BACKGROUND: Diabetic neuropathy is a prevalent and debilitating complication of diabetes, necessitating effective pain management strategies. While pharmacological treatments, including opioids, are commonly employed, they pose significant challenges due to the risk of developing opioid-induced hyperalgesia (OIH). This case report aims to illustrate the efficacy of a comprehensive, multidisciplinary approach in managing painful diabetic neuropathy complicated by OIH.
METHODS: A 64-year-old male patient presented to the Pain Treatment Clinic with severe lower limb pain due to diabetic polyneuropathy. He had a history of multiple comorbidities.
METHODS: The patient\'s condition and physical examination suggested the presence of opioid-induced hyperalgesia (OIH). Despite the increased dose of opioids, the patient did not report significant constipation or breathing difficulties but experienced drowsiness and dry mouth. A diagnosis of opioid and benzodiazepine dependence was made.
METHODS: The treatment plan involved the initiation of pregabalin and duloxetine, gradual reduction of opioid use, and psychiatric support for addiction management.
RESULTS: Over 12 months, the patient experienced significant pain reduction and minimal adverse effects.
CONCLUSIONS: Effective management of OIH involves gradual opioid tapering and a multimodal therapeutic approach. However, the optimal treatment strategies and the frequency of OIH occurrence remain areas of uncertainty, relying heavily on clinical expertise and individualized patient care. Further research is needed to refine these treatment strategies and improve patient outcomes.

BACKGROUND: Diabetes is a global health problem causing a significant burden on the healthcare systems both due to the disease itself and associated complications. Diabetic radiculoplexus neuropathies or Bruns-Garland syndrome constitutes a rare form of microvascular complications, more commonly affecting the lumbosacral plexus and, very rarely, the cervical plexus. We describe two Sri Lankan males who presented with diabetic lumbosacral radiculoplexus neuropathy and diabetic cervical radiculoplexus neuropathy as the initial manifestation of diabetes.
METHODS: Case 1: a 49-year-old Sri Lankan hotel chef presented with subacute painful weakness and wasting of the left upper arm for 3 months and weight loss. Left upper limb proximal muscles were wasted with diminished power and reflexes. A nerve conduction study showed comparative amplitude reduction. An electromyogram revealed positive sharp waves, frequent fibrillations, and high amplitude polyphasic motor unit potentials with reduced recruitment in proximal muscles of left upper limb. Case-2: a 47-year-old Sri Lankan carpenter presented with subacute progressive asymmetrical painful weakness and wasting of bilateral thighs for 5 months and weight loss. Lower limb proximal muscles were wasted with reduced power and knee jerks. The nerve conduction study was normal. The electromyogram was similar to case 1 involving both quadratus femoris muscles, which was more prominent on the left side. The work up for an underlying etiology revealed only elevated fasting blood glucose and HbA1c, suggesting a new diagnosis of diabetes associated with neurological symptoms. Patient 1 was diagnosed with diabetic cervical radiculoplexus neuropathy and patient 2 with diabetic lumbosacral radiculoplexus neuropathy. Both showed significant improvement following optimization of glycemic control together with symptomatic treatment and physiotherapy.
CONCLUSIONS: Diagnosis of diabetic radiculoplexus neuropathy requires a comprehensive workup to rule out other sinister pathologies. This case report has a dual importance; it describes diabetic radiculoplexus neuropathy as the very first manifestation of two previously healthy people, giving rise to a new diagnosis of diabetes and, at the same time, reporting on diabetic cervical radiculoplexus neuropathy, which is extremely rare and has never been previously reported in Sri Lanka.

BACKGROUND: Lumbosacral radiculoplexus neuropathy, also known as amyotrophy, is an uncommon monophasic disorder characterized by inflammation of the lumbosacral nerve roots and plexuses. Lumbosacral radiculoplexus neuropathy is usually associated with diabetes mellitus, is typically painful at presentation, and often associated with long-term residual neurologic deficits. We report a case of painless, nondiabetic lumbosacral radiculoplexus neuropathy in a young Chinese woman, who made a full recovery after treatment with intravenous immunoglobulin, adding an atypical case to the scarce literature on lumbosacral radiculoplexus neuropathy.
METHODS: A 35-year-old Chinese woman presented to our emergency department with 1-week history of painless left lower limb weakness and numbness. Examination revealed weakness confined to the left lower limb but spanning various nerves and myotomes, with abnormal sensation. Clinical localization to the lumbosacral plexus was supported by neurodiagnostic tests, and magnetic resonance imaging of the lumbosacral plexus showed that the nerve roots were also involved. After treatment with intravenous immunoglobulin for nondiabetic lumbosacral radiculoplexus neuropathy, the patient had a full recovery.
CONCLUSIONS: Our patient\'s case highlights that lumbosacral radiculoplexus neuropathy, an already rare disorder, can occur in the absence of diabetes mellitus and pain, making it even harder to recognize. A systematic and meticulous clinical approach, supported by intelligent selection of adjunctive tests, is required for localization and diagnosis. With an accurate diagnosis, our case also demonstrates that appropriate and prompt treatment can lead to complete recovery, despite previous reports suggesting a high prevalence of long-term residual deficits after lumbosacral radiculoplexus neuropathy.

Although diabetic neuropathy is a well-known cause of gastrointestinal motility disorders, it is rare that diabetic neuropathy brings about esophageal obstruction. Here, we report a case with Type 3C diabetes mellitus (DM) lasting over 15 years and repeated esophageal obstruction resulting in chicken-meat-induced esophageal obstruction and candidiasis. This case highlights the importance of management of DM to prevent the development of complications such as diabetic neuropathy and associated symptoms.

BACKGROUND: Surveillance of diabetes requires up-to-date information on the prevalence of diabetes and its complications over time. For this purpose, statutory health insurance (SHI) data is being increasingly used, as the data is available in a timely fashion and case numbers enable detailed estimates also of diabetes complications. The aim of the present study was the development and internal validation of case definitions for the prevalence estimation of diabetic retinopathy (DRP), diabetic polyneuropathy (DPN) and diabetic foot syndrome (DFS).
METHODS: Persons with diabetes differentiated by type 1, type 2, and other diabetes in an age- and sex-stratified sample of persons insured by Barmer SHI in 2018 (n=72,744) comprised the study popuation. Based on the central ICD codes for microvascular complications (DRP: H36.0; DPN: G63.2; DFS: E1X.74/.75), case definitions were developed including additional ICD codes for complications without direct diabetes reference. Subsequently, the case definitions were internally validated. For the validation, coding in the inpatient setting (m1S) or repeatedly in the outpatient setting (m2Q) as well as coding of specific procedures (EBM, OPS) and drug prescriptions or by relevant specialists were considered. Additionally, we analysed the documentation of the diagnoses in the previous years.
RESULTS: In 2018, the prevalence of the central ICD codes was 8.4% for DRP (H36.0), 18.9% for DPN (G63.2) and 13.4% for DFS (E1X.74/.75). After inclusion of additional ICD codes in the case definition, prevalence increased significantly for DRP (9.6%) and DPN (20.7%), and barely for DFS (13.5%). Internal validation confirmed the majority of diagnoses (DRP: 96.7%; DPN: 96.5% DFS: 95.8%) and m2Q represented the most relevant criterion. When up to four previous years were considered, prevalences were up to 30% higher for DPN and DFS and up to 64% higher for DRP.
CONCLUSIONS: The inclusion of additional ICD codes in the case definition of microvascular complications of diabetes appears meaningful, as this increases the sensitivity of the prevalence estimate. Internal validation suggests that the documented diagnoses are plausible. However, not all diagnoses are documented annually, leading to an underestimation of the prevalence using a cross-sectional study design of one year.
UNASSIGNED: Für die Surveillance von Diabetes bedarf es aktueller Daten zur Prävalenz des Diabetes und seiner Komplikationen im zeitlichen Verlauf. Hierbei werden zunehmend Daten der gesetzlichen Krankenversicherung (GKV) genutzt, da diese zeitnah zur Verfügung stehen und die Fallzahlen detaillierte Schätzungen auch von Diabeteskomplikationen erlauben. Ziel der vorliegenden Studie war die Entwicklung und interne Validierung von Falldefinitionen für die Prävalenzschätzung der diabetischen Retinopathie (DRP), der diabetischen Polyneuropathie (DPN) und des diabetischen Fußsyndroms (DFS).
METHODS: Datengrundlage der Studie bilden Personen mit Diabetes unterschieden nach Typ-1-, Typ-2- und sonstigem Diabetes in einer alters- und geschlechtsstratifizierten Stichprobe von Barmer Versicherten im Jahr 2018 (n=72.744). Ausgehend von den zentralen ICD-Codes für die mikrovaskulären Komplikationen (DRP: H36.0; DPN: G63.2; DFS: E1X.74/.75) wurden Falldefinitionen unter Einbezug weiterer ICD-Codes, die die Komplikation ohne direkten Diabetesbezug verschlüsseln, entwickelt. Anschließend wurden die Falldefinitionen intern validiert. Hierfür wurden eine Codierung im stationären (m1S) oder wiederholt im ambulanten Bereich (m2Q) sowie eine Codierung spezifischer Leistungen (EBM, OPS) und Arzneimittelverordnungen oder durch relevante Facharztgruppen betrachtet. Abschließend wurde das Vorliegen der Diagnosen in den Vorjahren analysiert.
UNASSIGNED: Im Jahr 2018 betrug die Prävalenz der zentralen ICD-Codes der DRP (H36.0) 8,4%, der DPN (G63.2) 18,9% und des DFS (E1X.74/.75) 13,4%. Unter Einbezug weiterer ICD-Codes in die Falldefinitionen erhöhten sich die Prävalenzen für DRP (9,6%) und DPN (20,7%) deutlich, für DFS kaum (13,5%). Die interne Validierung bestätigte den Großteil der Diagnosen (DRP: 96,7%; DPN: 96,5% DFS: 95,8%) und m2Q stellte das relevanteste Kriterium dar. Bei Berücksichtigung von bis zu vier Vorjahren fielen die Prävalenzen für DPN und DFS um bis zu 30% und für DRP um bis zu 64% höher aus.
UNASSIGNED: Der Einbezug zusätzlicher ICD-Codes in die Falldefinition von mikrovaskulären Komplikationen des Diabetes erscheint sinnvoll, da diese die Sensitivität der Prävalenzschätzung erhöht. Die interne Validierung deutet darauf hin, dass die dokumentierten Diagnosen plausibel sind. Allerdings wird ein Teil der Diagnosen nicht jährlich dokumentiert, was zu einer Unterschätzung in der querschnittlichen Betrachtung eines Jahres führt.

Biliary pseudolithiasis is a ceftriaxone (CTRX)-induced complication, but the risk in cases of elderly type 1 diabetes mellitus (T1DM) is unclear. Case 1: A 78-year-old woman with T1DM complicated by diabetic autonomic neuropathy was admitted with pneumonia and treated with CTRX. On day 8, biliary pseudolithiasis and cholecystitis were observed. Case 2: an 80-year-old woman with T1DM was suspected of having a urinary tract infection and treated with CTRX. After a week, she developed asymptomatic biliary pseudolithiasis with gastroparesis. CTRX-associated biliary pseudolithiasis was thus noted in these cases of elderly T1DM. CTRX should be cautiously administered, especially in elderly T1DM patients with diabetic autonomic neuropathy.

Diabetic neuropathy is a major cause of morbidity among diabetics, usually affecting patients with long-standing diabetes and advancing age. We present a case of atypical first clinical presentation of type 1 diabetes mellitus (T1DM) in a pediatric patient. A 15-year-old male patient presented to the emergency department with complaints of right foot weakness associated with mild paresthesia of 1-week duration. There were complaints of polyuria, polydipsia and weight loss in the same timeframe. On subsequent examination, the patient exhibited signs of right-sided foot drop with weak ankle dorsiflexion and eversion, accompanied by impaired sensation over the dorsum of the right foot. Lab results confirmed a diagnosis of T1DM and the patient was started on subcutaneous insulin injections. The patient’s foot drop recovered within one month of insulin initiation. This case highlights that T1DM may present atypically as acute onset neuropathy in pediatric patients, making it an important differential diagnosis.

BACKGROUND: Foot and ankle amputation is a feared complication of diabetic neuropathy and diabetes mellitus (DM) accounts for 80% of all in-hospital amputations. Magnetic resonance neurography is an effective tool in characterizing neuromuscular sequelae of the disease. However, conventional ankle MRI is more commonly performed and has not been studied to assess neuromuscular changes of DM.
OBJECTIVE: The objective is to characterize neuromuscular changes of diabetic patients in a case-control study using conventional ankle MRI.
METHODS: Between November 2019 and July 2021, 110 consecutive ankle MRI scans (n = 102 patients) at our county hospital were reviewed and met the inclusion criteria. Patients were divided into two cohorts, diabetic (N = 63) and non-diabetic (N = 39). Demographics, HgbA1c, and reason for MRI study were collected via retrospective chart review. The presence of intramuscular edema-like signal, pattern of the edema, muscle fatty infiltration, and measurements of the cross-sectional area of the posterior, medial, and lateral tibial nerves (PTN, MPN, and LPN) was recorded blinded to the clinical findings by two readers.
RESULTS: Muscle edema-like signal was much more likely to be found in DM (odds ratio 19.5, 95% CI 7.0-54.6, p < 0.001). DM also showed increase of 0.87 in the mean grade of muscle fatty infiltration (p < 0.001). There were higher rates of nerve T2 hyperintensity (odds ratio 14.0, 95% CI 3.1-62.7, p < 0.001) and the measured areas of the PTN, MPN, and LPN were also larger in DM compared to their non-diabetic counterparts (PTN: 0.16 cm2 vs. 0.10 cm2, p < 0.01; MPN: 0.09 cm2 vs. 0.05 cm2, p < 0.01; LPN: 0.07 cm2 vs. 0.04 cm2, p < 0.05).
CONCLUSIONS: Conventional ankle MRIs can be used to detect DM-related neuromuscular changes.

Painful diabetic neuropathy (PDN) is a common complication of diabetes mellitus, which reduces the quality of life. However, the association between PDN and environmental factors, especially ambient humidity, remains unclear. Therefore, this study investigated the impact of extreme humidity events on PDN. Data on PDN-related hospital admissions to two tertiary hospitals in Hefei, China (2014-2019) were obtained. A distributed lag non-linear model with a case-crossover design was used to quantitatively estimate the effects of ambient humidity on PDN, and the results were stratified by sex and age. The 1st, 10th, 90th, and 99th percentiles of relative humidity (RHU) were defined as extreme humidity, and the average relative humidity (74.94%) was set as the reference value. Non-linear exposure-response curves between the RHU and PDN cases were obtained. Extreme humidity (92%) had a significant effect on PDN with a relative risk (RR) of 1.13 (95% confidence interval (CI): 1.01-1.26) on a particular day, which increased with the RHU (RR: 1.21, 95% CI: 1.02-1.45 at 98% extreme humidity). Stratification analysis showed that women (RR: 1.38, 95% CI: 1.07-1.77) and patients aged < 65 years (RR: 1.26, 95% CI: 1.01-1.57) were highly susceptible to this effect on the same day. The results suggest that extreme humidity is a crucial trigger for PDN onset in diabetes patients. Furthermore, the effects vary with sex and age. This study provides detailed evidence of the adverse effects of extreme weather on diabetes patients.

A 62-year-old man was diagnosed as IgA nephropathy. He had a pancreatic tumor operation 19 years ago and had a normal plasma glucose test every year. One month after the medication of prednisolone acetate was administered his fasting plasma glucose elevated to 7.1mmol/L while he manifested symptoms of thirst, frequent urination, and weight loss. Approximately 3 months after the steroids, he started complaining of numbness, weakness, and muscle cramp in his lower extremities, blood tests showed elevated plasma glucose and electromyography (EMG) revealed impairment of the peripheral nerves in the lower extremity, diabetic peripheral neuropathy was diagnosed. Mecobalamin and Acupuncture were employed and steroids were discontinued, 8 months later he recovered part of his strength and sensation. This case presents a specific adverse drug reaction of corticosteroids that causes diabetes mellitus and subsequently leads to peripheral neuropathy in an acute onset.