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A History & Physical Exam is Worth 1000 Tests: Diabetic Amyotrophy PowerPoint PPT Presentation


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. A History & Physical Exam is Worth 1000 Tests: Diabetic Amyotrophy. Ryan R. Kraemer MD and Lisa L. Willett MD The University of Alabama at Birmingham. Treatment of Diabetic Amyotrophy. Clinical Features of Diabetic Amyotrophy. Evaluation and Diagnosis. Learning Objectives.

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A History & Physical Exam is Worth 1000 Tests: Diabetic Amyotrophy

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A history physical exam is worth 1000 tests diabetic amyotrophy

.

A History & Physical Exam is Worth 1000 Tests:

Diabetic Amyotrophy

Ryan R. Kraemer MD and Lisa L. Willett MD

The University of Alabama at Birmingham

Treatment of Diabetic Amyotrophy

Clinical Features of Diabetic Amyotrophy

Evaluation and Diagnosis

Learning Objectives

◦ Neuropathic pain medications and narcotics

◦ Steroids and IVIG: Benefit in case series

But, in RCT (n=75), no improvement in recovery time (some improvement in pain)

May require early initiation

◦ Depressionis common and requires treatment

◦ Prognosis: Pain usually resolves in 6 months - 2 years

Lumbosacral disease, may have residual weakness

◦To recognize thoracic diabetic amyotrophy as a cause of abdominal pain

◦ To recognize the importance of a detailed history and physical exam for diagnosis

◦To learn which studies are diagnostic for diabetic amyotrophy to prevent unnecessary tests and treatment for visceral disease

◦ Abrupt pain in the distribution of the involved nerve root

◦ Pain is sharp, burning, deep aching, stabbing, or tightening

◦ Weight loss (often profound) is common

◦ Hyperesthesia or hypoesthesia

◦ Lumbosacral: Often progresses to proximal and distal weakness of lower extremities with decreased reflexes and muscle wasting

◦ Thoracic: Mimics an intra-abdominal visceral process

Abdominal wall paresis may be present

◦ Given the sharp, burning, constant pain unrelated to oral intake,

a neurological evaluation was undertaken

◦ LP: WBC: 9 (100% lymphs), glucose 104, protein 145 ↑

◦ EMG & NCS: T10-S1 thoracolumbar polyradiculopathy

◦ MRI thoracic spine: unremarkable

◦ Diagnosis: Diabetic Amyotrophy

◦ Treatment: The patient was treated with gabapentin and

pregabalin with moderate pain relief

Patient Presentation

◦ 48 yo WM with DM 2 & HTN withabdominal pain x 3 mo.

- periumbilical, radiating to epigastrum and back

- 10/10 severity, constant, sharp, burning

◦ Associated 60 lb. weight loss, anorexia, nausea/vomiting

Outside Hospital Evaluation: all unremarkable

◦ CTA abdomen ◦ MRI L-spine and CT head

◦ US abdomen ◦ ERCP

◦ HIDA scan ◦ EGD/colonoscopy

◦ No relief after cholecystectomy and appendectomy

Physical Exam:

◦ T: 96 HR: 82 BP: 146/94 RR: 20

◦ Abdomen: severe pain with mild tactile stimulation in bilateral lower quadrants with voluntary guarding,

no rash, non-distended, no rebound, soft

◦ Lower Extremities: strength 4/5, DTRs 1+

Laboratory Data: HgA1C: 8.2

◦ Unremarkable: CBC, BMP, LFTs, amylase and lipase,

hepatitis serologies, PT and PTT, UA

Introduction

Take Home Points

◦ Diabetic amyotrophy results from immune mediated injury to the thoracic and/or lumbosacral nerve roots that causes the abrupt onset of pain in the distribution of the affected nerve

◦ Immune-mediated attack causes a microvasculitisof the nerve with inflammation and ischemicchanges

◦ Often in diabetics with decent glycemic control without retinopathy, neuropathy, or nephropathy

◦ Also known as:

1. diabetic polyradiculopathy

2. diabetic lumbosacral-

radiculoplexus neuropathy

3. proximal diabetic neuropathy

  • 1. Thoracic diabetic amyotrophy has an abrupt onset of abdominal pain with neuropathic features.

  • Thoracic diabetic amyotrophy is often mistaken for visceral disease and unnecessary imaging tests and surgeries are performed.

  • An EMG should be obtained in patients with abdominal pain with neuropathic features.

Diagnosis of Diabetic Amyotrophy

◦ EMG: diagnostic, characteristic features of denervation

◦ MRI to rule out structural disease

◦ CSF analysis often shows elevated protein level

◦ Sural nerve biopsy showing

epineural microscopic vasculitis

& mononuclear cellular infiltrate2

References

1. Dyck PJB, Norell JE, Dyck PJ. Microvascultis and ischemia in diabetic lumbosacral radiculoplexus neuropathy. Neurology 1999;53:2113-2121.

2. Dyck PJB, Windebank AJ. Diabetic and nondiabetic lumbosacral radiculoplexus neuropathies: New insights into pathophysiology and treatment. Muscle & Nerve; 25:477-491, 2002.

3. Longstreth GF. Diabetic Thoracic Polyradiculopathy: Ten Patients with Abdominal Pain. American Journal of Gastroenterology: 92,3 (502-505), 1997.

4. Dyck PJB, O’Brien P, Bosch EP, et al. The multi-center, double-blind controlled trial of IV methylprednisolone in diabetic lumbosacral radiculoplexus neuropathy. Neurology. 2006;66 (5 suppl 2):A191.

5.Longstreth GF, Newcomer AD. Abdominal Pain Caused by Diabetic Radiculopathy. Annals of Internal Medicine 86:166-168,1977.

6. Jaradeh SS, Prieto TE, Lobeck LJ. Progressive polyradiculopathy in diabetes: correlation of variables and clinical outcome after immunotherapy. J Neurol Neurosurg Psychiatry 1999 67:607-612.


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