Transcript Poster 3 - The University of Alabama at Birmingham

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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
Learning Objectives
◦ 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
Evaluation and Diagnosis
◦ Given the sharp, burning, constant pain unrelated to oral intake,
◦ LP: WBC: 9 (100% lymphs), glucose 104, protein 145 ↑
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
◦ 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
◦ MRI thoracic spine: unremarkable
◦ Hyperesthesia or hypoesthesia
Patient Presentation
◦ No relief after cholecystectomy and appendectomy
◦ Pain is sharp, burning, deep aching, stabbing, or tightening
◦ Weight loss (often profound) is common
pregabalin with moderate pain relief
Outside Hospital Evaluation: all unremarkable
◦ CTA abdomen
◦ MRI L-spine and CT head
◦ US abdomen
◦ ERCP
◦ HIDA scan
◦ EGD/colonoscopy
◦ Neuropathic pain medications and narcotics
◦ EMG & NCS: T10-S1 thoracolumbar polyradiculopathy
◦ Diagnosis: Diabetic Amyotrophy
Introduction
◦ 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 microvasculitis of the
nerve with inflammation and ischemic changes
◦ Often in diabetics with decent glycemic control without
retinopathy, neuropathy, or nephropathy
Treatment of Diabetic Amyotrophy
◦ Abrupt pain in the distribution of the involved nerve root
a neurological evaluation was undertaken
◦ Treatment: The patient was treated with gabapentin and
◦ 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
Clinical Features of Diabetic Amyotrophy
◦ 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
Diagnosis of Diabetic Amyotrophy
◦ EMG: diagnostic, characteristic features of denervation
◦ MRI to rule out structural disease
◦ CSF analysis often shows elevated protein level
◦ Depression is common and requires treatment
◦ Prognosis: Pain usually resolves in 6 months - 2 years
Lumbosacral disease, may have residual weakness
Take Home Points
1. Thoracic diabetic amyotrophy has an abrupt onset of
abdominal pain with neuropathic features.
2. Thoracic diabetic amyotrophy is often mistaken for
visceral disease and unnecessary imaging tests
and surgeries are performed.
3. An EMG should be obtained in patients with
abdominal pain with neuropathic features.
◦ Also known as:
1. diabetic polyradiculopathy
2. diabetic lumbosacralradiculoplexus neuropathy
3. proximal diabetic neuropathy
References
◦ Sural nerve biopsy showing
epineural microscopic vasculitis
& mononuclear cellular infiltrate2
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.