Endocrine Abstracts

Case: 55 year old male presented with severe sharp and burning pain at anterior aspect of both legs (radiating from groin to feet), worse at night, unable to keep bed sheets lying on legs due to pain (allodynia). Patient reported weight loss of 3 stones in last 1 year including a recent 1 stone weight loss in 2 months. Patient is a type II DM for the last 3 years. He was intolerant to Metformin and is on Gliclazide 160 mg BD. Alcohol intake around 40 units per week. Initial investigations revealed poorly controlled diabetes with ketonuria and glycosuria and HbA1c 116 and Hyponatremia Na 126 . Patient was started on basal bolus insulin, dietician review and optimization of Insulin and adequate pain control. After initial presentation, patient had several readmissions with symptoms of significant postural drop, ongoing weight loss leading to cachexia and ultimately bed bound along with significant hyponatremia

Investigations: Cortisol=215(1048 h)

Short Synacthen Test 00 min=102

60 min=550

CTCAP: Bilateral lower paratracheal and right hilar lymph nodes of unclear significance.

Neurology review: Lumbar puncture and immunological tests: No evidence of paraneoplastic syndrome.

Nerve conduction studies: Sensory motor polyneuropathy->axonal type.

Lumbosacral MRI-> Normal

PET scan->FDG avid lymph nodes

EBUS guided lymph nodes biopsy->negative

Further PET scan->reduction in size of lymph nodes

Further interval CT scan->resolution of the lymph nodes

Autonomic tests at NHNNà Normal

Results and treatment: Patient HbA1c improved to 68 mmol/mol with insulin and diet optimization.

Marked improvement in symptoms over next 7–8 months.

Weight slowly came up by 4 stones.

Postural symptoms resolved. Urinary catheter removed.

Sharp leg pains completely settled.

Has some difficulty in getting up from sitting but mobile with no support.

Conclusion and point of discussion: Learning points:

• A case of dramatic deterioration in a diabetic patient with severe weight loss and neuropathy à eventual spontaneous and marked recovery

• Clinical picture fits with the rare syndrome of ‘Diabetic neuropathic cachexia’

• Typically Men with T2 DM in 6th/7th decade life

• Severe rapid symptoms, Anorexia, marked weight loss, Bilateral painful neuropathy often with allodynia, Emotional disturbance, autonomic dysfunction

• Spontaneous recovery over months

• Retinopathy and nephropathy are usually absent

• Pathophysiological basis remains unknown

• Having knowledge of this syndrome, we can optimistically predict recovery.

Question for discussion:: • How far should we have investigated for weight loss? Was PET scan appropriate?

• Do we agree with the final diagnosis? OR is there an alternative more appropriate diagnosis