Diabetic amyotrophy

Neurology

Clinicals - History

Fact Explanation
Pain Affected muscle groups can become extremely painful. Patients complain of aching or burning pain. Initially the pain is localized to the back, hip, or thigh. Pain
Affected muscle groups can become extremely painful. Patients complain of aching or burning pain. Initially the pain is localized to the back, hip, or thigh.
Weakness Patients complain of acute or subacute unilateral or asymmetrical weakness of the quadriceps muscles and or shoulder girdle. Weakness
Patients complain of acute or subacute unilateral or asymmetrical weakness of the quadriceps muscles and or shoulder girdle.
Reduced muscle bulk Some patients may complain of reduced muscle bulk in the legs and in the shoulder girdle due to muscle wasting. Reduced muscle bulk
Some patients may complain of reduced muscle bulk in the legs and in the shoulder girdle due to muscle wasting.
Recent loss of weight Patients with diabetic amyotrophy may complain of recent weight loss. Weight loss is an initial presenting complain of diabetes mellitus as well. Recent loss of weight
Patients with diabetic amyotrophy may complain of recent weight loss. Weight loss is an initial presenting complain of diabetes mellitus as well.
History of diabetes mellitus Elderly patients with type 2 diabetes mellitus, and patients with type 1 diabetes mellitus can develop diabetic amyotrophy, especially if the blood sugar control is poor. History of diabetes mellitus
Elderly patients with type 2 diabetes mellitus, and patients with type 1 diabetes mellitus can develop diabetic amyotrophy, especially if the blood sugar control is poor.
Evidence of diabetic neuropathy Some patients may complain of coexisting diabetic neuropathy as well. Burning pain, tingling sensations, parasthesiae, hyperasthesiae, and deep aching pain are complains of diabetic neuropathy. Evidence of diabetic neuropathy
Some patients may complain of coexisting diabetic neuropathy as well. Burning pain, tingling sensations, parasthesiae, hyperasthesiae, and deep aching pain are complains of diabetic neuropathy.

Clinicals - Examination

Fact Explanation
BMI Most of the patients with diabetes are obese. BMI
Most of the patients with diabetes are obese.
Waist to hip ratio Increased waist to hip ratio is associated with increased risk of diabetes. Waist to hip ratio
Increased waist to hip ratio is associated with increased risk of diabetes.
Muscle wasting Quadriceps muscles of the thigh and muscles of the shoulder girdle shows asymmetrical wasting. Muscle wasting
Quadriceps muscles of the thigh and muscles of the shoulder girdle shows asymmetrical wasting.
Muscle weakness Diabetic amyotrophy results in weakness of the affected muscles of the hip joint and shoulder girdle. Muscle weakness
Diabetic amyotrophy results in weakness of the affected muscles of the hip joint and shoulder girdle.
Absent tendon reflexes The deep tendon reflexes are either reduced or absent. Absent tendon reflexes
The deep tendon reflexes are either reduced or absent.
Extensor plantar response Extensor plantar response can be detected in some patients. Extensor plantar response
Extensor plantar response can be detected in some patients.
Blood pressure Hypertension is a common recognized complication of diabetes. Blood pressure
Hypertension is a common recognized complication of diabetes.
Sensory impairment Distal polyneuropathy may cause sensory loss over the hands and feet (glove and stocking distribution). Isolated cranial nerve palsies or peripheral nerve palsies can also be associated with diabetic neuropathy. Sensory impairment
Distal polyneuropathy may cause sensory loss over the hands and feet (glove and stocking distribution). Isolated cranial nerve palsies or peripheral nerve palsies can also be associated with diabetic neuropathy.
Examination of foot Foot examination is important in patients with diabetes as foot deformities, pressure ulcers and callosities can be associated with neuropathy. Atherosclerosis involving the lower limb vessels (peripheral vascular disease) results in ischemic changes (dry skin, scanty hair, cold foot) and absent or diminished lower limb pulses. Examination of foot
Foot examination is important in patients with diabetes as foot deformities, pressure ulcers and callosities can be associated with neuropathy. Atherosclerosis involving the lower limb vessels (peripheral vascular disease) results in ischemic changes (dry skin, scanty hair, cold foot) and absent or diminished lower limb pulses.

Investigations - Diagnosis

Fact Explanation
Fasting blood sugar Fasting blood sugar of more than 126 mg/dl (7.0 mmol/l) is diagnostic of diabetes mellitus. Fasting blood sugar
Fasting blood sugar of more than 126 mg/dl (7.0 mmol/l) is diagnostic of diabetes mellitus.
Glycosylated hemoglobin (HbA1C) HbA1C of more than 6.5% indicates increased serum glucose and aids in diagnosing diabetes mellitus. Increased levels of HbA1C enables the prediction of macro and micro vascular complications of diabetes. Glycosylated hemoglobin (HbA1C)
HbA1C of more than 6.5% indicates increased serum glucose and aids in diagnosing diabetes mellitus. Increased levels of HbA1C enables the prediction of macro and micro vascular complications of diabetes.
Oral glucose tolerance test Oral glucose tolerance test is helpful in diagnosing diabetes. If the 2hour plasma glucose level is equal or more than 200mg/dl diabetes can be diagnosed. Oral glucose tolerance test
Oral glucose tolerance test is helpful in diagnosing diabetes. If the 2hour plasma glucose level is equal or more than 200mg/dl diabetes can be diagnosed.
Cerebro spinal fluid (CSF) full report Some patients may have increased protein concentration in CSF. Cerebro spinal fluid (CSF) full report
Some patients may have increased protein concentration in CSF.
Electromyelogram Electromyelogram indicates lesions in the lumbosacral roots, plexus and peripheral nerves. Electromyelogram
Electromyelogram indicates lesions in the lumbosacral roots, plexus and peripheral nerves.
CT/MRI Imaging studies are indicated to rule out cerebral and spinal cord lesions, which can also result in lower limb weakness and wasting. CT/MRI
Imaging studies are indicated to rule out cerebral and spinal cord lesions, which can also result in lower limb weakness and wasting.
Nerve conduction studies Affected distal nerves exhibit non-specific abnormalities in the nerve conduction or it can be normal. Nerve conduction studies are helpful in excluding other possible differentials rather than in diagnosing diabetic neuropathy. Nerve conduction studies
Affected distal nerves exhibit non-specific abnormalities in the nerve conduction or it can be normal. Nerve conduction studies are helpful in excluding other possible differentials rather than in diagnosing diabetic neuropathy.

Investigations - Management

Fact Explanation
Fasting blood sugar Fasting blood sugar should be regularly monitored in patients with diabetes. Fasting blood sugar
Fasting blood sugar should be regularly monitored in patients with diabetes.
Glycosylated hemoglobin (HbA1C) Glycemic control over the past 3 months is reflected by the HbA1C value. Higher the HbA1C poor the blood sugar control and higher the risk of developing micro and macro vascular complications of diabetes. Glycosylated hemoglobin (HbA1C)
Glycemic control over the past 3 months is reflected by the HbA1C value. Higher the HbA1C poor the blood sugar control and higher the risk of developing micro and macro vascular complications of diabetes.
Renal function test Renal failure can occur secondary to diabetic nephropathy. Assessment of serum electrolytes and serum creatinine are useful initial investigations to detect renal impairment. Renal function test
Renal failure can occur secondary to diabetic nephropathy. Assessment of serum electrolytes and serum creatinine are useful initial investigations to detect renal impairment.
Urinary albumin Microalbuminuria (urinary albumin >20 μg/min and ≤199 μg/min) is an early marker of diabetic nephropathy which is potentially reversible. Macroalbuminuria is diagnosed if urinary albumin excretion is more than 200 μg/min. Urinary albumin
Microalbuminuria (urinary albumin >20 μg/min and ≤199 μg/min) is an early marker of diabetic nephropathy which is potentially reversible. Macroalbuminuria is diagnosed if urinary albumin excretion is more than 200 μg/min.
ECG Myocardial infarction and myocardial ischemia can occur as a macrovascular complication of diabetes. ECG
Myocardial infarction and myocardial ischemia can occur as a macrovascular complication of diabetes.
Ophthalmoscope Ophthalmoscopic examination of the optic fundi will aid in making the diagnosis of diabetic retinopathy. Patients with type 1 diabetes mellitus should be followed up with annual ophthalmoscopic examination. Ophthalmoscope
Ophthalmoscopic examination of the optic fundi will aid in making the diagnosis of diabetic retinopathy. Patients with type 1 diabetes mellitus should be followed up with annual ophthalmoscopic examination.
Ophthalmoscopic examination Screening for retinopathy should be done with ophthalmoscopic examination of the fundi in patients with diabetes. It should be done within the first 5 years of the diagnosis of type 1 diabetes mellitus. Ophthalmoscopic examination
Screening for retinopathy should be done with ophthalmoscopic examination of the fundi in patients with diabetes. It should be done within the first 5 years of the diagnosis of type 1 diabetes mellitus.

Management - Supportive

Fact Explanation
Health education Patients should be educated about the chronic nature of diabetes and the necessity of life long treatment, life style modifications and long term monitoring of blood sugar control.
Health education is important in preventing DM. Adherence to healthy dietary habits (more fruits and vegetables, less fat and sugar) and regular exercise are helpful in primordial prevention. Obesity is an important risk factor associated with development of type 2 DM. Obese patients should be encouraged to lose weight and to achieve normal BMI.
Health education
Patients should be educated about the chronic nature of diabetes and the necessity of life long treatment, life style modifications and long term monitoring of blood sugar control.
Health education is important in preventing DM. Adherence to healthy dietary habits (more fruits and vegetables, less fat and sugar) and regular exercise are helpful in primordial prevention. Obesity is an important risk factor associated with development of type 2 DM. Obese patients should be encouraged to lose weight and to achieve normal BMI.
Analgesics Patients who complain of pain can be prescribed analgesics, either systemic or topical. These include tricyclic antidepressants, antiepileptic drugs, serotonin-norepinephrine reuptake inhibitors, opiates and opiate-like substances.
Tricyclic antidepressants are considered the first line treatment option in managing neuropathic pain in diabetes.
Analgesics
Patients who complain of pain can be prescribed analgesics, either systemic or topical. These include tricyclic antidepressants, antiepileptic drugs, serotonin-norepinephrine reuptake inhibitors, opiates and opiate-like substances.
Tricyclic antidepressants are considered the first line treatment option in managing neuropathic pain in diabetes.
Glycemic control Blood sugar control should be optimum in patients with diabetes, to delay the progression of the disease and to delay the onset of disease related micro and macrovascular complications. Insulin secretagogues (Sulfonylureas) and metformin are commonly used oral hypoglycemic drugs. Patients with type 2 diabetes mellitus can be treated with oral hypoglycemic drugs. Insulin is the second line treatment option in type 2 diabetes mellitus but the first line treatment in type 1 diabetes mellitus. Glycemic control
Blood sugar control should be optimum in patients with diabetes, to delay the progression of the disease and to delay the onset of disease related micro and macrovascular complications. Insulin secretagogues (Sulfonylureas) and metformin are commonly used oral hypoglycemic drugs. Patients with type 2 diabetes mellitus can be treated with oral hypoglycemic drugs. Insulin is the second line treatment option in type 2 diabetes mellitus but the first line treatment in type 1 diabetes mellitus.
Physical therapy Physical therapy can improve mobility and strength of affected muscles. Physical therapy
Physical therapy can improve mobility and strength of affected muscles.
Occupational therapy Occupational therapy makes the patients independent in their day-to-day activities. Occupational therapy
Occupational therapy makes the patients independent in their day-to-day activities.
Control of other risk factors Hypertension, smoking, and dyslipidemia are associated with poor outcome of diabetes and if not optimized patient can develop other macro and microvascular complications of diabetes. Control of other risk factors
Hypertension, smoking, and dyslipidemia are associated with poor outcome of diabetes and if not optimized patient can develop other macro and microvascular complications of diabetes.

Management - Specific

Fact Explanation
Conservative management Diabetic amyotrophy is commonly self-limiting and requires no specific treatment. Conservative management
Diabetic amyotrophy is commonly self-limiting and requires no specific treatment.
Intravenous immunoglobin (IVIg) Although not widely used, IVIg (0.4 g/kg twice weekly) when given for several months can improve symptoms and muscle power. Intravenous immunoglobin (IVIg)
Although not widely used, IVIg (0.4 g/kg twice weekly) when given for several months can improve symptoms and muscle power.
Plasma exchange This is one of the immunomodulatory treatment options for the treatment of diabetic amyotrophy. Plasma exchange
This is one of the immunomodulatory treatment options for the treatment of diabetic amyotrophy.
Corticosteroids Corticosteroids can also be used in the treatment of the diabetic amyotrophy. Pulsed methylprednisolone is proven to be effective. Corticosteroids
Corticosteroids can also be used in the treatment of the diabetic amyotrophy. Pulsed methylprednisolone is proven to be effective.
Immunosuppressive agents Immunosuppressive agents that can be used in the treatment of diabetic amyotrophy include cyclophosphamide and methylprednisolone. Immunosuppressive agents
Immunosuppressive agents that can be used in the treatment of diabetic amyotrophy include cyclophosphamide and methylprednisolone.

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