A History

1
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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
? Neuropathic pain medications and narcotics ?
Steroids and IVIG Benefit in case series But,
in RCT (n75), 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  
? 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  
? 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
? 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 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

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
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

• 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
1999532113-2121. 2. Dyck PJB, Windebank AJ.
Diabetic and nondiabetic lumbosacral
radiculoplexus neuropathies New insights into
pathophysiology and treatment. Muscle Nerve
25477-491, 2002. 3. Longstreth GF. Diabetic
Thoracic Polyradiculopathy Ten Patients with
Abdominal Pain. American Journal of
Gastroenterology 92,3 (502-505), 1997. 4. Dyck
PJB, OBrien P, Bosch EP, et al. The
multi-center, double-blind controlled trial of IV
methylprednisolone in diabetic lumbosacral
radiculoplexus neuropathy. Neurology. 200666 (5
suppl 2)A191. 5.Longstreth GF, Newcomer AD.
Abdominal Pain Caused by Diabetic Radiculopathy.
Annals of Internal Medicine 86166-168,1977. 6.
Jaradeh SS, Prieto TE, Lobeck LJ. Progressive
polyradiculopathy in diabetes correlation of
variables and clinical outcome after
immunotherapy. J Neurol Neurosurg Psychiatry 1999
67607-612.