thigh included a varying incidence of axonal and demyelinative lesions similar to those observed in DSSP, with mild inflammatory infiltration in 4 of them. The density of myelinated and of unmyelinated was variably decreased. This study shows that axonal and demyelinative lesions similar to those found in diabetic DSSP are present in proximal nerves in mild forms of proximal diabetic neuropathy; while nerve ischemia, inflammatory infiltration, and vasculitis are encountered in the most severe forms of proximal diabetic neuropathy.
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Affiliation(s)
- G Said
- Service de Neurologie, Hôpital de Bicêtre, Université Paris, France
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41
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Wilcox MS, Bilbao A. Sensitivity of electrophysiological studies and the carpal tunnel syndrome. Muscle Nerve 1993; 16:1265-6. [PMID: 8413381 DOI: 10.1002/mus.880161119] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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42
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Abstract
Diabetic neuropathy is the most frequent complication of diabetes and the leading cause of polyneuropathy in the Western world. A distal symmetric predominantly sensory polyneuropathy is the most common of the diverse neuropathies that occur secondary to diabetes. Pain is often the most bothersome and difficult to treat symptom of diabetic neuropathy. Autonomic neuropathy is a frequent feature of diabetic neuropathy and the source of many significant problems including postural hypotension, gastroparesis, diarrhea, constipation, neurogenic bladder, and male impotence. Physicians need to be familiar with the multiple, less common forms of diabetic neuropathy, as these often mimic other medical or neurologic conditions. The cause of diabetic neuropathy is not determined, but abundant evidence suggests that both metabolic and ischemic nerve injury are likely factors. These should not be considered mutually exclusive causes of diabetic neuropathy as both factors likely operate to different degrees to produce the clinical spectrum of neuropathies that are seen in diabetes. Although no effective treatment exists to cure diabetic neuropathy, improvement is possible with glycemic control and symptomatic therapy.
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Affiliation(s)
- M A Ross
- Department of Neurology, University of Iowa College of Medicine, Iowa City
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43
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Smith BE, Dyck PJ. Subclinical histopathological changes in the oculomotor nerve in diabetes mellitus. Ann Neurol 1992; 32:376-85. [PMID: 1416807 DOI: 10.1002/ana.410320312] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
To provide reference values for the oculomotor nerve, for example, fascicular area and myelinated fiber (MF) number and size distribution, in pathological states, and to determine whether oculomotor nerves from diabetic patients without a history of oculomotor palsy have subclinical structural alterations, the morphometric features of 15 control subjects and eight diabetic patients were evaluated at a proximal and a distal level. On average the control nerves had a fascicular area of 2.7 mm2, 22,311 MF, and a bimodal diameter distribution with peaks at approximately 5 to 6 and 10 to 11 microns and a range of 2 to 20 microns. In proximal nerve, glial bundles were found in one-half of the subjects and patients, with a peak of MF sizes that differed from fibers in nonglial areas. The nerves from diabetic patients departed from the nerves from control subjects in the following two respects: changed size distribution, suggesting atrophy of fibers, and microfasciculation of edge fibers in parts of the fascicles in one-half of the patients. We conclude that glial bundles are probably a normal variant. Microfasciculation occurred much more frequently in nerves from diabetic patients and may represent subclinical injury of unknown cause. The alteration in size distribution may reflect the diabetic state and is not necessarily a precursor to diabetic ophthalmoplegia.
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Affiliation(s)
- B E Smith
- Peripheral Neuropathy Research Laboratory, Mayo Clinic, Rochester, MN 55905
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44
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Affiliation(s)
- A N Gale
- Department of Neurological Science, Royal Free Hospital School of Medicine, London, UK
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45
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Medina-Sanchez M, Rodriguez-Sanchez C, Vega-Alvarez JA, Menedez-Pelaez A, Perez-Casas A. Proximal skeletal muscle alterations in streptozotocin-diabetic rats: a histochemical and morphometric analysis. THE AMERICAN JOURNAL OF ANATOMY 1991; 191:48-56. [PMID: 1829578 DOI: 10.1002/aja.1001910105] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The response of rat quadriceps muscle fibers to chronic streptozotocin (STZ) diabetes was studied. Transverse sections of rectus femoris muscle from diabetic and weight-matched control rats were assayed for myofibrilar adenosine triphosphatase (ATPase) and nicotinamide adenine dinucleotide-tetrazolium reductase (NADH-TR). A quantitative analysis was carried out by an automatic interactive analysis system focused on the fiber type size and distribution. STZ-induced diabetes caused important effects in this muscle, with changes in the distribution of oxidative enzyme reactions, type I fiber hypertrophy, and type II fiber atrophy, which was greater in type IIB than in type IIA. It is concluded that hypoinsulinism produces morphological alterations in proximal skeletal muscle fibers that are similar to those of neurogenic myopathy. Thus the pathological changes in these mammalian muscle fibers could explain the clinical syndrome seen in diabetic patients called "diabetic symmetrical proximal motor neuropathy," perhaps the least understood of the major neuropathic complications of diabetes.
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Affiliation(s)
- M Medina-Sanchez
- Departmento de Morfologia y Biologia Celular, Facultad de Medicina, Universidad de Oviedo, Spain
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46
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Abstract
The distributions of sensory abnormalities in 17 episodes of diabetic truncal neuropathy among 7 patients with diabetes mellitus are described. The patterns are highly variable: the distribution of adjacent main spinal nerves may be involved, resulting in a complete dermatomal band of dysesthesia, but almost two-thirds of the episodes were restricted to the distribution of the ventral or dorsal rami of the spinal nerves or branches of these rami or varying combinations of these distributions.
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Affiliation(s)
- J D Stewart
- Division of Neurology, Montreal General Hospital, Quebec, Canada
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47
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Abstract
Diabetic neuropathy is a common complication of diabetes mellitus with significant morbidity and mortality. Hyperglycemia with its secondary metabolic, vascular, and enzymatic consequences is most likely to be the predominant cause. The clinical manifestations includes a wide range of somatic and autonomic syndromes. Painful diabetic neuropathy may require symptomatic treatment. The precise role of therapies such as continuous subcutaneous insulin therapy and aldose reductase inhibitors remains to be clarified.
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Affiliation(s)
- H E Bays
- Department of Medicine, University of Louisville School of Medicine, Kentucky
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48
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Abstract
Diabetic neuropathy is a common complication of diabetes that may be associated both with considerable morbidity (painful polyneuropathy, neuropathic ulceration) and mortality (autonomic neuropathy). The epidemiology and natural history of diabetic neuropathy is clouded with uncertainty, largely due to confusion in the definition and measurement of this disorder. We have reviewed a variety of the clinical manifestations associated with somatic and autonomic neuropathy and discussed current views related to the management of the different abnormalities. Although unproven, the best evidence suggests that near normal control of blood glucose in the early years following onset of diabetes may help delay the development of clinically significant nerve impairment. Intensive therapy to achieve normalization of blood glucose may also lead to reversibility of early diabetic neuropathy, but again this is unproven. Our ability to manage successfully the many different manifestations of diabetic neuropathy depends ultimately on our success in uncovering the pathogenic processes underlying this disorder. The recent resurgence of interest in the vascular hypothesis, for example, has opened up new avenues of investigation for therapeutic intervention. Paralleling our increased understanding of the pathogenesis of diabetic neuropathy, there must be refinements in our ability to measure quantitatively the different types of defects that occur in this disorder. These tests must be validated and standardized to allow comparability between studies and more meaningful interpretation of study results.
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Affiliation(s)
- A Vinik
- Department of Internal Medicine, School of Public Health, University of Michigan, Ann Arbor 48109
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49
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Abstract
A case fulfilling the criteria for the diagnosis of diabetic amyotrophy is reported. Based on the clinical and electrodiagnostic features, it is concluded that diabetic amyotrophy is a recognizable clinical entity that can be differentiated from other diabetic neuropathies. The site of the lesion and the pathogenesis in diabetic amyotrophy remain controversial. The usual course of the illness is one of gradual improvement over weeks to months.
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Affiliation(s)
- S Chokroverty
- Department of Neurology, UMDNJ-Robert Wood Johnson Medical School, New Brunswick
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50
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Fierro B, Modica A, D'Arpa A, Santangelo R, Raimondo D. Analysis of F-wave in metabolic neuropathies: a comparative study in uremic and diabetic patients. Acta Neurol Scand 1987; 75:179-85. [PMID: 3033975 DOI: 10.1111/j.1600-0404.1987.tb07914.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Motor nerve conduction study along the entire length of the ulnar and tibialis posterior nerves was carried out in 30 diabetics compared with 30 uremic patients and 30 control subjects. The conduction in the proximal and the distal nerve segments was evaluated by the determination of the M and F latencies, MNCV (between the stimulus sites), FWCV (between the spinal cord and the stimulus sites), and F-ratio (conduction time ratio of proximal to distal segment). In both groups of patients the lower limbs appear much more involved than the upper, where the ulnar nerve is more commonly affected in uremic than in diabetic patients. In diabetic neuropathy the motor conduction abnormalities are diffuse over the total length of the nerve, but more marked distally in the ulnar nerve.
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