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Trofin D, Salmen BM, Salmen T, Trofin DM, Reurean-Pintilei D. Advancing the Diagnosis of Diabetic Neuropathies: Electrodiagnostic and Skin Autofluorescence Methods. J Pers Med 2024; 14:884. [PMID: 39202075 PMCID: PMC11355645 DOI: 10.3390/jpm14080884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Revised: 08/17/2024] [Accepted: 08/19/2024] [Indexed: 09/03/2024] Open
Abstract
INTRODUCTION Diabetic neuropathy (DN) is a generic term for various neuropathies coexisting in a single patient. Clinical diagnosis alone can be misleading, yet routine electrodiagnostic studies in diabetes care are rare. Skin autofluorescence (SAF) is a recognized DN risk factor with potential screening value. This article highlights the diagnostic challenges and raises awareness of the often underdiagnosed neuropathic conditions in diabetes patients. MATERIAL AND METHODS We present common entrapment neuropathy cases from our diabetes clinic's electrodiagnosis laboratory in Iași, Romania. We selected seven type 2 diabetes patients with sensory or sensory-motor distal polyneuropathy and atypical DN presentations investigated through electroneurography (ENG) and electromyography (EMG) with the Neurosoft® EMG instrument and SAF measured by standard procedures. Subsequently, a narrative literature review was conducted. RESULTS Entrapment neuropathies were diagnosed in all the patients: three carpal tunnel syndromes, two ulnar neuropathies (one proximal, one distal), one peroneal neuropathy, and one case of meralgia paresthetica. The lower-limb cases showed radiculoplexopathy, and there was one case of superficial radial nerve neuropathy. The SAF values ranged from 2.5 AU to 3.4 AU. CONCLUSIONS Electrodiagnosis is essential for detecting focal neuropathies in patients with sensory-motor distal polyneuropathy. Elevated SAF levels may correlate with symptom severity, although further research, including large cohorts, is needed.
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Affiliation(s)
- Dan Trofin
- Department of Diabetes, Nutrition and Metabolic Diseases, Consultmed Medical Centre, 700544 Iasi, Romania; (D.T.); (D.R.-P.)
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, University of Medicine and Pharmacy “Grigore T. Popa” Iasi, 700454 Iasi, Romania
| | - Bianca-Margareta Salmen
- Doctoral School of Carol Davila, University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Teodor Salmen
- Doctoral School of Carol Davila, University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | | | - Delia Reurean-Pintilei
- Department of Diabetes, Nutrition and Metabolic Diseases, Consultmed Medical Centre, 700544 Iasi, Romania; (D.T.); (D.R.-P.)
- Department of Medical-Surgical and Complementary Sciences, Faculty of Medicine and Biological Sciences, “Ștefan cel Mare” University, 720229 Suceava, Romania
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Dao KT, Leepakshi J, Abraham J, Aranguri CM, Clarke M, Ly BT, Veedu HK, Sabetian K. A Severe Case of Diabetic Lumbosacral Radiculoplexus Neuropathy: A Diagnosis of Exclusion. Cureus 2024; 16:e61969. [PMID: 38978950 PMCID: PMC11230586 DOI: 10.7759/cureus.61969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2024] [Indexed: 07/10/2024] Open
Abstract
Diabetic lumbosacral radiculoplexus neuropathy (DLSRPN), also known as diabetic amyotrophy, is a rare disease of exclusion that is difficult to diagnose due to its non-specific clinical presentation of neuropathy, autonomic symptoms, and potential weight loss. Due to this, many differential diagnoses are raised before making a diagnosis of such an uncommon disease. However, once the diagnosis is made, the management of this disease can vary. Here, we would like to discuss the etiology, pathophysiology, diagnosis, and management of this disease, as well as present a rare case of diabetic lumbosacral radiculoplexus neuropathy in a 50-year-old male.
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Affiliation(s)
- Kevin T Dao
- Internal Medicine, University of California Los Angeles-Kern Medical Center, Bakersfield, USA
| | - Johar Leepakshi
- Internal Medicine, Western University of Health Sciences, Pomona, USA
| | - Jesslin Abraham
- Internal Medicine, University of California Los Angeles-Kern Medical Center, Bakersfield, USA
| | - Cesar M Aranguri
- Internal Medicine, University of California Los Angeles-Kern Medical Center, Bakersfield, USA
| | - Matthew Clarke
- Internal Medicine, University of California Los Angeles-Kern Medical Center, Bakersfield, USA
| | - Britney T Ly
- Neurology, University of California Los Angeles-Kern Medical Center, Bakersfield, USA
| | - Hari K Veedu
- Neurology, University of California Los Angeles-Kern Medical Center, Bakersfield, USA
| | - Katayoun Sabetian
- Neurology, University of California Los Angeles-Kern Medical Center, Bakersfield, USA
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Zaino B, Goel R, Devaragudi S, Prakash A, Vaghamashi Y, Sethi Y, Patel N, Kaka N. Diabetic neuropathy: Pathogenesis and evolving principles of management. Dis Mon 2023; 69:101582. [PMID: 37164794 DOI: 10.1016/j.disamonth.2023.101582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
The global rise of prediabetes and diabetes has spawned an epidemic of complications associated with these conditions. Neuropathy is the most common consequence, with distal symmetric polyneuropathy (DSP) being the most prevalent. Diabetic neuropathy (DN) is a debilitating consequence of diabetes mellitus resulting in the highest morbidity and death, besides imposing a substantial financial burden on the patient. Loss of sensory function commencing distally in the lower limbs, accompanied by discomfort and considerable morbidity, characterizes diabetic neuropathy. The clinical evaluation and therapeutic options for diabetic peripheral neuropathy are multifaceted. At least fifty percent of people with diabetes acquire diabetic neuropathy over time. Good glycemic control halts the evolution in individuals with Type 1 diabetes mellitus. These results have prompted fresh attempts to comprehend the origin and develop new guidelines for prevention and treatment. New recommendations have also been established for the treatment of painful DN using separate classes of medications, with an emphasis on avoiding the use of opioids. Although our comprehension of the intricacies of diabetic neuropathy has progressed significantly over the past decade, the unique processes driving the neuropathy in type 1 and type 2 diabetes remain unexplained. Currently, glycemic control and pain management are the only effective therapies. While glucose management significantly reduces neuropathy development in type 1 diabetics, the effect is considerably lower in type 2 diabetics. Evidence supports the use of anticonvulsants and antidepressants for diabetic peripheral neuropathy pain treatment. However, the absence of disease-modifying medications for diabetic DSP necessitates the identification of unrecognized modifiable risk factors. It is imperative to identify the 'missed' risk factors and targets, allowing comprehensive, individualized care for patients.
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Affiliation(s)
- Basem Zaino
- Tishreen University, Syria; PearResearch, India
| | - Rashika Goel
- Punjab Institute of Medical Sciences, India; PearResearch, India
| | - Sanjana Devaragudi
- Apollo Institute of Medical Sciences and Research, Hyderabad, India; PearResearch, India
| | - Ananya Prakash
- Narayana Institute of Cardiac Sciences, Bangalore, India; PearResearch, India
| | - Yogeshkumar Vaghamashi
- Bicol Christian College of Medicine, Legazpi city, Philippines; Narayana Institute of Cardiac Sciences, Bangalore, India
| | - Yashendra Sethi
- PearResearch, India; Government Doon Medical College, Dehradun, Uttarakhand, India
| | - Neil Patel
- PearResearch, India; GMERS Medical College Himmatnagar, India.
| | - Nirja Kaka
- PearResearch, India; GMERS Medical College Himmatnagar, India
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Billerot E, Nguyen TH, Sedira N, Espinoza S, Vende B, Heron E, Habas C. Ocular motor nerve palsy in patients with diabetes: High-resolution MR imaging of nerve enhancement. J Fr Ophtalmol 2023; 46:726-736. [PMID: 37210294 DOI: 10.1016/j.jfo.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVE To evaluate the extent of signal abnormality in impaired ocular motor nerves using high signal and spatial resolution MRI sequences and to discuss the involvement of inflammatory or microvascular impairment in patients with diabetic ophthalmoplegia. METHODS We conducted a retrospective study of 10 patients referred for acute ocular motor nerve palsy in the context of diabetes mellitus from September 15th, 2021 to April 24th, 2022. 3T MRI evaluation included diffusion, 3D TOF, FLAIR, coronal STIR and post-injection 3D T1 SPACE DANTE sequences. RESULTS Ten patients were included: 9 males and 1 female aged from 46 to 79 years. Five patients presented with cranial nerve (CN) III palsy, and 5 presented with CN VI palsy. Third nerve palsy was pupil-sparing in 4 patients and pupil-involved in 1 patient. Pain was associated in all patients with CN III deficiencies and in 2 patients CN VI deficiencies. In all patients, MRI sequences ruled out mass effect and vascular pathology, such as acute stroke or aneurysm. Eight patients presented with STIR hypersignals, some with enlargement of the involved nerve. The diagnosis was confirmed through a post-injection 3D T1 SPACE DANTE sequence, which showed extended enhancement along the abnormal portion of the nerve. CONCLUSION High-resolution MRI evaluation of diplopia in diabetic patients is used to rule out a diagnosis of acute stroke and contributes to the positive diagnosis of ocular motor nerve impairment, possibly combining the influences of inflammatory and microvascular phenomena. Dedicated MR imaging should be included in the initial diagnosis and longitudinal follow-up of patients with diabetic ophthalmoplegia.
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Affiliation(s)
- E Billerot
- Department of Neuroimaging, centre hospitalier national d'ophtalmologie des Quinze-Vingts, Paris, France
| | - T H Nguyen
- Department of Neuroimaging, centre hospitalier national d'ophtalmologie des Quinze-Vingts, Paris, France.
| | - N Sedira
- Department of Internal Medicine, centre hospitalier national d'ophtalmologie des Quinze-Vingts, Paris, France
| | - S Espinoza
- Department of Neuroimaging, centre hospitalier national d'ophtalmologie des Quinze-Vingts, Paris, France
| | - B Vende
- Department of Neuroimaging, centre hospitalier national d'ophtalmologie des Quinze-Vingts, Paris, France
| | - E Heron
- Department of Internal Medicine, centre hospitalier national d'ophtalmologie des Quinze-Vingts, Paris, France
| | - C Habas
- Department of Neuroimaging, centre hospitalier national d'ophtalmologie des Quinze-Vingts, Paris, France
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Oh AJ, Javaheri M, Hosseini H, Prasad PS. Purtscher-like retinopathy in a 19-year-old with maturity-onset diabetes of the young: a case report. J Med Case Rep 2023; 17:255. [PMID: 37331978 DOI: 10.1186/s13256-023-03985-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/15/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND We report the first case of Purtscher-like retinopathy in a patient with 17q12 deletion-associated maturity-onset diabetes of the young. CASE PRESENTATION A 19-year-old diabetic Hispanic male with history of cataracts and toe amputations presented with sudden onset of painless bilateral vision loss for 1 week with no associated trauma. Visual acuity was counting fingers at six feet in both eyes. Dilated retinal examination revealed bilateral peripapillary cotton wool spots and intraretinal hemorrhages, and significant subretinal and intraretinal fluid on optical coherence tomography. Fluorescein angiography revealed arteriolar staining and leakage around the disc with areas of capillary nonperfusion, supporting the diagnosis of Purtscher-like retinopathy. Systemic workup revealed multiple diabetic complications including chronic osteomyelitis of multiple toes, nonhealing diabetic foot ulcers, neurogenic bladder and bowel, and bilateral lower-extremity muscular neuropathies. Genetic evaluation revealed a 17q12 deletion, which is associated with maturity-onset diabetes of the young 5. On follow-up examination, he received a single intravitreal antivascular endothelial growth factor injection in the left eye (off label) for persistent macular edema. Although his retinal edema improved, his visual acuity remained poor. CONCLUSIONS The presentation of our patient's multiple diabetic complications along visual symptoms suggests Purtscher-like retinopathy can be a sequela of uncontrolled diabetes. Purtscher-like retinopathy is a rare but possible consideration in diabetic patients who present with acute-onset vision loss.
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Affiliation(s)
- Angela J Oh
- Department of Ophthalmology, Harbor-UCLA Medical Center, 1000 West Carson, Torrance, CA, 90502, USA.
- UCLA Stein Eye Institute, 100 Stein Plaza Driveway, Los Angeles, CA, 90095, USA.
| | - Michael Javaheri
- Department of Ophthalmology, Harbor-UCLA Medical Center, 1000 West Carson, Torrance, CA, 90502, USA
| | - Hamid Hosseini
- Department of Ophthalmology, Harbor-UCLA Medical Center, 1000 West Carson, Torrance, CA, 90502, USA
- UCLA Stein Eye Institute, 100 Stein Plaza Driveway, Los Angeles, CA, 90095, USA
| | - Pradeep S Prasad
- Department of Ophthalmology, Harbor-UCLA Medical Center, 1000 West Carson, Torrance, CA, 90502, USA
- UCLA Stein Eye Institute, 100 Stein Plaza Driveway, Los Angeles, CA, 90095, USA
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Naum R, Gwathmey KG. Autoimmune polyneuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:587-608. [PMID: 37562888 DOI: 10.1016/b978-0-323-98818-6.00004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
The autoimmune peripheral neuropathies with prominent motor manifestations are a diverse collection of unusual peripheral neuropathies that are appreciated in vast clinical settings. This chapter highlights the most common immune-mediated, motor predominant neuropathies excluding acute, and chronic inflammatory demyelinating polyradiculoneuropathy (AIDP and CIDP, respectively). Other acquired demyelinating neuropathies such as distal CIDP and multifocal motor neuropathy will be covered. Additionally, the radiculoplexus neuropathies, resulting from microvasculitis-induced injury to nerve roots, plexuses, and nerves, including diabetic and nondiabetic lumbosacral radiculoplexus neuropathy and neuralgic amyotrophy (i.e., Parsonage-Turner syndrome), will be included. Finally, the motor predominant peripheral neuropathies encountered in association with rheumatological disease, particularly Sjögren's syndrome and rheumatoid arthritis, are covered. Early recognition of these distinct motor predominant autoimmune neuropathies and initiation of immunomodulatory and immunosuppressant treatment likely result in improved outcomes.
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Affiliation(s)
- Ryan Naum
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
| | - Kelly Graham Gwathmey
- Neuromuscular Division, Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States.
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Smith S, Normahani P, Lane T, Hohenschurz-Schmidt D, Oliver N, Davies AH. Pathogenesis of Distal Symmetrical Polyneuropathy in Diabetes. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071074. [PMID: 35888162 PMCID: PMC9319251 DOI: 10.3390/life12071074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 12/13/2022]
Abstract
Distal symmetrical polyneuropathy (DSPN) is a serious complication of diabetes associated with significant disability and mortality. Although more than 50% of people with diabetes develop DSPN, its pathogenesis is still relatively unknown. This lack of understanding has limited the development of novel disease-modifying therapies and left the reasons for failed therapies uncertain, which is critical given that current management strategies often fail to achieve long-term efficacy. In this article, the pathogenesis of DSPN is reviewed, covering pathogenic changes in the peripheral nervous system, microvasculature and central nervous system (CNS). Furthermore, the successes and limitations of current therapies are discussed, and potential therapeutic targets are proposed. Recent findings on its pathogenesis have called the definition of DSPN into question and transformed the disease model, paving the way for new research prospects.
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Affiliation(s)
- Sasha Smith
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Pasha Normahani
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Tristan Lane
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Department of Vascular Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - David Hohenschurz-Schmidt
- Pain Research Group, Department of Surgery and Cancer, Imperial College London, London SW10 9NH, UK;
| | - Nick Oliver
- Section of Metabolic Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London W2 1PG, UK;
- Division of Medicine and Integrated Care, Imperial College Healthcare NHS Trust, London W2 1NY, UK
| | - Alun Huw Davies
- Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London W6 8RF, UK; (S.S.); (P.N.); (T.L.)
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
- Correspondence:
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Qureshi Z, Ali MN, Khalid M. An Insight into Potential Pharmacotherapeutic Agents for Painful Diabetic Neuropathy. J Diabetes Res 2022; 2022:9989272. [PMID: 35127954 PMCID: PMC8813291 DOI: 10.1155/2022/9989272] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 11/11/2021] [Accepted: 12/27/2021] [Indexed: 12/20/2022] Open
Abstract
Diabetes is the 4th most common disease affecting the world's population. It is accompanied by many complications that deteriorate the quality of life. Painful diabetic neuropathy (PDN) is one of the debilitating consequences of diabetes that effects one-third of diabetic patients. Unfortunately, there is no internationally recommended drug that directly hinders the pathological mechanisms that result in painful diabetic neuropathy. Clinical studies have shown that anticonvulsant and antidepressant therapies have proven fruitful in management of pain associated with PDN. Currently, the FDA approved medications for painful diabetic neuropathies include duloxetine, pregabalin, tapentadol extended release, and capsaicin (for foot PDN only). The FDA has also approved the use of spinal cord stimulation system for the treatment of diabetic neuropathy pain. The drugs recommended by other regulatory bodies include gabapentin, amitriptyline, dextromethorphan, tramadol, venlafaxine, sodium valproate, and 5 % lidocaine patch. These drugs are only partially effective and have adverse effects associated with their use. Treating painful symptoms in diabetic patient can be frustrating not only for the patients but also for health care workers, so additional clinical trials for novel and conventional treatments are required to devise more effective treatment for PDN with minimal side effects. This review gives an insight on the pathways involved in the pathogenesis of PDN and the potential pharmacotherapeutic agents. This will be followed by an overview on the FDA-approved drugs for PDN and commercially available topical analgesic and their effects on painful diabetic neuropathies.
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Affiliation(s)
- Zunaira Qureshi
- Department of Biomedical Engineering and Sciences, School of Mechanical and Manufacturing Engineering, National University of Sciences and Technology, H-12, 44000 Islamabad, Pakistan
| | - Murtaza Najabat Ali
- Department of Biomedical Engineering and Sciences, School of Mechanical and Manufacturing Engineering, National University of Sciences and Technology, H-12, 44000 Islamabad, Pakistan
| | - Minahil Khalid
- Department of Biomedical Engineering and Sciences, School of Mechanical and Manufacturing Engineering, National University of Sciences and Technology, H-12, 44000 Islamabad, Pakistan
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Boo G, Ji A, Morton A. Diabetic ketoacidosis and unilateral thigh pain. Emerg Med Australas 2021; 33:580-581. [PMID: 33682369 DOI: 10.1111/1742-6723.13735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 01/09/2021] [Indexed: 11/27/2022]
Affiliation(s)
- George Boo
- Endocrine Department, Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - Amanda Ji
- Endocrine Department, Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - Adam Morton
- Endocrine Department, Mater Hospital Brisbane, Brisbane, Queensland, Australia
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