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Titolo P, Rampini AD, Lavorato A, Battiston B, Ciclamini D, Isoardo G, Vincitorio F, Garbossa D, Papalia I, Costa AL, Galeano M, Colonna MR. Biopsy of the anterior interosseous motor branch for the pronator quadratus muscle: a safe and minimally invasive diagnostic tool for peripheral neuropathies. Anatomical surgery and surgical technique. Clin Neurol Neurosurg 2024; 246:108508. [PMID: 39241694 DOI: 10.1016/j.clineuro.2024.108508] [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: 04/26/2024] [Revised: 08/10/2024] [Accepted: 08/12/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND AND OBJECTIVES Choosing the correct site for a nerve biopsy remains a challenge due to nerve sacrifice and major donor site complications, such as neuroma, as seen in sural nerve biopsy. Selecting a deeper donor nerve can help in burying nerve stumps in deep soft tissues, preventing neuroma. Moreover, using an expendable, deeply situated motor nerve can aid indiagnosis when a motor neuropathy is suspected. The authors propose using the pronator quadratus (PQ) branch for this purpose, as it is located deep between the bellies of the flexor muscles and the interosseous membrane in the forearm. This branch is expendable since the denervation of the PQ has a negligible effect on forearm pronation, which is primarily sustained by the pronator teres. METHODS The surgical approach is the same as the approach for anterior interosseous nerve transfer to the motor component of the ulnar nerve in the distal forearm: access is in the midline in the middle third of the forearm under local anesthesia Blunt dissection is performed, separating and retracting the flexor musculotendinous junction to reach the interosseous membrane where the PQ branch is identified. A careful dissection of the nerve branch is performed, allowing a 2 cm long segment to be cut and removed. The proximal stump is then buried into an adjacent muscle belly and the surgical site is closed. RESULTS The technique is safe and reproducible in experienced hands. CONCLUSION This technique may be especially applicable in cases where neurologists need to study motor neuropathies. Contraindications of the technique include wrist instability and high median nerve palsies.
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Affiliation(s)
- Paolo Titolo
- Traumatology-Reconstructive Microsurgery, Department of Orthopedics and Traumatology, CTO Hospital of Turin, Turin, Italy
| | | | | | - Bruno Battiston
- Traumatology-Reconstructive Microsurgery, Department of Orthopedics and Traumatology, CTO Hospital of Turin, Turin, Italy
| | - Davide Ciclamini
- Traumatology-Reconstructive Microsurgery, Department of Orthopedics and Traumatology, CTO Hospital of Turin, Turin, Italy
| | - Gianluca Isoardo
- Department of Neurosciences and Mental Health, Hospital " City of Health and Science of Turin, Turin, Italy
| | - Francesca Vincitorio
- Department of Neurosciences and Mental Health, Hospital " City of Health and Science of Turin, Turin, Italy
| | - Diego Garbossa
- Department of Neurosciences and Mental Health, Hospital " City of Health and Science of Turin, Turin, Italy
| | - Igor Papalia
- Department of Biological and Morphological Sciences and Imaging University of Messina, Messina, Italy
| | - Alfio L Costa
- Department of Neurosciences, Plastic Surgery, University of Padua, Padua, Italy
| | - Mariarosaria Galeano
- Department of Biological and Morphological Sciences and Imaging University of Messina, Messina, Italy
| | - Michele R Colonna
- Department of Human Pathology of the Adult, the Child and the Adolescent, University of Messina, Messina, Italy.
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Ambawatte S, Wijewickrama P, Gunarathne K, Somasundaram N. Bruns Garland Syndrome as the first presentation of type 2 diabetes: two case reports and a practical approach to diagnosis. J Med Case Rep 2024; 18:99. [PMID: 38360756 PMCID: PMC10870480 DOI: 10.1186/s13256-023-04327-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 12/18/2023] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Diabetes is a global health problem causing a significant burden on the healthcare systems both due to the disease itself and associated complications. Diabetic radiculoplexus neuropathies or Bruns-Garland syndrome constitutes a rare form of microvascular complications, more commonly affecting the lumbosacral plexus and, very rarely, the cervical plexus. We describe two Sri Lankan males who presented with diabetic lumbosacral radiculoplexus neuropathy and diabetic cervical radiculoplexus neuropathy as the initial manifestation of diabetes. CASE DESCRIPTION Case 1: a 49-year-old Sri Lankan hotel chef presented with subacute painful weakness and wasting of the left upper arm for 3 months and weight loss. Left upper limb proximal muscles were wasted with diminished power and reflexes. A nerve conduction study showed comparative amplitude reduction. An electromyogram revealed positive sharp waves, frequent fibrillations, and high amplitude polyphasic motor unit potentials with reduced recruitment in proximal muscles of left upper limb. Case-2: a 47-year-old Sri Lankan carpenter presented with subacute progressive asymmetrical painful weakness and wasting of bilateral thighs for 5 months and weight loss. Lower limb proximal muscles were wasted with reduced power and knee jerks. The nerve conduction study was normal. The electromyogram was similar to case 1 involving both quadratus femoris muscles, which was more prominent on the left side. The work up for an underlying etiology revealed only elevated fasting blood glucose and HbA1c, suggesting a new diagnosis of diabetes associated with neurological symptoms. Patient 1 was diagnosed with diabetic cervical radiculoplexus neuropathy and patient 2 with diabetic lumbosacral radiculoplexus neuropathy. Both showed significant improvement following optimization of glycemic control together with symptomatic treatment and physiotherapy. CONCLUSION Diagnosis of diabetic radiculoplexus neuropathy requires a comprehensive workup to rule out other sinister pathologies. This case report has a dual importance; it describes diabetic radiculoplexus neuropathy as the very first manifestation of two previously healthy people, giving rise to a new diagnosis of diabetes and, at the same time, reporting on diabetic cervical radiculoplexus neuropathy, which is extremely rare and has never been previously reported in Sri Lanka.
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Affiliation(s)
| | | | - Kamal Gunarathne
- Neuro-Electrophysiology Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Noel Somasundaram
- Diabetes & Endocrinology, Unit National Hospital of Sri Lanka, Colombo, Sri Lanka
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Mashauri HL, Makunga FJ, Luhwago EC, Ndale E, Kilonzo KG. Is it myocardial infarction? A case report of C7 cervical radiculopathy with cervical angina. SAGE Open Med Case Rep 2024; 12:2050313X231223434. [PMID: 38187813 PMCID: PMC10768626 DOI: 10.1177/2050313x231223434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/08/2023] [Indexed: 01/09/2024] Open
Abstract
Cervical radiculopathy refers to the mechanical compression or inflammation of any of the cervical roots which lead to their dysfunction. Male sex, uncontrolled diabetes mellitus, manual labor-related occupation or activities are among the possible factors which can predispose or precipitate the occurrence of cervical radiculopathy. A 63 years old male presented with cervicogenic angina which was refractory to painkillers. C7 cervical radiculopathy might present with cervicogenic angina and pose a clinical diagnosis challenge given its similarity in clinical presentation with other clinical conditions like myocardial infarction. Clinicians should have a high index of suspicion to differentiate the two conditions. Nevertheless, ruling out firstly myocardial infarction and pulmonary embolism among patients presenting with chest pain is of clinical benefit in terms of morbidity and mortality of a patient. Furthermore, proper and timely physical examination should be emphasized to be conducted to every patient so as to avoid delayed diagnosis and management.
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Affiliation(s)
- Harold L Mashauri
- Department of Epidemiology and Biostatistics, Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
- Department of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
- Department of Emergency Medicine, Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
| | - Frank J Makunga
- Department of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
| | - Elisha C Luhwago
- Department of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
| | - Eliasa Ndale
- Department of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
| | - Kajiru G Kilonzo
- Department of Internal Medicine, Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Kilimanjaro, Tanzania
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Meiling JB, Boon AJ, Niu Z, Howe BM, Hoskote SS, Spinner RJ, Klein CJ. Parsonage-Turner Syndrome and Hereditary Brachial Plexus Neuropathy. Mayo Clin Proc 2024; 99:124-140. [PMID: 38176820 DOI: 10.1016/j.mayocp.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/10/2023] [Accepted: 06/23/2023] [Indexed: 01/06/2024]
Abstract
Parsonage-Turner syndrome and hereditary brachial plexus neuropathy (HBPN) present with indistinguishable attacks of rapid-onset severe shoulder and arm pain, disabling weakness, and early muscle atrophy. Their combined incidence ranges from 3 to 100 in 100,000 persons per year. Dominant mutations of SEPT9 are the only known mutations responsible for HBPN. Parsonage and Turner termed the disorder "brachial neuralgic amyotrophy," highlighting neuropathic pain and muscle atrophy. Modern electrodiagnostic and imaging testing assists the diagnosis in distinction from mimicking disorders. Shoulder and upper limb nerves outside the brachial plexus are commonly affected including the phrenic nerve where diaphragm ultrasound improves diagnosis. Magnetic resonance imaging can show multifocal T2 nerve and muscle hyperintensities with nerve hourglass swellings and constrictions identifiable also by ultrasound. An inflammatory immune component is suggested by nerve biopsies and associated infectious, immunization, trauma, surgery, and childbirth triggers. High-dose pulsed steroids assist initial pain control; however, weakness and subsequent pain are not clearly responsive to steroids and instead benefit from time, physical therapy, and non-narcotic pain medications. Recurrent attacks in HBPN are common and prophylactic steroids or intravenous immunoglobulin may reduce surgical- or childbirth-induced attacks. Rehabilitation focusing on restoring functional scapular mechanics, energy conservation, contracture prevention, and pain management are critical. Lifetime residual pain and weakness are rare with most making dramatic functional recovery. Tendon transfers can be used when recovery does not occur after 18 months. Early neurolysis and nerve grafts are controversial. This review provides an update including new diagnostic tools, new associations, and new interventions crossing multiple medical disciplines.
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Affiliation(s)
- James B Meiling
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Andrea J Boon
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA; Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Zhiyv Niu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Sumedh S Hoskote
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Christopher J Klein
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
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Vazquez Do Campo R, Dyck PJB. Focal inflammatory neuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:273-290. [PMID: 38697745 DOI: 10.1016/b978-0-323-90108-6.00009-0] [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: 05/05/2024]
Abstract
This chapter focuses on neuropathies that present with focal involvement of nerve roots, plexus, and/or peripheral nerves associated with autoimmune and inflammatory mechanisms that present with focal involvement of nerve roots, plexus and/or peripheral nerves. The clinical presentation, diagnosis, and treatment of focal autoimmune demyelinating neuropathies, focal nonsystemic vasculitic disorders (diabetic and nondiabetic radiculoplexus neuropathies, postsurgical inflammatory neuropathy, and neuralgic amyotrophy), and focal neuropathies associated with sarcoidosis and bacterial and viral infections are reviewed.
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Affiliation(s)
- Rocio Vazquez Do Campo
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - P James B Dyck
- Division of Neuromuscular Medicine, Department of Neurology, Mayo Clinic, Rochester, MN, United States; Peripheral Neuropathy Research Laboratory, Mayo Clinic, Rochester, MN, United States.
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Kozyreva AA, Bembeeva RT, Druzhinina ES, Zavadenko NN, Kolpakchi LM, Pilia SV. [Modern aspects of diagnosis and treatment of chronic inflammatory demyelinating polyneuropathy in children]. Zh Nevrol Psikhiatr Im S S Korsakova 2024; 124:58-68. [PMID: 38465811 DOI: 10.17116/jnevro202412402158] [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: 03/12/2024]
Abstract
OBJECTIVE Analysis of demographic, clinical, laboratory, electrophysiological and neuroimaging data and pathogenetic therapy of pediatric patients with chronic inflammatory demyelinating polyneuropathy (CIDP). MATERIAL AND METHODS Patients (n=30) were observed in a separate structural unit of the Russian Children's Clinical Hospital of the Russian National Research Medical University named after. N.I. Pirogova Ministry of Health of the Russian Federation in the period from 2006 to 2023. The examination was carried out in accordance with the recommendations of the Joint Task Force of the European Federation of Neurological Societies and the Peripheral Nerve Society on the Management of CIDP (2021). All patients received immunotherapy, including intravenous immunoglobulin (IVIG) (n=1), IVIG and glucocorticosteroids (GCS) (n=17, 56.7%), IVIG+GCS+plasmapheresis (n=12, 40.0%). Alternative therapy included cyclophosphamide (n=1), cyclophosphamide followed by mycophenolate mofetil (n=1), rituximab (n=2, 6.6%), azathioprine (n=3), mycophenolate mofetil (n=2, 6.6%). RESULTS In all patients, there was a significant difference between scores on the MRCss and INCAT functional scales before and after treatment. At the moment, 11/30 (36.6%) patients are in clinical remission and are not receiving pathogenetic therapy. The median duration of remission is 48 months (30-84). The longest remission (84 months) was observed in a patient with the onset of CIDP at the age of 1 year 7 months. CONCLUSION Early diagnosis of CIDP is important, since the disease is potentially curable; early administration of pathogenetic therapy provides a long-term favorable prognosis.
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Affiliation(s)
- A A Kozyreva
- Pirogov Russian National Research Medical University, Moscow, Russia
- Russian Children's Clinical Hospital, Moscow, Russia
| | - R Ts Bembeeva
- Pirogov Russian National Research Medical University, Moscow, Russia
- Russian Children's Clinical Hospital, Moscow, Russia
| | - E S Druzhinina
- Pirogov Russian National Research Medical University, Moscow, Russia
- Russian Children's Clinical Hospital, Moscow, Russia
| | - N N Zavadenko
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - L M Kolpakchi
- Russian Children's Clinical Hospital, Moscow, Russia
| | - S V Pilia
- Russian Children's Clinical Hospital, Moscow, Russia
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Kotb MA, Bedewi MA, Almalki DM, AlAseeri AA, Sandougah KJ, Soliman SB, Aldossary NM, Aboulela WH. Ultrasound assessment of the brachial plexus nerve root cross-sectional areas in asymptomatic patients with type 2 diabetes. Medicine (Baltimore) 2023; 102:e36806. [PMID: 38206708 PMCID: PMC10754578 DOI: 10.1097/md.0000000000036806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 12/06/2023] [Indexed: 01/13/2024] Open
Abstract
Type 2 diabetes mellitus (T2D) is one of the most common metabolic diseases and is often associated with cervical radiculoplexus neuropathies. Magnetic resonance imaging is the modality of choice for evaluating the brachial plexus, however, the use of ultrasound for its evaluation has increased and has been shown to be an additional reliable method. We aimed to compare the cross-sectional areas of the C5, C6, and C7 nerve roots of the brachial plexus, at the interscalene groove, in asymptomatic patients with T2D to that of an asymptomatic control cohort without T2D. A total of 25 asymptomatic patients with T2D were recruited from outpatient clinics. A total of 18 asymptomatic subjects without T2D were also recruited from hospital staff volunteers to form the control cohort. High-resolution ultrasound imaging of the bilateral C5, C6, and C7 nerve roots of the brachial plexus was performed in the short axis, at the level of the interscalene grooves. The nerve root cross-sectional areas were recorded and compared. In the patients with T2D, HbA1c and fasting blood glucose (FBG) levels were obtained as well as the duration of T2D in years and correlated with cross-sectional areas. The cross-sectional areas of C6 and C7 were significantly smaller in the T2D cohort. Additionally, HbA1c, and FBG levels as well as the duration of T2D were negatively correlated with the C5, C6, and C7 cross-sectional areas. Our study demonstrated smaller brachial plexus nerve root cross-sectional areas in asymptomatic patients with T2D which negatively correlated with HbA1c, and FBG levels as well as the duration of T2D.
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Affiliation(s)
- Mamdouh Ali Kotb
- Department of Internal Medicine, Prince Sattam Bin Abdulaziz University, College of Medicine, Al-Kharj, Kingdom of Saudi Arabia
- Neurology Department, Faculty of Medicine, Minia University, Minia, Egypt
| | - Mohamed A. Bedewi
- Department of Internal Medicine, Prince Sattam Bin Abdulaziz University, College of Medicine, Al-Kharj, Kingdom of Saudi Arabia
| | - Daifallah Mohamed Almalki
- Department of Internal Medicine, Prince Sattam Bin Abdulaziz University, College of Medicine, Al-Kharj, Kingdom of Saudi Arabia
| | - Ali Abdullah AlAseeri
- Department of Internal Medicine, Prince Sattam Bin Abdulaziz University, College of Medicine, Al-Kharj, Kingdom of Saudi Arabia
| | - Kholoud J. Sandougah
- Department of Medicine, College of Medicine, Al Imam Mohammed Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Steven B. Soliman
- Division of Musculoskeletal Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI
| | - Nasser M. Aldossary
- Department of Internal Medicine, Prince Sattam Bin Abdulaziz University, College of Medicine, Al-Kharj, Kingdom of Saudi Arabia
| | - Wael Hamed Aboulela
- Neurosurgery Department, Faculty of Medicine, Minia University, Minia, Egypt
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Skolka M, Shelly S, Pinto MV, Dubey D, Oishi T, Uhm JH, Santilli A, Staff NP, Spinner RJ, Dyck PJB, Robertson CE, Klein CJ. Clinical, Neurophysiologic, and Pathologic Features in Patients With Early-Onset Postradiation Neuropathy. Neurology 2023; 101:e1455-e1460. [PMID: 37400240 PMCID: PMC10573132 DOI: 10.1212/wnl.0000000000207545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 05/05/2023] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVES The objective of this study was to study early-onset radiation-induced neuropathy reviewing neurologic course, steroid response, and available nerve biopsies. METHODS Patients coded with radiation-induced neuropathy within 6 months of radiation were reviewed from January 1,1999, to August 31, 2022. Patients had to have electrodiagnostically confirmed neuropathy localized within or distal to radiation fields. Neurologic course and nerve biopsies were reviewed. RESULTS Twenty-eight patients (16 male and 12 female patients, mean age 63.8 years) were identified. The average radiation dose was 4,659 cGy (range 1,000-7,208). Tumor infiltration was not observed on MRI and PET. Postradiation onsets averaged 2 months (range 0-5). Localizations included brachial (n = 4) plexopathies, lumbosacral (n = 12) plexopathies, radiculopathies (n = 10), and mononeuropathies (n = 2). Neuropathic pain (n = 25) and weakness (n = 25) were typical. The clinical courses were subacute monophasic (n = 14), chronic progressive (n = 8), or static (n = 1), and 5 were without follow-up. Nerve biopsies (n = 8) showed an inflammatory ischemic process with perivascular inflammatory infiltrates (n = 7) or microvasculitis (n = 2). Nine patients, 7 with monophasic courses, received steroid burst therapy with symptom improvement in 8. No patients recovered entirely back to baseline. DISCUSSION In contrast to chronic radiation-induced neuropathy, early-onset patients most commonly have painful monophasic courses with residual deficits, possibly steroid responsive. An ischemic inflammatory pathogenesis is suggested.
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Affiliation(s)
- Michael Skolka
- From the Department of Neurology (M.S., M.V.P., D.D., T.O., J.H.U., A.S., N.P.S., P.J.B.D., C.E.R., C.J.K.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.), Rambam Health Care Clinic, Haifa, Israel; Department of Neurosurgery (R.J.S.); and Department of Laboratory Medicine and Pathology (C.J.K.), Mayo Clinic, Rochester, MN
| | - Shahar Shelly
- From the Department of Neurology (M.S., M.V.P., D.D., T.O., J.H.U., A.S., N.P.S., P.J.B.D., C.E.R., C.J.K.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.), Rambam Health Care Clinic, Haifa, Israel; Department of Neurosurgery (R.J.S.); and Department of Laboratory Medicine and Pathology (C.J.K.), Mayo Clinic, Rochester, MN
| | - Marcus V Pinto
- From the Department of Neurology (M.S., M.V.P., D.D., T.O., J.H.U., A.S., N.P.S., P.J.B.D., C.E.R., C.J.K.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.), Rambam Health Care Clinic, Haifa, Israel; Department of Neurosurgery (R.J.S.); and Department of Laboratory Medicine and Pathology (C.J.K.), Mayo Clinic, Rochester, MN
| | - Divyanshu Dubey
- From the Department of Neurology (M.S., M.V.P., D.D., T.O., J.H.U., A.S., N.P.S., P.J.B.D., C.E.R., C.J.K.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.), Rambam Health Care Clinic, Haifa, Israel; Department of Neurosurgery (R.J.S.); and Department of Laboratory Medicine and Pathology (C.J.K.), Mayo Clinic, Rochester, MN
| | - Tatsuya Oishi
- From the Department of Neurology (M.S., M.V.P., D.D., T.O., J.H.U., A.S., N.P.S., P.J.B.D., C.E.R., C.J.K.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.), Rambam Health Care Clinic, Haifa, Israel; Department of Neurosurgery (R.J.S.); and Department of Laboratory Medicine and Pathology (C.J.K.), Mayo Clinic, Rochester, MN
| | - Joon H Uhm
- From the Department of Neurology (M.S., M.V.P., D.D., T.O., J.H.U., A.S., N.P.S., P.J.B.D., C.E.R., C.J.K.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.), Rambam Health Care Clinic, Haifa, Israel; Department of Neurosurgery (R.J.S.); and Department of Laboratory Medicine and Pathology (C.J.K.), Mayo Clinic, Rochester, MN
| | - Ashley Santilli
- From the Department of Neurology (M.S., M.V.P., D.D., T.O., J.H.U., A.S., N.P.S., P.J.B.D., C.E.R., C.J.K.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.), Rambam Health Care Clinic, Haifa, Israel; Department of Neurosurgery (R.J.S.); and Department of Laboratory Medicine and Pathology (C.J.K.), Mayo Clinic, Rochester, MN
| | - Nathan P Staff
- From the Department of Neurology (M.S., M.V.P., D.D., T.O., J.H.U., A.S., N.P.S., P.J.B.D., C.E.R., C.J.K.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.), Rambam Health Care Clinic, Haifa, Israel; Department of Neurosurgery (R.J.S.); and Department of Laboratory Medicine and Pathology (C.J.K.), Mayo Clinic, Rochester, MN
| | - Robert J Spinner
- From the Department of Neurology (M.S., M.V.P., D.D., T.O., J.H.U., A.S., N.P.S., P.J.B.D., C.E.R., C.J.K.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.), Rambam Health Care Clinic, Haifa, Israel; Department of Neurosurgery (R.J.S.); and Department of Laboratory Medicine and Pathology (C.J.K.), Mayo Clinic, Rochester, MN
| | - P James B Dyck
- From the Department of Neurology (M.S., M.V.P., D.D., T.O., J.H.U., A.S., N.P.S., P.J.B.D., C.E.R., C.J.K.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.), Rambam Health Care Clinic, Haifa, Israel; Department of Neurosurgery (R.J.S.); and Department of Laboratory Medicine and Pathology (C.J.K.), Mayo Clinic, Rochester, MN
| | - Carrie Elizabeth Robertson
- From the Department of Neurology (M.S., M.V.P., D.D., T.O., J.H.U., A.S., N.P.S., P.J.B.D., C.E.R., C.J.K.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.), Rambam Health Care Clinic, Haifa, Israel; Department of Neurosurgery (R.J.S.); and Department of Laboratory Medicine and Pathology (C.J.K.), Mayo Clinic, Rochester, MN
| | - Christopher J Klein
- From the Department of Neurology (M.S., M.V.P., D.D., T.O., J.H.U., A.S., N.P.S., P.J.B.D., C.E.R., C.J.K.), Mayo Clinic, Rochester, MN; Department of Neurology (S.S.), Rambam Health Care Clinic, Haifa, Israel; Department of Neurosurgery (R.J.S.); and Department of Laboratory Medicine and Pathology (C.J.K.), Mayo Clinic, Rochester, MN.
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Elafros MA, Callaghan BC. Diabetic Neuropathies. Continuum (Minneap Minn) 2023; 29:1401-1417. [PMID: 37851036 PMCID: PMC11088946 DOI: 10.1212/con.0000000000001291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE This article provides an up-to-date review of the diagnosis and management of the most common neuropathies that occur in patients with diabetes. LATEST DEVELOPMENTS The prevalence of diabetes continues to grow worldwide and, as a result, the burden of diabetic neuropathies is also increasing. Most diabetic neuropathies are caused by hyperglycemic effects on small and large fiber nerves, and glycemic control in individuals with type 1 diabetes reduces neuropathy prevalence. However, among people with type 2 diabetes, additional factors, particularly metabolic syndrome components, play a role and should be addressed. Although length-dependent distal symmetric polyneuropathy is the most common form of neuropathy, autonomic syndromes, particularly cardiovascular autonomic neuropathy, are associated with increased mortality, whereas lumbosacral radiculoplexus neuropathy and treatment-induced neuropathy cause substantial morbidity. Recent evidence-based guidelines have updated the recommended treatment options to manage pain associated with distal symmetric polyneuropathy of diabetes. ESSENTIAL POINTS Identifying and appropriately diagnosing the neuropathies of diabetes is key to preventing progression. Until better disease-modifying therapies are identified, management remains focused on diabetes and metabolic risk factor control and pain management.
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Davies JL, Lodermeier KA, Klein DM, Carter RE, Dyck PJB, Litchy WJ, Dyck PJ. Composite nerve conduction scores and signs for diagnosis and somatic staging of diabetic polyneuropathy: Mid North American ethnic cohort survey. Muscle Nerve 2023; 68:29-38. [PMID: 36734298 PMCID: PMC10272036 DOI: 10.1002/mus.27793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023]
Abstract
INTRODUCTION/AIMS In the Diabetes Control and Complications Trial (DCCT), the minimal nerve conduction (NC) criterion for diabetic sensorimotor polyneuropathy (DSPN) was abnormality of NC in more than one peripheral nerve without specifying the attributes of NCs to be evaluated. In the present study, we assess individual and composite scores of NCs meeting the DCCT criterion and signs for improved diagnosis and assessment of DSPN severity. METHODS Evaluated were 13 attributes and 6 composite NC scores and signs and symptoms in 395 healthy subjects (HS) and 388 persons with diabetes (DM). RESULTS Percent abnormality between subjects with DM and HS was remarkably different among individual attributes and the six composite NC scores. For diagnosis of DSPN using the DCCT criterion, assessment of conduction velocities (CVs) and distal latencies (DLs) provided sensitive diagnoses of DSPN. NC amplitudes provided stronger measures of severity. In studied cohorts, DSPN was staged: N0, no NC abnormality using NC score 2 (CVs and DLs), 60.0%; N1, NC abnormality only, 18.4%; N2, NC abnormality and signs of feet or legs, 16.3%; and N3, NC abnormality and signs of thighs, 5.3%. DISCUSSION For sensitive and standard diagnosis of DSPN using the DCCT NC criterion, specifically defined composite scores of CVs and DLs, e.g., score 2, is recommended. A composite score of amplitudes, e.g., score 4, provides a stronger measure of neuropathy severity. Also, provided are HS reference values of evaluated attributes of NCs and estimates of staged severity of DSPN of mid North American DM cohorts.
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11
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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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12
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Younger DS. Adult and childhood vasculitis. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:653-705. [PMID: 37562892 DOI: 10.1016/b978-0-323-98818-6.00008-x] [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
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability, making this a disorder of paramount importance to all clinicians. There has been remarkable progress in the pathogenesis, diagnosis, and treatment of primary CNS and PNS vasculitides, predicated on achievement in primary systemic forms. Primary neurological vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible. Clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, unfortunately without the benefit of RCTs, and tempered by the recognition of anticipated medication side effects. It may be said that efforts to define a disease are attempts to understand the very concept of the disease. This has been especially evident in systemic and neurological disorders associated with vasculitis. For the past 100 years, since the first description of granulomatous angiitis of the brain, the CNS vasculitides have captured the attention of generations of clinical investigators around the globe to reach a better understanding of vasculitides involving the central and peripheral nervous system. Since that time it has become increasingly evident that this will necessitate an international collaborative effort.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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13
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Wang P, Liu B, Rong T, Wu B. Is diabetes the risk factor for poor neurological recovery after cervical spine surgery? A review of the literature. Eur J Med Res 2022; 27:263. [PMID: 36419189 PMCID: PMC9686083 DOI: 10.1186/s40001-022-00879-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 11/01/2022] [Indexed: 11/25/2022] Open
Abstract
The poor prognosis of cervical spine surgery is mainly manifested as poor neurological recovery and the presence of new upper extremity dysfunction that promotes significant psychological and physiological burdens on patients. Many factors influence the prognosis of cervical spine surgery, including the age of patients, the time and mode of surgery, and the surgical technique used. However, in clinical studies, it has been observed that patients with diabetes have a higher probability of poor prognosis after surgery. Therefore, we review the pathophysiology of diabetic neuropathies and discuss its impact on cervical nerve system function, especially in cervical nerve roots and upper limb peripheral nerve conduction.
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14
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Fukami Y, Koike H, Katsuno M. Current perspectives on the diagnosis, assessment, and management of vasculitic neuropathy. Expert Rev Neurother 2022; 22:941-952. [PMID: 36609209 DOI: 10.1080/14737175.2022.2166831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Vasculitic neuropathy can present associated with both primary and secondary systemic vasculitis as a result from underlying diseases such as rheumatic diseases and infections, Moreover, confined vasculitis in the peripheral nervous system may be present. Thus, the diagnosis and management of vasculitic neuropathy require multidisciplinary approaches. AREAS COVERED Current views as well as relevant clinical research on the diagnosis, assessment, and management of vasculitic neuropathy are reviewed to suggest appropriate treatment strategies. We searched PubMed and Google Scholar for reports published between July 2017 and July 2022. EXPERT OPINION For the treatment of vasculitic neuropathy, determining the causative primary disease is important and often requires diagnosis by tissue biopsy. Due to the scarce research on the treatment of vasculitic neuropathy, treatment is empirically based on findings from studies of systemic vasculitides involving other organs, particularly antineutrophil cytoplasmic antibody-associated vasculitis. In addition to conventional glucocorticoids and immunosuppressive agents, complement-targeted therapy, anti-B-cell therapy, and disease-specific molecular targeted therapies have recently gained relevance. Future research is needed to develop new patient-specific therapeutic options.
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Affiliation(s)
- Yuki Fukami
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Clinical Research Education, Nagoya University Graduate School of Medicine, Nagoya, Japan
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15
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Rajabally YA. Contemporary challenges in the diagnosis and management of chronic inflammatory demyelinating polyneuropathy. Expert Rev Neurother 2022; 22:89-99. [PMID: 35098847 DOI: 10.1080/14737175.2022.2036125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Despite extensive research, multiple inter-related diagnostic and management challenges remain for chronic inflammatory demyelinating polyneuropathy (CIDP). AREAS COVERED A literature review was performed on diagnosis and treatment in CIDP. The clinical features and disease course were evaluated. Investigative techniques, including electrophysiology, cerebrospinal fluid examination, neuropathology, imaging and neuroimmunology, were considered in relation to technical aspects, sensitivity, specificity, availability and cost. Available evidenced-based treatments and those with possible efficacy despite lack of evidence, were considered, as well as current methods for evaluation of treatment effects. EXPERT OPINION CIDP remains a clinical diagnosis, supported first and foremost by electrophysiology. Other investigative techniques have limited impact. Most patients with CIDP respond to available first-line treatments and immunosuppression may be efficacious in those who do not. Consideration of the natural history and of the high reported remission rate, of under-recognised associated disabling features, of treatment administration modalities and assessment methods, require enhanced attention.
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Affiliation(s)
- Yusuf A Rajabally
- Inflammatory Neuropathy Clinic, Department of Neurology, University Hospitals Birmingham, Birmingham, UK.,Aston Medical School, Aston University, Birmingham, UK
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16
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Chen W, Wu X, Li S, Zhang Y, Huang Y, Zhuang Y, Bai X, Chen X, Lin X. Optical coherence tomography of the retina combined with color Doppler ultrasound of the tibial nerve in the diagnosis of diabetic peripheral neuropathy. Front Endocrinol (Lausanne) 2022; 13:938659. [PMID: 36339439 PMCID: PMC9634106 DOI: 10.3389/fendo.2022.938659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 10/03/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To investigate the value of the retinal nerve fiber layer (RNFL) thickness in the optic disc and the cross-sectional area (CSA) of lower limb nerves in the diagnosis of diabetic peripheral neuropathy (DPN) separately and in combination. METHODS A total of 140 patients with type 2 diabetes were enrolled, including 51 patients with DPN (DPN group) and 89 patients without DPN (NDPN group). Clinical data and biochemical parameters were collected. Electromyography/evoked potential instrument was performed for nerve conduction study. Optical coherence tomography was performed to measure the RNFL thickness of the optic disc. Color Doppler ultrasound was performed to measure CSA of lower limb nerves. RESULTS The RNFL thickness was lower and the CSA of the tibial nerve (TN) in the DPN group was larger than that in the NDPN group. The album/urine creatinine ratio, diabetic retinopathy, and CSA of TN at 3 cm were positively correlated with DPN. The RNFL thickness in the superior quadrant of the optic disc was negatively correlated with DPN. For RNFL thickness to diagnose DPN, the area under the curve (AUC) of the superior quadrant was the largest, which was 0.723 (95% confidence interval [CI]: 0.645-0.805), and the best cutoff value was 127.5 μm (70.5% sensitivity, 72.1% specificity). For CSA of TN to diagnose DPN, the AUC of the distance of 5 cm was the largest, which was 0.660 (95% CI: 0.575-0.739), and the best cutoff value was 13.50 mm2 (82.0% sensitivity, 41.6% specificity). For the combined index, the AUC was greater than that of the above two indicators, which was 0.755 (95% CI: 0.664-0.846), and the best cutoff value was 0.376 (64.3% sensitivity, 83.0% specificity). CONCLUSIONS Patients with DPN have a reduction of the RNFL thickness and an increase in the CSA of TN, and these two changes are related to DPN. The RNFL thickness of the optic disc and the CSA of TN can be used as diagnostic indicators of DPN, and the combination of the two indicators has a higher diagnostic value.
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Affiliation(s)
- Weimiao Chen
- Department of Clinical Nutrition, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
- *Correspondence: Xiahong Lin, ; ; Weimiao Chen,
| | - Xiaohong Wu
- Department of Endocrinology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Shilin Li
- Department of Ultrasound, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yan Zhang
- Department of Ophthalmology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yinqiong Huang
- Department of Endocrinology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yong Zhuang
- Department of Endocrinology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xuefeng Bai
- Department of Endocrinology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xiaoyu Chen
- Department of Endocrinology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Xiahong Lin
- Department of Endocrinology, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
- Department of Geriatric Medicine, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
- *Correspondence: Xiahong Lin, ; ; Weimiao Chen,
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17
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Baum P, Toyka KV, Blüher M, Kosacka J, Nowicki M. Inflammatory Mechanisms in the Pathophysiology of Diabetic Peripheral Neuropathy (DN)-New Aspects. Int J Mol Sci 2021; 22:10835. [PMID: 34639176 PMCID: PMC8509236 DOI: 10.3390/ijms221910835] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/30/2021] [Accepted: 10/04/2021] [Indexed: 12/15/2022] Open
Abstract
The pathogenesis of diabetic neuropathy is complex, and various pathogenic pathways have been proposed. A better understanding of the pathophysiology is warranted for developing novel therapeutic strategies. Here, we summarize recent evidence from experiments using animal models of type 1 and type 2 diabetes showing that low-grade intraneural inflammation is a facet of diabetic neuropathy. Our experimental data suggest that these mild inflammatory processes are a likely common terminal pathway in diabetic neuropathy associated with the degeneration of intraepidermal nerve fibers. In contrast to earlier reports claiming toxic effects of high-iron content, we found the opposite, i.e., nutritional iron deficiency caused low-grade inflammation and fiber degeneration while in normal or high non-heme iron nutrition no or only extremely mild inflammatory signs were identified in nerve tissue. Obesity and dyslipidemia also appear to trigger mild inflammation of peripheral nerves, associated with neuropathy even in the absence of overt diabetes mellitus. Our finding may be the experimental analog of recent observations identifying systemic proinflammatory activity in human sensorimotor diabetic neuropathy. In a rat model of type 1 diabetes, a mild neuropathy with inflammatory components could be induced by insulin treatment causing an abrupt reduction in HbA1c. This is in line with observations in patients with severe diabetes developing a small fiber neuropathy upon treatment-induced rapid HbA1c reduction. If the inflammatory pathogenesis could be further substantiated by data from human tissues and intervention studies, anti-inflammatory compounds with different modes of action may become candidates for the treatment or prevention of diabetic neuropathy.
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Affiliation(s)
- Petra Baum
- Department of Neurology, University of Leipzig, Liebigstraße 20, D-04103 Leipzig, Germany;
| | - Klaus V. Toyka
- Department of Neurology, University of Würzburg, Josef-Schneider-Str. 11, D-97080 Würzburg, Germany;
| | - Matthias Blüher
- Department of Medicine, University of Leipzig, Liebigstraße 20, D-04103 Leipzig, Germany;
| | - Joanna Kosacka
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University of Leipzig, D-04103 Leipzig, Germany;
| | - Marcin Nowicki
- Institute of Anatomy, University of Leipzig, Liebigstraße 13, D-04103 Leipzig, Germany
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18
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Kim W, Kang SH, An JY. Posterior Interosseous Fascicular Constriction Within the Radial Nerve in a Diabetic Patient With Bilateral Neuralgic Amyotrophy: A Case Report. Front Neurol 2021; 12:701571. [PMID: 34566846 PMCID: PMC8457354 DOI: 10.3389/fneur.2021.701571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/09/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Neuralgic amyotrophy (NA) is an acute, monophasic, painful inflammatory dysimmune focal, or multifocal mononeuropathy. The lesion in NA is not always restricted to the brachial plexus but also involves individual nerves or branches. The prognosis of NA is less favorable than previously assumed, but the reasons for poor recovery remain unknown. Nerve constriction may be one of the causes of poor prognosis in NA. Case Presentation: Herein, we described a 54-year-old male with a history of type 2 diabetes in whom bilateral neuralgic amyotrophy developed with constriction of the posterior interosseous fascicle within the radial nerve. The patient experienced sudden-onset severe pain in both shoulders followed, 2 days later, by weakness in bilateral shoulders and the left forearm extensors over the subsequent month. The left forearm extensors were more severely affected than both shoulder girdle muscles. He noted a 7-kg weight loss for 1 month before pain onset. After diagnosing diabetic NA based on the clinical symptoms, imaging, and electrophysiological studies, treatment with systemic steroids improved pain and weakness in both shoulder muscles. Weakness in the left forearm extensors persisted after 1 month of steroid treatment. Follow-up ultrasound revealed constriction of the posterior interosseous fascicle within the main trunk of the left radial nerve at the elbow. Surgical exploration at 6 months after onset identified fascicle constriction, for which neurolysis was performed. Weakness in the extensors of the wrist and fingers did not improve during the 16-month follow-up. Conclusion: A single constriction of the fascicle within a peripheral nerve may often be under-recognized if NA presents with variable degrees of weakness in bilateral upper limbs. Furthermore, fascicular constriction without edema of the parent nerve may be easily missed on the initial ultrasound. A lack of early recognition of nerve constriction and delay in surgical intervention can result in unfavorable outcomes. The physician should consider the possibility of the fascicular constriction when evaluating patients suspected of brachial NA with significant weakness in the distal upper limb compared to the proximal weakness or weakness of the distal upper limb that does not improve over time.
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Affiliation(s)
- Woojun Kim
- Department of Neurology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Soo Hwan Kang
- Department of Orthopedic Surgery, College of Medicine, St. Vincent's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Jae Young An
- Department of Neurology, College of Medicine, St. Vincent's Hospital, The Catholic University of Korea, Seoul, South Korea
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19
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Samakidou G, Eleftheriadou I, Tentolouris A, Papanas N, Tentolouris N. Rare diabetic neuropathies: It is not only distal symmetrical polyneuropathy. Diabetes Res Clin Pract 2021; 177:108932. [PMID: 34216680 DOI: 10.1016/j.diabres.2021.108932] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/12/2021] [Accepted: 06/20/2021] [Indexed: 11/25/2022]
Abstract
The prevalence of diabetes mellitus is increasing at an epidemic level, leading to a consequent increase of its chronic complications, including neuropathy. Diabetic neuropathy constitutes a heterogeneous group of disorders with distinct clinical presentations and pathophysiological mechanisms. These distinct forms may be categorised according to their clinical presentation as symmetrical (distal symmetrical polyneuropathy, autonomic and acute sensory neuropathy) and focal or multifocal (radiculoplexus neuropathies, entrapment syndromes, cranial palsies and other mononeuropathies). Additionally, people with diabetes may have neuropathies due to causes other than diabetes. The commonest forms of diabetic neuropathy are distal symmetrical polyneuropathy and autonomic neuropathy. However, clinicians should be aware that people with diabetes may suffer from less common forms of neuropathy and should be able to recognise their symptoms and signs. The recognition of the rare diabetic neuropathies is crucial, as they often lead to different clinical outcomes and require different management. The aim of the present narrative, non-systematic review is to outline the rare types of diabetic neuropathies.
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Affiliation(s)
- Georgia Samakidou
- Diabetes Centre, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Ioanna Eleftheriadou
- Diabetes Centre, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Anastasios Tentolouris
- Diabetes Centre, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Nikolaos Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Nikolaos Tentolouris
- Diabetes Centre, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece.
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20
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Han CY, Tarr AM, Gewirtz AN, Kaunzner UW, Roy-Burman P, Cutler TS, MacGowan DJ. Brachial plexopathy as a complication of COVID-19. BMJ Case Rep 2021; 14:e237459. [PMID: 33766961 PMCID: PMC8006770 DOI: 10.1136/bcr-2020-237459] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 12/23/2022] Open
Abstract
COVID-19 affects a wide spectrum of organ systems. We report a 52-year-old man with hypertension and newly diagnosed diabetes mellitus who presented with hypoxic respiratory failure due to COVID-19 and developed severe brachial plexopathy. He was not treated with prone positioning respiratory therapy. Associated with the flaccid, painfully numb left upper extremity was a livedoid, purpuric rash on his left hand and forearm consistent with COVID-19-induced microangiopathy. Neuroimaging and electrophysiological data were consistent with near diffuse left brachial plexitis with selective sparing of axillary, suprascapular and pectoral fascicles. Given his microangiopathic rash, elevated D-dimers and paucifascicular plexopathy, we postulate a patchy microvascular thrombotic plexopathy. Providers should be aware of this significant and potentially under-recognised neurologic complication of COVID-19.
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Affiliation(s)
| | - Andrew M Tarr
- Neurology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York City, New York, USA
| | - Alexandra N Gewirtz
- Neurology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York City, New York, USA
| | | | - Paula Roy-Burman
- Medicine, Weill Cornell Medical College, New York City, New York, USA
| | - Todd S Cutler
- Medicine, Weill Cornell Medical College, New York City, New York, USA
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21
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Pinto MV, Ng PS, Howe BM, Laughlin RS, Thapa P, Dyck PJ, Dyck PJB. Lumbosacral Radiculoplexus Neuropathy: Neurologic Outcomes and Survival in a Population-Based Study. Neurology 2021; 96:e2098-e2108. [PMID: 33653898 DOI: 10.1212/wnl.0000000000011799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/19/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether patients in the community with lumbosacral radiculoplexus neuropathy (LRPN) have milder neuropathy than referral patients, we characterized the outcomes and survival of population-based compared to referral-based LRPN cohorts. BACKGROUND Previously, we found that the incidence of LRPN is 4.16/100,000/y, a frequency greater than other inflammatory neuropathies. The survival of patients with LRPN is uncharacterized. METHODS Sixty-two episodes in 59 patients with LRPN were identified over 16 years (2000-2015). Clinical findings were compared to previous referral-based LRPN cohorts. Survival data were compared to those of age- and sex-matched controls. RESULTS At LRPN diagnosis, median age was 70 years, median Neuropathy Impairment Score (NIS) 22 points, 92% had pain, 95% had weakness, 23% were wheelchair-bound, and median modified Rankin Scale score (mRS) was 3 (range 1-4). At last follow-up, median NIS improved to 17 points (p < 0.001) with 56% having ≥4 points improvement, 16% were wheelchair-bound, and median mRS was 2. Compared to referral-based LRPN cohorts, community patients with LRPN had less impairment, less bilateral disease (37% vs 92%), and less wheelchair usage (23% vs 49%). LRPN survival was 86% at 5 years and 55% at 10 years. Compared to age- and sex-matched controls, patients with LRPN had 76% increased risk of death (p = 0.016). In multivariate analysis, diabetes, age, stroke, chronic kidney disease, peripheral artery disease, and coronary artery disease were significant mortality risk factors but LRPN was not. CONCLUSION LRPN is a painful, paralytic, asymmetric, monophasic, sometimes bilateral pan-plexopathy that improves over time but leaves patients with impairment. Although having LRPN increases mortality, this increase is probably due to comorbidities (diabetes) rather than LRPN itself.
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Affiliation(s)
- Marcus V Pinto
- From the Departments of Neurology (M.V.P., R.S.L., P.J.D., P.J.B.D.), Radiology (B.M.H.), and Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN; and Department of Neurology, National Neuroscience Institute (P.-S.N.), Singapore
| | - Peng-Soon Ng
- From the Departments of Neurology (M.V.P., R.S.L., P.J.D., P.J.B.D.), Radiology (B.M.H.), and Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN; and Department of Neurology, National Neuroscience Institute (P.-S.N.), Singapore
| | - Benjamin M Howe
- From the Departments of Neurology (M.V.P., R.S.L., P.J.D., P.J.B.D.), Radiology (B.M.H.), and Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN; and Department of Neurology, National Neuroscience Institute (P.-S.N.), Singapore
| | - Ruple S Laughlin
- From the Departments of Neurology (M.V.P., R.S.L., P.J.D., P.J.B.D.), Radiology (B.M.H.), and Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN; and Department of Neurology, National Neuroscience Institute (P.-S.N.), Singapore
| | - Prabin Thapa
- From the Departments of Neurology (M.V.P., R.S.L., P.J.D., P.J.B.D.), Radiology (B.M.H.), and Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN; and Department of Neurology, National Neuroscience Institute (P.-S.N.), Singapore
| | - Peter J Dyck
- From the Departments of Neurology (M.V.P., R.S.L., P.J.D., P.J.B.D.), Radiology (B.M.H.), and Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN; and Department of Neurology, National Neuroscience Institute (P.-S.N.), Singapore.
| | - P James B Dyck
- From the Departments of Neurology (M.V.P., R.S.L., P.J.D., P.J.B.D.), Radiology (B.M.H.), and Biomedical Statistics and Informatics (P.T.), Mayo Clinic, Rochester, MN; and Department of Neurology, National Neuroscience Institute (P.-S.N.), Singapore.
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22
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Kesserwani H. Severe Post-Herpetic Lumbar Plexopathy Responds to Pulse Intravenous Methylprednisolone: A Case Report With a Side Note on its Parallel Semiology to Diabetic Radiculoplexopathy and the Vascular Invasiveness of the Varicella-Zoster Virus. Cureus 2020; 12:e12171. [PMID: 33489582 PMCID: PMC7813428 DOI: 10.7759/cureus.12171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Post-herpetic lumbar plexopathy (post-herpetic segmental paresis), immune-mediated lumbar plexopathy and diabetic radiculoplexopathy (diabetic amyotrophy) have similar and seemingly parallel semiologies. The latter two conditions have an underlying microvasculitic pathological substrate that has shown potential (yet unproven) amelioration with immunodulatory therapy. These observations gave us the motivation to treat our patient with intravenous methylprednisolone for a profound proximal left leg weakness due to post-herpetic segmental paresis. In this case report, we outline in detail the clinical and electophysiolgical phenotype of this disease and we demonstrate the spectacular improvement of left leg power that had previously remained static for three months. In the discussion section, we review the vascular invasiveness of the varicella-zoster virus.
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Karam C. Peripheral Neuropathies Associated With Vasculitis and Autoimmune Connective Tissue Disease. ACTA ACUST UNITED AC 2020; 26:1257-1279. [PMID: 33003001 DOI: 10.1212/con.0000000000000917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article discusses peripheral neuropathies associated with vasculitis (isolated or in the setting of systemic vasculitis) and autoimmune connective tissue disease and provides a brief overview of their diagnostic evaluation and management. RECENT FINDINGS The classification of systemic vasculitic neuropathy and nonsystemic vasculitic neuropathy continues to evolve. Classification according to the presence of antineutrophil cytoplasmic antibodies and their subtypes facilitates prognostication and management. Recent research on antineutrophil cytoplasmic antibody-associated vasculitis has added to our understanding of its neurologic complications. The treatment of vasculitis is also evolving, and new nonsystemic vasculitic neuropathy classification has impacted the treatment and management of this disorder. New classification criteria for Sjögren syndrome (which commonly causes neurologic complications) facilitate accurate and timely diagnosis. SUMMARY Vasculitis and autoimmune connective tissue disease are underrecognized and treatable causes of peripheral neuropathy. Furthermore, peripheral neuropathy may reveal an underlying rheumatologic or vasculitic disorder. Rapid recognition and treatment are essential. Familiarity with the diagnosis and treatment of neuropathies in the setting of connective tissue disease and vasculitis reduces morbidity and, in some cases, mortality.
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Gstoettner C, Mayer JA, Rassam S, Hruby LA, Salminger S, Sturma A, Aman M, Harhaus L, Platzgummer H, Aszmann OC. Neuralgic amyotrophy: a paradigm shift in diagnosis and treatment. J Neurol Neurosurg Psychiatry 2020; 91:879-888. [PMID: 32487526 DOI: 10.1136/jnnp-2020-323164] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 05/07/2020] [Accepted: 05/10/2020] [Indexed: 01/22/2023]
Abstract
Neuralgic amyotrophy (NA), also known as Parsonage-Turner syndrome, is characterised by sudden pain attacks, followed by patchy muscle paresis in the upper extremity. Recent reports have shown that incidence is much higher than previously assumed and that the majority of patients never achieve full recovery. Traditionally, the diagnosis was mainly based on clinical observations and treatment options were confined to application of corticosteroids and symptomatic management, without proven positive effects on long-term outcomes. These views, however, have been challenged in the last years. Improved imaging methods in MRI and high-resolution ultrasound have led to the identification of structural peripheral nerve pathologies in NA, most notably hourglass-like constrictions. These pathognomonic findings have paved the way for more accurate diagnosis through high-resolution imaging. Furthermore, surgery has shown to improve clinical outcomes in such cases, indicating the viability of peripheral nerve surgery as a valuable treatment option in NA. In this review, we present an update on the current knowledge on this disease, including pathophysiology and clinical presentation, moving on to diagnostic and treatment paradigms with a focus on recent radiological findings and surgical reports. Finally, we present a surgical treatment algorithm to support clinical decision making, with the aim to encourage translation into day-to-day practice.
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Affiliation(s)
- Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Johannes A Mayer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department for Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tuebingen at the Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Stephanie Rassam
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department of General, Visceral, Endocrine and Transplantation Surgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Laura A Hruby
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Salminger
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department of Bioengineering, Imperial College London, London, UK
| | - Martin Aman
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Department of Hand, Plastic and Reconstructive Surgery, Burn Center-Hand and Plastic Surgery, University of Heidelberg, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Leila Harhaus
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center-Hand and Plastic Surgery, University of Heidelberg, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Hannes Platzgummer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria .,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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Patel K, Horak H, Tiryaki E. Diabetic neuropathies. Muscle Nerve 2020; 63:22-30. [DOI: 10.1002/mus.27014] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 06/20/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Kamakshi Patel
- Department of Neurology, University of Texas Medical Branch Galveston Texas USA
| | - Holli Horak
- Department of Neurology, University of Arizona Tucson Arizona USA
| | - Ezgi Tiryaki
- Department of Neurology, University of Minnesota Minneapolis Minnesota USA
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Abstract
Diabetic lumbosacral radiculoplexus neuropathy, also known as diabetic amyotrophy, has a characteristic course of sudden onset of unilateral pain in the thigh and hip, which may spread to the other side in weeks to months and proceeds with progressive lower extremity weakness, often resulting in the inability to walk unassisted. The syndrome is typically monophasic, and most patients will recover at least to some degree. Less typical features include lack of pain, distal predominant weakness, absence of diabetes, and upper extremity involvement. This article provides a series of interesting cases to highlight the diagnostic challenges and discusses management decision making.
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Affiliation(s)
| | - Duaa Jabari
- Neuromuscular Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard MS 2012, Kansas City, KS 66160, USA
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[Causes, spectrum, and treatment of the diabetic neuropathy]. DER NERVENARZT 2020; 91:714-721. [PMID: 32647958 DOI: 10.1007/s00115-020-00948-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Half of all diabetics are affected by a diabetic neuropathy. Microangiopathy, dysfunctional Schwann cell interactions, accumulation of toxic metabolites, and inflammatory processes all contribute to nerve damage. OBJECTIVE Overview and perspectives of the pathophysiology as well as the current and future treatment implications. METHODS Literature search (1990-2020). RESULTS Clinically predominant are sensory and autonomic symptoms; however, muscle weakness can occur as well. Complications such as unrecognized myocardial infarctions and the diabetic foot syndrome are potentially life-threatening and can cause major disability. The pathophysiology of neuropathies in type 1 and type 2 diabetes mellitus differs due to additional risk factors of the metabolic syndrome. To reduce the risk of neuropathy, an intensive insulin therapy is superior compared to the conventional insulin therapy. Oral antidiabetic drugs should be chosen based on individual risk profiles. Metformin can cause an iatrogenic vitamin B12 deficiency. In the treatment of neuropathic pain, the calcium channel blocker pregabalin has the highest recommendation level. The tricyclic antidepressant amitriptyline is considered to be equally effective, but it is contraindicated in autonomic dysregulation and cognitive impairment. Alternatively, the serotonin-norepinephrine reuptake inhibitor duloxetine is approved for the symptomatic treatment of diabetic neuropathies. Controversially discussed medications include alpha-lipoic acid, epalrestat, and L‑serine. CONCLUSION The diabetic neuropathy is frequent and causes severe complications. A good understanding of the underlying pathophysiology can contribute to the development of novel treatment strategies in the future.
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Update on classification, epidemiology, clinical phenotype and imaging of the nonsystemic vasculitic neuropathies. Curr Opin Neurol 2020; 32:684-695. [PMID: 31313704 DOI: 10.1097/wco.0000000000000727] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Single-organ vasculitis of the peripheral nervous system (PNS) is often designated nonsystemic vasculitic neuropathy (NSVN). Several variants or subtypes have been distinguished, including migratory sensory neuropathy, postsurgical inflammatory neuropathy, diabetic radiculoplexus neuropathies, skin-nerve vasculitides, and, arguably, neuralgic amyotrophy. NSVN often presents as nondiabetic lumbosacral radiculoplexus neuropathy (LRPN). This review updates classification, clinical features, epidemiology, and imaging of these disorders. RECENT FINDINGS A recent study showed the annual incidence of LRPN in Olmstead County, Minnesota to be 4.16/100 000:2.79/100 000 diabetic and 1.27/100 000 nondiabetic. This study was the first to determine the incidence or prevalence of any vasculitic neuropathy. In NSVN, ultrasonography shows multifocal enlargement of proximal and distal nerves. In neuralgic amyotrophy, MRI and ultrasound reveal multifocal enlargements and focal constrictions in nerves derived from the brachial plexus. Histopathology of these chronic lesions shows inflammation and rare vasculitis. Diffusion tensor imaging of tibial nerves in NSVN revealed decreased fractional anisotropy in one study. SUMMARY Single-organ PNS vasculitides are the most common inflammatory neuropathies. Neuralgic amyotrophy might result from PNS vasculitis, but further study is necessary. The usefulness of focal nerve enlargements or constrictions in understanding pathological mechanisms, directing biopsies, and monitoring disease activity in NSVN should be further investigated.
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Sasaki H, Kawamura N, Dyck PJ, Dyck PJB, Kihara M, Low PA. Spectrum of diabetic neuropathies. Diabetol Int 2020; 11:87-96. [PMID: 32206478 PMCID: PMC7082443 DOI: 10.1007/s13340-019-00424-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 12/29/2019] [Indexed: 02/06/2023]
Abstract
The diabetic state results in neuropathy. The main causative mechanism is hyperglycemia, although microvascular involvement, hypertriglyceridemia, as well as genetic and immune mechanisms may be contributory. There is a growing spectrum of types of diabetic neuropathies that differ based on the type of fibers involved (e.g. myelinated, unmyelinated, autonomic, somatic), distribution of nerves involved, and mechanisms of neuropathy. The most common type is distal sensory neuropathy (DSN), which affects the distal ends of large myelinated fibers, more often sensory than motor, and is often asymptomatic. The next-most common is distal small fiber neuropathy (DSFN), which largely affects the unmyelinated fibers and carries the phenotype of burning feet syndrome. Diabetic autonomic neuropathy (DAN) occurs when widespread involvement of autonomic unmyelinated fibers occurs, and patients can be incapacitated with orthostatic hypotension as well as neurogenic bladder and bowel involvement. Radiculoplexus diabetic neuropathy causes proximal weakness and pain, usually in the lower extremity, and has a combination of immune, inflammatory, and vascular mechanisms. The nerve roots and plexus are involved. These patients present with proximal weakness of a subacute onset, often with severe pain and some autonomic failure. Finally, rapid and sustained reduction of blood glucose can result in treatment-induced diabetic neuropathy (TIND), which largely affects the sensory and autonomic fibers. This occurs if HbA1c is rapidly reduced within 3 months, and the likelihood is proportional to the original A1c and the size of the reduction.
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Affiliation(s)
| | | | - Peter J. Dyck
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
| | - P. James B. Dyck
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
| | | | - Phillip A. Low
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
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Abstract
PURPOSE OF REVIEW Diabetic peripheral neuropathy eventually affects nearly 50% of adults with diabetes during their lifetime and is associated with substantial morbidity including pain, foot ulcers, and lower limb amputation. This review summarizes the epidemiology, risk factors, and management of diabetic peripheral neuropathy and related lower extremity complications. RECENT FINDINGS The prevalence of peripheral neuropathy is estimated to be between 6 and 51% among adults with diabetes depending on age, duration of diabetes, glucose control, and type 1 versus type 2 diabetes. The clinical manifestations are variable, ranging from asymptomatic to painful neuropathic symptoms. Because of the risk of foot ulcer (25%) and amputation associated with diabetic peripheral neuropathy, aggressive screening and treatment in the form of glycemic control, regular foot exams, and pain management are important. There is an emerging focus on lifestyle interventions including weight loss and physical activity as well. The American Diabetes Association has issued multiple recommendation statements pertaining to diabetic neuropathies and the care of the diabetic foot. Given that approximately 50% of adults with diabetes will be affected by peripheral neuropathy in their lifetime, more diligent screening and management are important to reduce the complications and health care burden associated with the disease.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Halsted 668, Baltimore, MD, 21287, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument St., Suite 2-600, Baltimore, MD, 21287, USA.
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Galeano-Valle F, Benito-Martinez E, Álvarez-Sala-Walther L, Oprea-Ilies G, Umpierrez GE, Pasquel FJ. An atypical presentation of diabetic myonecrosis. AACE Clin Case Rep 2019; 5:e77-e81. [PMID: 31206028 DOI: 10.4158/accr-2018-0228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Diabetes myonecrosis, also called diabetic muscle infarction (DMI), is a rare complication of diabetes. Given its rarity, our understanding of the underlying causes or the optimal management of DMI cases remains unclear. Methods We report on a patient who experienced 2 episodes of DMI and we also review the literature. Results A 46-year-old male with longstanding type 2 diabetes mellitus with multiple microvascular complications presented with acute-onset painful right thigh induration. On physical examination, he had right thigh swelling, tenderness, and crepitus. Blood tests showed leukocytosis, elevated creatine phosphokinase, and elevated acute-phase reactants. Microbiological cultures were negative. Glycated hemoglobin was 6.4% (46 mmol/mol). Magnetic resonance imaging demonstrated T2 hyperintensity involving the quadriceps group. The clinical and laboratory signs suggested a muscle infection. A muscle biopsy was suggestive of DMI. Eleven months later, the patient presented again with a 4-week history of left thigh pain and weakness in both legs. On examination, he had bilateral thigh anterior tenderness without evidence of swelling or induration. He also had marked bilateral proximal motor deficiency and inability to stand or ambulate. Despite a different clinical presentation, imaging features were consistent with DMI. The patient was managed with conservative therapy. His strength improved significantly after 3 months of follow up. Conclusion The typical clinical presentation of DMI includes unilateral acute-onset pain in the quadriceps, local swelling, and the appearance of a palpable painful mass. The second episode in our patient illustrates an atypical clinical presentation of DMI and shows the importance of the correlation of clinical and imaging findings for the diagnosis of DMI.
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Affiliation(s)
- Francisco Galeano-Valle
- Department of Medicine, School of Medicine, Universidad Complutense Madrid, Spain; Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain. Instituto de investigaciones Sanitarias Gregorio Marañón
| | | | - Luis Álvarez-Sala-Walther
- Department of Medicine, School of Medicine, Universidad Complutense Madrid, Spain; Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain. Instituto de investigaciones Sanitarias Gregorio Marañón
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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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Younger DS. Cervical and Lumbosacral Radiculoplexus Neuropathy Following Influenza Vaccination. ACTA ACUST UNITED AC 2019. [DOI: 10.4236/wjns.2019.94019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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An JY, Bae DW, Walker FO. Ultrasonography in the Early Diagnosis of Diabetic Lumbosacral Radiculoplexus Neuropathy. J Clin Neurol 2019; 15:250-252. [PMID: 29856164 PMCID: PMC6444135 DOI: 10.3988/jcn.2019.15.2.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 02/22/2018] [Accepted: 02/26/2018] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jae Young An
- Department of Neurology, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Dae Woong Bae
- Department of Neurology, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Francis O. Walker
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, USA
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Llewelyn D, Llewelyn JG. Diabetic amyotrophy: a painful radiculoplexus neuropathy. Pract Neurol 2018; 19:164-167. [DOI: 10.1136/practneurol-2018-002105] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2018] [Indexed: 11/03/2022]
Abstract
Diabetic lumbosacral radiculoplexus neuropathy is a monophasic syndrome of diffuse pain and weakness that typically affects the lower limbs asymmetrically and is often associated with significant weight loss. Recovery can be prolonged and unpredictable. It is a clinical diagnosis and investigations are performed mainly to exclude other causes. Although it is most likely caused by a microvasculitis, there is no evidence to support using intravenous immunoglobulin or any long-term immunosuppression. Pulsed methylprednisolone may help pain if given within 2–3 months of symptom onset.
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Lumbosacral plexus root thickening: Establishing normal root dimensions using magnetic resonance neurography. Clin Anat 2018; 31:782-787. [DOI: 10.1002/ca.23073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 03/13/2018] [Indexed: 11/07/2022]
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Electrodiagnosis in the Patient with Metabolic Syndrome: Adding Value to Patient Care. Phys Med Rehabil Clin N Am 2018; 29:735-749. [PMID: 30293627 DOI: 10.1016/j.pmr.2018.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Patients with metabolic syndrome are at increased risk of peripheral neuropathy; entrapment neuropathies, such as carpal tunnel syndrome; and spine disease that can lead to radiculopathy or spinal stenosis. Electrodiagnostic studies are a valuable part of patient care in this population. They can confirm suspected diagnoses, uncover additional conditions, and lead to the diagnosis of other causes of neuropathy that require treatment. By assessing the severity of neuropathy, patients at high risk for falls, functional decline, and foot ulcers are identified to guide prevention, treatment, and patient education.
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Abstract
PURPOSE OF REVIEW This article describes clinical features of axonal sensorimotor polyneuropathies based on selected etiologies. RECENT FINDINGS Axonal sensorimotor polyneuropathies have been well described for some time. Recent advances include the assessment of the incidence of peripheral neuropathy in the elderly, the recognition of the limited influence of electrodiagnostic testing on the clinical management of uncomplicated axonal sensorimotor polyneuropathy, the development of guidelines for treatment of painful neuropathy, the identification of risk factors predisposing patients for chemotherapy-induced neuropathy, a report on the association of metabolic syndrome and idiopathic axonal sensorimotor neuropathy, and the availability of more cost-effective genetic testing for identifying inherited polyneuropathies. SUMMARY Axonal sensorimotor polyneuropathies carry an extensive list of differential diagnoses. Diagnosis is based on detailed history, physical examination, recognition of associated neurologic and non-neurologic features, and appropriate testing. Disease-modifying treatments are lacking in many cases. Management focuses on modification of predisposing lifestyle and medical factors, rehabilitation, and pain relief.
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Morishima R, Nagaoka U, Nagao M, Isozaki E. Chronic Brachial Plexus Neuritis That Developed into Typical Neuralgic Amyotrophy and Positively Responded to Immunotherapy. Intern Med 2018; 57:1021-1026. [PMID: 29269655 PMCID: PMC5919865 DOI: 10.2169/internalmedicine.9482-17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Based on the hypothesis that autoimmunity plays a role in the pathogenesis of neuralgic amyotrophy (NA), immunotherapy is sometimes administered. Early intervention is recommended for a good prognosis. We herein report the case of a 55-year-old man who presented with neuralgia, weakness, and muscle atrophy in his right shoulder girdle and upper arm, which progressed for ten months following a marine sports accident. The patient was diagnosed with NA. His neurological deficits gradually improved after several courses of immunotherapy, suggesting that in addition to being effective for treating early-stage disease, immunotherapy may be effective for treating chronic cases.
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Affiliation(s)
- Ryo Morishima
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Utako Nagaoka
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Masahiro Nagao
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
| | - Eiji Isozaki
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan
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Muniz Neto FJ, Kihara Filho EN, Miranda FC, Rosemberg LA, Santos DCB, Taneja AK. Demystifying MR Neurography of the Lumbosacral Plexus: From Protocols to Pathologies. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9608947. [PMID: 29662907 PMCID: PMC5832061 DOI: 10.1155/2018/9608947] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/29/2017] [Indexed: 12/14/2022]
Abstract
Magnetic resonance neurography is a high-resolution imaging technique that allows evaluating different neurological pathologies in correlation to clinical and the electrophysiological data. The aim of this article is to present a review on the anatomy of the lumbosacral plexus nerves, along with imaging protocols, interpretation pitfalls, and most common pathologies that should be recognized by the radiologist: traumatic, iatrogenic, entrapment, tumoral, infectious, and inflammatory conditions. An extensive series of clinical and imaging cases is presented to illustrate key-points throughout the article.
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Affiliation(s)
- Francisco J. Muniz Neto
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Eduardo N. Kihara Filho
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Frederico C. Miranda
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Laercio A. Rosemberg
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Durval C. B. Santos
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Atul K. Taneja
- Musculoskeletal Radiology Division, Imaging Department, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Rajabally YA, Stettner M, Kieseier BC, Hartung HP, Malik RA. CIDP and other inflammatory neuropathies in diabetes — diagnosis and management. Nat Rev Neurol 2017; 13:599-611. [DOI: 10.1038/nrneurol.2017.123] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Neuropatia nei diabetici. Neurologia 2017. [DOI: 10.1016/s1634-7072(16)81776-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Illes Z, Blaabjerg M. Cerebrospinal fluid findings in Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2017; 146:125-138. [PMID: 29110767 DOI: 10.1016/b978-0-12-804279-3.00009-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The classic immunologic alteration of the cerebrospinal fluid (CSF) in Guillain-Barré syndrome (GBS), albuminocytologic dissociation, has been known since the original paper by Guillain, Barré, and Strohl. Albuminocytologic dissociation has been also described in other forms of the GBS spectrum, such as axonal motor or motor-sensory forms (AMAN, AMSAN), the anti-GQ1b spectrum of Miller Fisher syndrome, and Bickerstaff brainstem encephalitis. Cytokines, chemokines, antibodies, complement components, and molecules with a putative neuroprotective role or indicating axonal damage have also been examined using different methods. Besides these candidate approaches, proteomics has been recently applied to discover potential biomarkers. The overall results support the immunopathogenesis of GBS, but albuminocytologic dissociation remained the only consistent CSF biomarker supporting the diagnosis of GBS. Chronic inflammatory neuropathies also comprise a heterogeneous group of diseases. Increased protein in the CSF is a supportive factor of chronic inflammatory demyelinating polyneuropathy, especially in the absence of definite electrophysiologic criteria. A number of other markers have also been investigated in the CSF of patients with chronic inflammatory neuropathies, similar to GBS. However, none has been used in supporting diagnosis, differentiating among syndromes, or predicting the clinical course and treatment responses.
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Affiliation(s)
- Zsolt Illes
- Department of Neurology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Morten Blaabjerg
- Department of Neurology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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Kotov SV, Rudakova IG, Isakova EV, Belova YA, Volchenkova TV, Khirbek M, Stashuk GA. Diabetic asymmetric proximal neuropathy. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:59-62. [DOI: 10.17116/jnevro20171171159-62] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Pop-Busui R, Boulton AJM, Feldman EL, Bril V, Freeman R, Malik RA, Sosenko JM, Ziegler D. Diabetic Neuropathy: A Position Statement by the American Diabetes Association. Diabetes Care 2017; 40:136-154. [PMID: 27999003 PMCID: PMC6977405 DOI: 10.2337/dc16-2042] [Citation(s) in RCA: 1203] [Impact Index Per Article: 171.9] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Rodica Pop-Busui
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | | | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Vera Bril
- Department of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA
| | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar and New York, NY
| | - Jay M Sosenko
- Division of Endocrinology, University of Miami Miller School of Medicine, Miami, FL
| | - Dan Ziegler
- German Diabetes Center Düsseldorf, Leibniz Center for Diabetes Research at Heinrich Heine University, and Department of Endocrinology and Diabetology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
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Kotlęga D, Gołąb-Janowska M, Zaborowski G, Ciećwież S, Nowacki P. Simultaneous acute shoulder arthritis and multiple mononeuropathy in a newly diagnosed type 2 diabetes patient - First case report. Neurol Neurochir Pol 2016; 50:474-480. [PMID: 27471096 DOI: 10.1016/j.pjnns.2016.07.003] [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: 12/25/2015] [Revised: 07/08/2016] [Accepted: 07/13/2016] [Indexed: 11/16/2022]
Abstract
Diabetes is a common disorder that leads to the musculoskeletal symptoms such as the shoulder arthritis. The involvement of peripheral nervous system is one of the troublesome for the patients as it provokes chronic sensory symptoms, lower motor neuron involvement and autonomic symptoms. In the course of the disease there has been several types of neuropathies described. A 41-year-old male patient was admitted to the internal medicine department because of the general weakness, malaise, polydypsia and polyuria since several days. The initial blood glucose level was 780mg/dl. During the first day the continuous insulin infusion was administered. On the next day when he woke up, the severe pain in the right shoulder with limited movement, right upper extremity weakness and burning pain in the radial aspect of this extremity appeared. On examination right shoulder joint movement limitation was found with the muscle weakness and sensory symptoms in the upper limbs. The clinical picture indicated on the right shoulder arthritis and the peripheral nervous system symptoms such as the right musculocutaneous, supraspinatus, right radial nerve and left radial nerve damage. We present a first case report of simultaneous, acute involvement of the shoulder joint and multiple neuropathy in a patient with newly diagnosed type 2 diabetes, presumably in the state of ketoacidosis.
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Affiliation(s)
- Dariusz Kotlęga
- Department of Neurology, Pomeranian Medical University in Szczecin, Szczecin, Poland; Aldemed Centrum Medyczne, Zielona Góra, Poland.
| | - Monika Gołąb-Janowska
- Department of Neurology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Grzegorz Zaborowski
- Magnetic Resonance Laboratory, Affidea Lubuskie Centrum Medyczne, Zielona Góra, Poland
| | - Sylwester Ciećwież
- Department of Gynaecology and Urogynaecology, Pomeranian Medical University, Szczecin, Poland
| | - Przemysław Nowacki
- Department of Neurology, Pomeranian Medical University in Szczecin, Szczecin, Poland
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