J Neurol Res
Journal of Neurology Research, ISSN 1923-2845 print, 1923-2853 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Neurol Res and Elmer Press Inc
Journal website http://www.neurores.org

Review

Volume 6, Number 5-6, December 2016, pages 91-94


Peripheral Neuropathies Associated With Diabetes Mellitus: A Review

Abu Khalid Muhammad Maruf Raza

Department of Pathology, Jahurul Islam Medical College, Bajitpur, Kishoregonj, Bangladesh

Manuscript accepted for publication December 07, 2016
Short title: Peripheral Neuropathies Associated With DM
doi: https://doi.org/10.14740/jnr412e

Abstract▴Top 

The review aimed to describe various diabetes mellitus-associated peripheral neuropathies, various related diseases and clinical features. English-language literature search using a combination of words (diabetic neuropathy and diagnosis) was used to identify original studies, consensus statements, and reviews published in the last few years. The diverse neuropathies of diabetes mellitus can be seen in various research articles which are found in clinical practice. Prompt diagnosis and recognition of these with the institution of appropriate treatment measures would go a long way towards reducing morbidity and mortality outcomes.

Keywords: Diabetes; Peripheral; Neuropathies

Introduction▴Top 

Diabetic peripheral neuropathy is defined as the presence of symptoms and signs of peripheral nerve dysfunction in people with diabetes after the exclusion of other causes [1]. It manifests in the somatic, sensory and/or autonomic parts of the peripheral nervous system [2]. The sensory phenotype is divided into small, large or mixed fiber types. Symptoms of neuropathy are very common, and subclinical neuropathy is more common than clinical neuropathy [3]. Neuropathy may remain undetected, and progress over time leading to serious complications. With the rising global burden of diabetes, peripheral neuropathy, and other diabetes complications are expected to be on the increase. This would negatively affect their quality of life and mortality. The most common clinical presentation of diabetic peripheral neuropathy is distal symmetrical polyneuropathy [4].

This review focuses on the common neuropathies encountered in clinical practice. We also bring to fore the rarely thought about neuropathies commonly misdiagnosed as other conditions. A good knowledge of these neuropathies would go a long way in improving the patient care offered by the diabetes clinician.

Anatomic Considerations▴Top 

Small fiber neuropathies manifest with painful paresthesias most commonly over the lower limb. The pain may be dull, aching, burning, lancinating or cramp-like. Paresthesias may manifest as a sensation of coldness, numbness or tingling. There may be associated diminution of pain and temperature perception in the lower limbs in a glove and stocking distribution. Features of large fiber neuropathy include loss of ankle jerk, impaired position, and vibration sensory ataxia. Mixed small and large fiber neuropathy is the most common variety of painful diabetic neuropathy [5].

Acute Painful Neuropathy▴Top 

First described by Archer and Watkins [6] in 1983, is a distinct and common variant of distal symmetrical polyneuropathy that presents with abrupt onset of severe sensory symptoms with little or no sensory and motor signs. It usually follows a period of change in glycemic control. It usually starts with rapid weight loss over a short period followed by severe, unremitting pain mostly in the feet. Optimizing glycemic control eventually leads to weight gain and remission of symptoms [7].

Chronic Sensorimotor Distal Symmetrical Polyneuropathy (DSPN)▴Top 

Chronic sensorimotor DSPN is the most common form of diabetic neuropathy. It is present in more than 10% of patients at the diagnosis of type 2 diabetes with an insidious onset. More than 80% of patients with clinical diabetic neuropathy have a distal symmetrical form of the disorder [8].

Symptoms may be positive or negative. Positive symptoms include feelings of pins and needles, tingling, burning, and neuropathic pain. Negative symptoms include numbness, impaired tactile, thermal and pain sensation. Positive symptoms, probably due to neural hyperexcitability, include pins and needles and pain which may be of varying qualities (burning, aching or lancinating). These negative and positive sensory symptoms may coexist. Symptoms begin distally in the toes and the feet and gradually extend proximally to involve the hands and fingers. This pattern of spread or progression reflects the dying-back nature of underlying nerve damage [9].

Painful Small Fiber Neuropathy▴Top 

It is a variant of distal sensorimotor polyneuropathy in which the small myelinated fibers are affected alone or out of proportion to large nerve fibers. Key complaints are burning or stabbing pain in the feet which may be spontaneous [10]. This form of neuropathy is usually distressing and debilitating, impairing patient’s quality of life.

Focal Limb Neuropathies▴Top 

Most persons with diabetes and upper limb neuropathic symptoms and signs will either have a mononeuropathy or multiple mononeuropathies. This adds to the disability already imposed by the polyneuropathy that is almost always present. Ulnar neuropathies in people with diabetes are often insidious and are mainly motor with limited sensory symptoms and signs. Such focal neuropathies can easily go undetected because their symptoms are thought to be due to a polyneuropathy [11]. When sensory or motor symptoms are more prominent in the hands than feet, carpal tunnel syndromes or ulnar neuropathies should be suspected and excluded.

Cranial Neuropathies (Diabetic Ophthalmoplegia)▴Top 

Oculomotor nerve palsies are the most common cranial neuropathy observed in diabetic patients. It rarely occurs in children. It affects mostly middle-aged adults. The pupillary function is spared. It has been attributed to ischemia occurring centrally within the third nerve, preserving the peripherally located parasympathetic pupil-constrictor fibers. This is in contrast to compressive lesions of the oculomotor nerve, such as an aneurysm of the posterior communicating artery, in which the pupillary fibers are affected [12]. Sixth nerve palsies also occur, but rarely. It is unclear whether seventh nerve palsies occur more frequently in people with diabetes than in the general population.

Compression Neuropathies▴Top 

Compression or entrapment neuropathies are more common in people with diabetes. They include carpal tunnel syndrome (CTS), ulnar neuropathy at the elbow (UNE), meralgia paraesthetica (entrapment of the lateral femoral cutaneous nerve of the thigh) at the inguinal ligament or peroneal neuropathy at the fibular head [13]. Nerve conduction studies should be carried to conform compressive median or ulnar mononeuropathies and to screen for associated axonal injury. Those found to have pure demyelinating neuropathy usually respond well to positional splints while those with active demyelination are treated with carpal tunnel decompression which is nearly as effective for diabetic patients as for normoglycemic controls [14].

Diabetic Truncal Radiculoneuropathy▴Top 

It occurs in the setting of long-standing diabetes with other complications, especially polyneuropathy. Most of the affected individuals are in the fifth or sixth decade of life with a variable duration of diabetes [15]. It presents gradually with painful paresthesias in variable size patches unilaterally or bilaterally in the lower anterior chest or upper abdomen with nocturnal worsening. Associated involvement of motor nerve fibers can lead to bulging of the abdominal wall in the paraesthetic areas, best appreciated when the patient is standing.

Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)▴Top 

Patients with diabetes mellitus (DM) seem to develop clinical and electrophysiologic characteristics in keeping with CIDP. This condition tends to occur more frequently in people with diabetes than in non-diabetics. The rapid onset and progression of the neuropathy, demyelinating features on nerve conduction studies and an excellent response to immunomodulatory treatments distinguish this entity from the far more frequent chronic diabetic sensorimotor polyneuropathy [16]. Treatment should be instituted promptly to prevent ongoing demyelination and the secondary axonal loss that would result in permanent disability.

Hypoglycemic Neuropathy▴Top 

It is a distal symmetrical predominantly sensory neuropathy occurring on a background of recurrent episodic symptoms secondary to hypoglycemia. Hypoglycemia causes effects in both the central and peripheral nervous systems. Energy depletion plays a key role in the pathogenesis of hypoglycemia-induced neuropathy [17]. Ischemia also plays a role. The electrophysiological findings are suggestive of a primary axonal neuropathy with evidence of secondary demyelination. The pathologic changes in hypoglycemic neuropathy may include axonal neuropathy, anterior horn cells destruction in cervical spinal cord with normal dorsal and ventral roots and dorsal root ganglia, or even a normal nerve [18]. There is a need to exclude the presence of an insulinoma as the literature on humans developing a hypoglycemic neuropathy is small and related to the presence of an insulinoma.

Impaired Glucose Tolerance Neuropathy▴Top 

This occurs in persons with normal fasting glucose and glycosylated hemoglobin values. However, they have impaired glucose tolerance (IGT) on oral glucose tolerance testing. This form of diabetic neuropathy manifests as a predominantly sensory neuropathy. Small fiber neuropathic changes occur more commonly in persons with IGT than the normal population [19]. This neuropathy is clinically similar to early diabetic neuropathy with a predilection for small fiber damage leading to distressing pain and autonomic symptoms.

Diabetic Autonomic Neuropathy (DAN)▴Top 

Autonomic nerve involvement is probably the most undiagnosed complication. DAN may present in multiple organ systems in undiagnosed patients and can result in significant morbidity and mortality. Autonomic dysfunction may already exist at the time of type 2 DM diagnosis, and its prevalence in the diabetic population rises with time. In type 1 DM, hypoglycemia unawareness is the most common symptom [20]. Autonomic nerve fibers are invariably involved in chronic sensorimotor polyneuropathy, frequently subclinical in the early stages of the polyneuropathy, although it may be detected using sensitive methods to measure and quantify autonomic function. When symptomatic, this may result in impaired sweating and some skin vasomotor changes. However, the autonomic nervous system may become widely involved and dominate the clinical picture. In most patients, the symptoms are not severe, but some have devastating DAN. The neuropathy may affect all or selected organs or systems innervated by the autonomic nervous system. Thus one or more of the following may develop gastroparesis, diarrhea, constipation, orthostatic hypotension, bladder dysfunction, and erectile dysfunction. About 40% of diabetic men develop erectile dysfunction which may occur in the absence of, or in association with, other manifestations of DAN [21]. The clinical examination of the autonomic nervous system is limited. A resting tachycardia and a fixed heart rate of deep breathing or when the patient goes from lying to standing indicate vagal parasympathetic dysfunction. The simple bedside measurement of lying-standing blood pressure change is an important test for sympathetic vasoconstrictor dysfunction.

Conclusion▴Top 

It is important for clinicians to be knowledgeable about the various neuropathic complications of DM. Autonomic involvement which is a leading cause of mortality in these patients may mistake for other disease complications. Prompt diagnosis and recognition of these with the institution of appropriate treatment measures would go a long way towards reducing morbidity and mortality outcomes.


References▴Top 
  1. Boulton AJ, Malik RA, Arezzo JC, Sosenko JM. Diabetic somatic neuropathies. Diabetes Care. 2004;27(6):1458-1486.
    doi pubmed
  2. Boulton AJ, Vinik AI, Arezzo JC, Bril V, Feldman EL, Freeman R, Malik RA, et al. Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care. 2005;28(4):956-962.
    doi pubmed
  3. Eastman RC. Neuropathy in Diabetes. In: Harris MI, Ed. Diabetes in America, National Diabetes Information, Clearinghouse, 2nd Edition. 1995;339-360.
  4. Kasznicki J. Advances in the diagnosis and management of diabetic distal symmetric polyneuropathy. Arch Med Sci. 2014;10(2):345-354.
    doi pubmed
  5. Vinik AI, Mehrabyan A. Diabetic neuropathies. Med Clin North Am. 2004;88(4):947-999, xi.
    doi pubmed
  6. Archer AG, Watkins PJ, Thomas PK, Sharma AK, Payan J. The natural history of acute painful neuropathy in diabetes mellitus. J Neurol Neurosurg Psychiatry. 1983;46(6):491-499.
    doi pubmed
  7. Thomas PK. Classification, differential diagnosis, and staging of diabetic peripheral neuropathy. Diabetes. 1997;46(Suppl 2):S54-57.
    doi pubmed
  8. De Freitas MRG. Diabetic neuropathy I-Epidemiology, classification, clinical and electrophysiologic aspects. A study of 210 cases. Rev Brasileira Neurol. 1992;28:69-73.
  9. Boulton AJ, Armstrong WD, Scarpello JH, Ward JD. The natural history of painful diabetic neuropathy - a 4-year study. Postgrad Med J. 1983;59(695):556-559.
    doi pubmed
  10. Vital C, Vital A, Dupont M, Gin H, Rouanet-Larriviere M, Lacut JY. Acute painful diabetic neuropathy: two patients with recent IDDM. Journal of the Peripheral Nervous System. 1996;2(2):151-154.
  11. Dyck PJ, Dyck PJB, Englestad J. Pathologic alterations of nerve. Peripheral Neuropathy. 2005;1:733-829.
    doi
  12. Said G. Focal and multifocal diabetic neuropathies. Arq Neuropsiquiatr. 2007;65(4B):1272-1278.
    doi pubmed
  13. Asbury AK, Aldredge H, Hershberg R, Fisher CM. Oculomotor palsy in diabetes mellitus: a clinico-pathological study. Brain. 1970;93(3):555-566.
    doi pubmed
  14. Thomsen NO, Cederlund R, Rosen I, Bjork J, Dahlin LB. Clinical outcomes of surgical release among diabetic patients with carpal tunnel syndrome: prospective follow-up with matched controls. J Hand Surg Am. 2009;34(7):1177-1187.
    doi pubmed
  15. Pourmand R. Diabetic neuropathy. Neurol Clin. 1997;15(3):569-576.
    doi
  16. Krendel DA, Costigan DA, Hopkins LC. Successful treatment of neuropathies in patients with diabetes mellitus. Arch Neurol. 1995;52(11):1053-1061.
    doi pubmed
  17. Hsu YC, Zhan HL, Yang CP. Clinical and experimental evidence of hypoglycemic neuropathy. Diabetes Res Open Journal. 2015;1(5):131-135.
    doi
  18. Tom MI, Richardson JC. Hypoglycemia from islet cell tumour of pancreas with amyotrophy and cerebrospinal nerve cell changes: A case report. Journal of Neuropathology and Experimental Neurology. 1951;10(1):57-66.
    doi
  19. Boulton AJ, Malik RA. Neuropathy of impaired glucose tolerance and its measurement. Diabetes Care. 2010;33(1):207-209.
    doi pubmed
  20. Vinik AI, Maser RE, Mitchell BD, Freeman R. Diabetic autonomic neuropathy. Diabetes Care. 2003;26(5):1553-1579.
    doi pubmed
  21. Toyry JP, Niskanen LK, Mantysaari MJ, Lansimies EA, Uusitupa MI. Occurrence, predictors, and clinical significance of autonomic neuropathy in NIDDM. Ten-year follow-up from the diagnosis. Diabetes. 1996;45(3):308-315.
    doi pubmed


This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


Journal of Neurology Research is published by Elmer Press Inc.

 
Home     |     Log In     |      About     |      Search     |      Current     |      Archives     |      Submit      |     Subscribe


 

     

Aims and Scope

Current Issues

Conflict of Interest

About Publisher

Editorial Board

Archives

Copyright

Company Profile

Editorial Office

Misconduct and Retraction

Permissions

Company Registration

Contact Us

Abstracting and Indexing

ICMJE

Ownership

Instructions to Authors

Access

Declaration of Helsinki

Contact Publisher

Submission Checklist

Reprints

Terms of Use

Company Address

Submit a Manuscript

Open Access Policy

Privacy Policy

Browse Journals

Publishing Fee

Publishing Policy

Disclaimer

Recent Highlights

Peer-Review Process

Publishing Quality

Code of Ethics

Advertising Policy

Manuscript Tracking

Advanced Search

For Librarians

Careers

Publishing Process

Publication Frequency

For Reviewers

Propose a New Journal

       
       

Journal of Neurology Research, bimonthly, ISSN 1923-2845 (print), 1923-2853 (online), published by Elmer Press Inc.     
The content of this site is intended for health care professionals.
This is an open-access journal distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Creative Commons Attribution license (Attribution-NonCommercial 4.0 International CC-BY-NC 4.0)


This journal follows the International Committee of Medical Journal Editors (ICMJE) recommendations for manuscripts submitted to biomedical journals,
the Committee on Publication Ethics (COPE) guidelines, and the Principles of Transparency and Best Practice in Scholarly Publishing.

website: www.neurores.org   editorial contact: editor@neurores.org
Address: 9225 Leslie Street, Suite 201, Richmond Hill, Ontario, L4B 3H6, Canada

© Elmer Press Inc. All Rights Reserved.

DECLARATION: THIS JOURNAL SITE OUTLOOK IS DESIGNED BY THE PUBLISHER AND COPYRIGHT PROTECTED. DO NOT COPY!