Distal Painful Autonomic Neuropathy (original) (raw)
2018, Evaluation and Management of Autonomic Disorders
https://doi.org/10.1007/978-3-319-72251-1_11
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Abstract
A 64-year-old man in the last 4 years has noted a history of slowly progressive nocturnal paresthesia with burning, prickling, and pain in both feet. At that time, a primary care consultation showed body mass index of 31 (obese range), glycemia, and hemoglobin A1c were normal. High serum triglyceride levels = 210 mg/dL, and impaired glucose tolerance test was found. He was advised to do a lifestyle modification (diet and exercise). The patient did not follow medical
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Peripheral neuropathy does not invariably coexist with autonomic neuropathy in diabetes mellitus
European Journal of Internal Medicine, 2001
Background: Peripheral somatic and autonomic neuropathies are the most common types of diabetic polyneuropathy. Although duration and degree of hyperglycemia are considered to be risk factors for both autonomic and peripheral neuropathy, recent studies have raised the question of a different development and natural history of these neuropathies in diabetes. In addition, a few studies have investigated the relationship between chronic painful and autonomic neuropathy. The aim of this study was to investigate to what extent autonomic and peripheral neuropathy coexist, as well as whether painful neuropathy is more common in diabetic patients with autonomic neuropathy. Methods: Subjects with type 1 (n552; mean age 31.7 years) and type 2 diabetes (n553; mean age 54.5 years) were studied. Evaluation of peripheral neuropathy was based on clinical symptoms (neuropathic symptom score), signs (neuropathy disability score), and quantitative sensory testing (vibration perception threshold). Assessment of autonomic neuropathy was based on the battery of standardized cardiovascular autonomic function tests. Results: Prevalence rates of pure autonomic and of pure peripheral neuropathy in patients with type 1diabetes were 28.8 and 13.5%, respectively. The respective rates in patients with type 2 diabetes were 20.7% (P50.33 vs. type 1 diabetes) and 20.7% (P50.32). Peripheral and autonomic neuropathy coexisted in 28.8% of type 1 and in 45.3% of type 2 diabetic subjects (P50.08). Prevalence rates of chronic painful neuropathy in subjects with type 1 diabetes, with and without autonomic neuropathy, were 16.6 and 22.7%, respectively (P50.85) and in type 2 diabetic subjects 20 and 22.2%, respectively (P50.58). Multivariate analysis after adjustment for age, sex, blood pressure, duration of diabetes, HBA , and presence of retinopathy or 1c microalbuminuria showed that neither the indices of peripheral nerve function (neuropathic symptom score, neuropathy disability score, vibration perception threshold) nor the presence of peripheral neuropathy or chronic painful neuropathy are associated with the presence of autonomic neuropathy in individuals with either type 1 or type 2 diabetes. Conclusions: Peripheral and autonomic neuropathies do not invariably coexist in diabetes. In addition, chronic painful neuropathy may be present irrespective of the presence of autonomic neuropathy.
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Diabetic Medicine, 2000
We report the clinico-pathological features and management of a 49-year-old male with a 30-year history of Type 1 diabetes mellitus who had nephropathy (proteinuria 1.81 g/24 h, creatinine 136 mmol/l), proliferative retinopathy and severe somatic and autonomic neuropathy. A sural nerve biopsy demonstrated marked myelinated ®bre loss with unmyelinated ®bre degeneration and regeneration combined with extensive endoneurial microangiopathy. The management of the patient's blood pressure problems (supine hypertension) and symptomatic postural hypotension is discussed.
Diabetes, 1986
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An update on the diagnosis and treatment of diabetic somatic and autonomic neuropathy
F1000Research
Diabetic peripheral neuropathy (DPN) is the most common chronic complication of diabetes. It poses a significant challenge for clinicians as it is often diagnosed late when patients present with advanced consequences such as foot ulceration. Autonomic neuropathy (AN) is also a frequent and under-diagnosed complication unless it is overtly symptomatic. Both somatic and autonomic neuropathy are associated with increased mortality. Multiple clinical trials have failed because of limited efficacy in advanced disease, inadequate trial duration, lack of effective surrogate end-points and a lack of deterioration in the placebo arm in clinical trials of DPN. Multifactorial risk factor reduction, targeting glycaemia, blood pressure and lipids can reduce the progression of DPN and AN. Treatment of painful DPN reduces painful symptoms by about 50% at best, but there is limited efficacy with any single agent. This reflects the complex aetiology of painful DPN and argues for improved clinical ph...
The natural history of recently diagnosed autonomic neuropathy over a period of 2 years
1998
Background: Patients with diabetic autonomic neuropathy (DAN) have an increased cardiovascular mortality rate compared with normals or diabetic patients without DAN. Indices of standard cardiovascular autonomic function tests and heart rate variability (HRV) are reliable markers of the presence and severity of DAN. Objective: The present prospective study investigated the natural history of values of HRV indices and cardiovascular reflex tests in patients with recently diagnosed asymptomatic DAN, over a period of 2 years, at 3 month intervals. Patients and methods: A total of 30 consecutive patients (nine men and 21 women), of median age 51 (range 25-65) years, eight with type 1 and 22 with Type 2 diabetes mellitus, were included in the study, at the time that the presence of DAN was confirmed, as this was established if at least two of cardiovascular autonomic function tests became abnormal. The expiration/inspiration (E/I) ratio, S.D. and mean circular resultant of R-R intervals, the Valsalva index, the 30:15 ratio, and the blood pressure response to standing as well as normalised spectral power indices of HRV were used. Results: All measured indices, except the Valsalva index, deteriorated in all 30 patients during the 2 year follow-up. Most of HRV indices values deteriorated significantly in comparison to baseline at month 12, while the values of cardiovascular reflex tests displayed significant deterioration, in comparison to baseline, between months 15 and 21. Fourteen patients developed symptoms of DAN during the 2 year period. Patients with better glycemic control exhibited deterioration of DAN markers at the same time period with those with poor glycemic control. Conclusions: Our data suggest that the progression of DAN is significant during the 2 years subsequent to its discovery. This was defined by the deterioration of the mean values of HRV indices and standard cardiovascular autonomic function tests, and by the development of autonomic symptoms in some patients. HRV indices are the earlier markers of DAN deterioration.
Diabetic Sensory and Motor Neuropathy - NEJM
A 65-year-old woman with a 5-year history of type 2 diabetes (a recent hemoglobin A 1C level was 9.5%) reports the recent onset of burning, tingling, and stabbing pain in her feet that is worse at night and interferes with sleep and activities of daily living. Her medications include 500 mg of metformin and 2 mg of glimepiride, each taken twice daily. On physical examination, the patient is alert and oriented to person, place, and time. Her blood pressure is 140/90 mm Hg. She has reduced sensation to pinpricks in the knees, reduced ability to detect vibration from a 128-Hz tuning fork, and a loss of proprioception and of sensation to a 1-g monofilament (but not to a 10-g monofilament) in her toes. Strength in the lower legs is 5 out of 5 (normal) proximally and 4 out of 5 distally, and there is slightly weak dorsiflexion of both big toes, with no indication of entrapment. Her ankle reflexes are absent. She has no foot ulcers, and her pulses are easily palpable. How should her case be further evaluated and managed?
Frequency of Autonomic Neuropathy Occurrence among Diabetic Patients
Objectives: Diabetic autonomic neuropathy (DAN) is the most common and grave complication of diabetes mellitus (DM). In this study, we determined the frequency of autonomic neuropathy among both type1 and type 2 diabetic patients in Pakistan. Materials and Methods: This study was conducted at Capital Development Authority (CDA) Hospital, Pakistan. The adult patients who had DM for at least last five years were assessed for this study. Four cardiovascular reflex tests were performed on each patient. Pre-prandial and two hours postprandial blood glucose were also measured. Results: A total of 200 patients were recruited for the study. Of them, 133 (66.5%) patients had autonomic neuropathy. Cardiovascular involvement was seen in 86 (43%), gastrointestinal involvement in 93(46%) and genitourinary involvement in 15 (7.5%) patients. The frequency of autonomic neuropathy did not differ between type 1 and type 2 DM patients (p=0.246). However, the frequency of autonomic neuropathy was found to be predominant among the subjects with long history of DM (p=0.016). Conclusion: We conclude that frequency of autonomic dysfunction is more common among patients with long standing DM patients. Hence, all the diabetic patients with disease duration of more than 5 years should be evaluated for autonomic dysfunction.
Does This Patient With Diabetes Have Large-Fiber Peripheral Neuropathy?
Jama-journal of The American Medical Association, 2010
In the cases below, the clinician would like to know if the following patients with diabetes may have large-fiber peripheral neuropathy (LFPN). Case 1 A 59-year-old woman with type 2 diabetes admits that she rarely checks her blood glucose level and is not careful with her diet. She denies any numbness or tingling in her feet, but on routine examination she cannot feel a Semmes-Weinstein monofilament. Case 2 A 63-year-old man with a 7-year history of poorly controlled type 2 diabetes mellitus presents with numbness and paresthesias in his feet. He feels like he is walking on sand. On examination, decreased vibration sense at both ankles is found. WHY IS THIS QUESTION IMPORTANT? Peripheral neuropathy in patients with diabetes mellitus increases the risk of foot ulceration and diabetic foot infection 7-fold. 1-3 This, in turn, contributes to considerable morbidity and is the causative role in up to 61% of lower extremity amputations. 4 The mortality rate within 5 years after such amputation ranges from 39% to 80%. 5 Diabetes patients with predominantly LFPN tend to experience numbness and tingling in the feet, whereas those with small-fiber involvement describe sharp, burning, or shooting pain sensations. Large-fiber peripheral neuropathy is often heralded by the insensate foot, though patients may be unaware of their condition. Nearly half of diabetes patients with foot ulceration lack symptoms of numbness or pain. 6,7 While most guidelines (http://guidelines.gov; search on "diabetic foot neuropathy") recommend annual inspection of the feet and monofilament testing for LFPN, some guidelines suggest options to use vibra-See also Patient Page. CME available online at www.jamaarchivescme.com and questions on p 1546.
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References (5)
- Singer W, Spies J, McArthur J, Low J, Griffin J, Nickander K, et al. Prospective evaluation of somatic and autonomic small fibers in selected autonomic neuropathies. Neurology. 2004;62:612-8.
- Devigili G, Tugnoli V, Penza P, Camozzi F, Lombardi R, Melli G, et al. The diagnostic criteria for small fibre neuropathy: from symptoms to neuropathology. Brain. 2008;13:1912-25.
- Gibbons CH. Small fiber neuropathies. Continuum (Minneap Minn). 2014;20(5 Peripheral Nervous System Disorders):1398-412.
- Themistocleous AC, Ramirez JD, Serra J, Bennett DL. The clini- cal approach to small fibre neuropathy and painful channelopa- thy. Pract Neurol. 2014;14:368-79.
- Chan AC, Wilder-Smith EP. Small fiber neuropathy: Getting big- ger! Muscle Nerve. 2016;53:671-82.
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Introduction: One of the major diseases of worldwide concern is the Diabetes mellitus. 2.8 percent is the current global prevalence of DM in all the age groups and is estimated to be more than 4 percent by the end of 2030. Treatment and prevention of the risk factors to minimize the morbidity of the disease is the present need of thee hour for reducing the prevalence of the disease. Peripheral neuropathy often accompanies DM and also is an important cause of foot ulceration, and amputation. Hence; we investigated the influence of the IGT on peripheral or autonomic nervous system. Material and Methods: The present study was conducted in the department of physiology of the medical institution and included a total of 50 patients with age group of 37 to 62 years who were diagnosed with IGT on testing the 2hPG (second-hour plasma glucose) in oral glucose tolerance testing. 50 normal healthy controls were also included in the present study with comparable age and other demographic parameters. The difference between the longest and the shortest R-R intervals was named 'a'. The median of all R-R intervals was named 'b'. The ratio of 'a' to 'b' was multiplied by 100. The result gives the heart rate variation variability. Increase in pressure above or equal to 16 mmHg was accepted as normal response, increase in pressure between 11 and 15 mmHg was accepted as borderline response, and increase in pressure lower than 11 mmHg was accepted as abnormal response. All the results were analyzed by SPSS software. Results: The mean heart rate variation in the patients group and control group was 21.45 and 23.41 respectively. The mean E:I rate in the patients group and the control group was 1.42 and 1.28 respectively. Non-significant results were obtained while comparing the heart rate variation, E:I rate and valsalva rate in between the two study groups. Non-significant results were obtained while comparing the blood pressure response in between the patients of the two study groups. Conclusion: The degeneration of small-fibers was reached as a conclusion of the evaluation of queries about the complaints, neurological examination, and electrophysiological tests.
Clinicopathological features of acute autonomic and sensory neuropathy
2010
Acute autonomic and sensory neuropathy is a rare disorder that has been only anecdotally reported. We characterized the clinical, electrophysiological, pathological and prognostic features of 21 patients with acute autonomic and sensory neuropathy. An antecedent event, mostly an upper respiratory tract or gastrointestinal tract infection, was reported in two-thirds of patients. Profound autonomic failure with various degrees of sensory impairment characterized the neuropathic features in all patients. The initial symptoms were those related to autonomic disturbance or superficial sensory impairment in all patients, while deep sensory impairment accompanied by sensory ataxia subsequently appeared in 12 patients. The severity of sensory ataxia tended to become worse as the duration from the onset to the peak phase of neuropathy became longer (P50.001). The distribution of sensory manifestations included the proximal regions of the limbs, face, scalp and trunk in most patients. It tended to be asymmetrical and segmental, rather than presenting as a symmetric polyneuropathy. Pain of the involved region was a common and serious symptom. In addition to autonomic and sensory symptoms, coughing episodes, psychiatric symptoms, sleep apnoea and aspiration, pneumonia made it difficult to manage the clinical condition. Nerve conduction studies revealed the reduction of sensory nerve action potentials in patients with sensory ataxia, while it was relatively preserved in patients without
Peripheral Autonomic Neuropathy
Journal of Neuropathology & Experimental Neurology, 2012
Skin biopsy has gained widespread use for the diagnosis of somatic small-fiber neuropathy, but it also provides information on sympathetic fiber morphology. We aimed to ascertain the diagnostic accuracy of skin biopsy in disclosing sympathetic nerve abnormalities in patients with autonomic neuropathy. Peripheral nerve fiber autonomic involvement was confirmed by routine autonomic laboratory test abnormalities. Punch skin biopsies were taken from the thigh and lower leg of 28 patients with various types of autonomic neuropathy for quantitative evaluation of skin autonomic innervation. Results were compared with scores obtained from 32 agematched healthy controls and 25 patients with somatic neuropathy. The autonomic cutoff score was calculated using the receiver operating characteristic curve analysis. Skin biopsy disclosed a significant autonomic innervation decrease in autonomic neuropathy patients versus controls and somatic neuropathy patients. Autonomic innervation density was abnormal in 96% of patients in the lower leg and in 79% of patients in the thigh. The abnormal findings disclosed by routine autonomic tests ranged from 48% to 82%. These data indicate the high sensitivity and specificity of skin biopsy in detecting sympathetic abnormalities; this method should be useful for the diagnosis of autonomic neuropathy, together with currently available routine autonomic testing.
Updates on the Diagnosis and Treatment of Peripheral Autonomic Neuropathies
Current Neurology and Neuroscience Reports, 2022
Purpose of Review Autonomic neuropathies are a complex group of disorders and result in diverse clinical manifestations that affect the cardiovascular, gastrointestinal, urogenital, and sudomotor systems. We focus this review on the diagnosis and treatment of peripheral autonomic neuropathies. We summarize the diagnostic tools and current treatment options that will help the clinician care for individuals with peripheral autonomic neuropathies. Recent Findings Autonomic neuropathies occur often in conjunction with somatic neuropathies but they can also occur in isolation. The autonomic reflex screen is a validated tool to assess sympathetic postganglionic sudomotor, cardiovascular sympathetic noradrenergic, and cardiac parasympathetic (i.e., cardiovagal) function. Initial laboratory evaluation for autonomic neuropathies includes fasting glucose or oral glucose tolerance test, thyroid function tests, kidney function tests, vitamin-B12, serum, and urine protein electrophoresis with immunofixation. Other laboratory tests should be guided by the clinical context. Reduced intraepidermal nerve density on skin biopsy is a finding, not a diagnosis. Skin biopsy can be helpful in selected individuals for the diagnosis of disorders affecting small nerve fibers; however, we strongly discourage the use of skin biopsy without clinical-physiological correlation. Ambulatory blood pressure monitoring may lead to early identification of patients with cardiovascular autonomic neuropathy in the primary care setting. Disease-modifying therapies should be used when available in combination with nonpharmacological management and symptomatic pharmacologic therapies. Autonomic function testing can guide the therapeutic decisions and document improvement with treatment. Summary A systematic approach guided by the autonomic history and standardized autonomic function testing may help clinicians when identifying and/or counseling patients with autonomic neuropathies. Treatment should be individualized and disease-modifying therapies should be used when available.
Clinical Study Of Autonomic Neuropathy In Diabetes Mellitus
Diabetic autonomic neuropathy (DAN) is a serious & common complication of diabetes often overlooked & misdiagnosed. The aim of present study is to observe the presenting manifestations of autonomic neuropathy in diabetes. Material & Methods: 94 diabetes patients proven with blood sugar fasting & post prandial & HbA1c value of RIMS Ranchi Jharkhand India were evaluated for presence or absence of autonomic neuropathy symptoms to diagnose DAN. Battery of tests devised by Ewing & Clarke et al. was done. Tran abdominal USG was done before voiding, and then patients were directed to void urine after that USG was done to look for post-void residue urine volume. Observation: out of 94 patients 67 (71%) had one or more tests positive for parasympathetic dysfunction & 44 patients (47%) was positive for sympathetic dysfunction. Advanced CAN was present in 34 patients (37%) & 38 patients (40%) had early CAN. Out of 94 patients, 50 patients (53%) had post-void residual urine volume ≥ 100 ml while 44 patients (47%) had post-void residual volume < 100 ml.
Idiopathic Autonomic Neuropathy
Archives of Neurology, 2004
Background: The clinical characteristics of autoimmune autonomic neuropathy are only partially defined. More than 50% of patients with high levels of ganglionic acetylcholine receptor (AChR) autoantibodies have a combination of sicca complex (marked dry eyes and dry mouth), abnormal pupillary light response, upper gastrointestinal tract symptoms, and neurogenic bladder. Objective: To compare patients with idiopathic autonomic neuropathy who were seropositive (n=19) and seronegative (n= 87) for ganglionic AChR antibodies. Design: Retrospective review of autonomic programmatic database.
Subclinical autonomic neuropathy in Saudi type 2 diabetic patients
Neurosciences (Riyadh, Saudi Arabia), 2007
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