Diabetic distal symmetric polyneuropathy

Genetic testing

NCV/EMG

Laboratory

Imaging

Biopsy

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Fig. 2. Diabetic neuropathy. Pes planus A, sensory loss may induce osteous changes with collapse of the small foot bones-see X ray B

Fig. 3. Sural nerve biopsy from a patient with diabetic neuropathy and an asymptomatic control subject. A Normal sural nerve showing an abundant and normal distribution of myelinated fibers. B Sural nerve from a patient with diabetes showing severe loss of axons. C High magnification view of B showing loss of myelinated fibers, splaying of myelin with early onion bulb form formation

Anatomy/distribution

Both large and small sensory and motor nerves are affected in diabetic distal symmetric polyneuropathy (DPN). DPN is a length dependent neuropathy affecting the feet first.

Symptoms

DPN is most commonly a slowly progressive disorder. A rapid onset can be seen in newly diagnosed type 1 patients when rigorous glycemic control is abruptly instituted. Equally common among men and women, 85% of patients have an insensate foot with negative sensory and motor symptoms. Fifteen percent of patients have positive symptoms with paresthesias, dysesthesias, pain and muscle cramps. Patients with an insensate foot are at risk for foot injury and ulceration.

Clinical syndrome/ signs

DPN occurs in both type 1 and type 2 diabetic patients. The severity of DPN correlates with the degree and duration of diabetes. After 25 years of diabetes, at least 50% if not more of patients have DPN. Examination of the feet reveals atrophic skin changes, callous and fissure formation (Fig. 2). Commonly all sensory modalities are decreased in a stocking-glove pattern with loss of ankle reflexes. Weakness is uncommon and present distally in only the most severe cases. When sensation loss reaches the midcalf, early sensory loss is found in the fingers.

Pathogenesis

Diagnosis

The Diabetes Control and Complications Trials (DCCT) confirmed that hyperglycemia underlies the development of DPN. It is likely that the hyperglycemic state disrupts both the normal metabolism and blood flow of peripheral nerves.

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