. 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:
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
◦ 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
◦ 48 yo WM with DM 2 & HTN with abdominal 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
◦ 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
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-
3. proximal diabetic neuropathy
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
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