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A History & Physical Exam is Worth 1000 Tests: Diabetic Amyotrophy A History & Physical Exam is...
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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 ◦ 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 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, Treatment of Diabetic Amyotrophy ◦ 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 ◦ Depression is common and requires treatment ◦ Prognosis: Pain usually resolves in 6 months - 2 years Lumbosacral disease, may have residual weakness References Evaluation and Diagnosis Patient Presentation 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. . Clinical Features of Diabetic Amyotrophy ◦ 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 ◦ 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 ◦ Also known as: 1. diabetic polyradiculopathy 2. diabetic lumbosacral- radiculoplexus neuropathy 3. proximal diabetic neuropathy Introduction 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 infiltrate 2 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. ◦ 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 Learning Objectives
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Transcript of A History & Physical Exam is Worth 1000 Tests: Diabetic Amyotrophy A History & Physical Exam is...
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 MDThe University of Alabama at Birmingham
Ryan R. Kraemer MD and Lisa L. Willett MDThe University of Alabama at Birmingham
◦ 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
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
Treatment of Diabetic Amyotrophy◦ Neuropathic pain medications and narcotics
◦ Steroids and IVIG: Benefit in case seriesBut, in RCT (n=75), no improvement in recovery
time (some improvement in pain)May require early initiation
◦ Depression is common and requires treatment
◦ Prognosis: Pain usually resolves in 6 months - 2 years Lumbosacral disease, may have residual weakness
References
Evaluation and Diagnosis
Patient Presentation
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.
. .
Clinical Features of Diabetic Amyotrophy◦ 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 processAbdominal 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
◦ 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
◦ Also known as:
1. diabetic polyradiculopathy 2. diabetic lumbosacral- radiculoplexus neuropathy 3. proximal diabetic neuropathy
Introduction
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
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.
◦ 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
Learning Objectives
