Diabetes mellitus (DM) is a global health issue. Sri Lanka has the second highest diabetes prevalence at 2079 years in South-East-Asia (1). Diabetic-radiculoplexus-neuropathy is a rare entity causing significant disability, also known as diabetic amyotrophy and Bruns-Garland syndrome, occurring due to immune mediated microvasculitis (2). Although Diabetic-lumbo-sacral-radiculoplexes-neuropathy (DLRPN) is well described, Diabetic-cervical-radiculoplexus-neuropathy (DCRPN) is rare. We report two cases of DLRPN and DCRPN as the first presentation of DM.
Case-1: A previously healthy 49-year-old Sri Lankan hotel chef presented with painful weakness and wasting of left arm for 3 months with weight loss. Left shoulder-girdle muscles were wasted with diminished power and reflexes. He had high Erythrocyte-sedimentation-rate (ESR) at 60 mm/hr, with normal C-Reactive protein (CRP). His cerebrospinal fluid (CSF) showed albumino-cytological-dissociation with high CSF protein at 70 mg/dl and unremarkable high volume cytospin. His magnetic resonance imaging (MRI) of cervico-thoracic spine with brachial plexus was normal. His Fasting blood glucose (FBG) was198 mg/dl, and HbA1C was 9%, confirming newly diagnosed DM. Nerve conduction study (NCS) showed comparative amplitude reduction. 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 previously healthy 47-year-old carpenter presented with asymmetrical painful weakness of thighs for 5 months with weight loss and fatigue. Lower limb proximal muscles were asymmetrically wasted with reduced power and knee jerks. He had high ESR of 72 mm/hr with normal CRP and CSF showing albumino-cytological-dissociation with unremarkable high volume cytospin. He was diagnosed with DM on admission, with FBG of 208 mg/dl and HbA1C of 9.4%. MRI and NCS were normal. Electromyogram showed similar changes in both quadratus femoris, more on left side. Both had no trauma history, infection or osmotic symptoms. Screening for an alternative aetiology was unremarkable. Patient1 was diagnosed with DCRPN while patient2 with DLRPN. Both showed significant improvement following optimization of glycemic control, with symptomatic treatment and physiotherapy.
DCRPN and DLRPN were never reported as the first presentation of diabetes in Sri Lanka. DCRPN is rare and can lead to misdiagnosis. This is an eye opener to consider a new diagnosis of diabetes mellitus even in previously healthy patients presenting with radiculo-plexus neuropathies to the Neurology department.
1. International Diabetes Federation. IDF Diabetes Atlas [Internet]. 9 th ed. Brussels, Belgium; 2019. Available from: https://www.diabetesatlas.org
2. James B Dyck P, Windebank AJ. Diabetic and nondiabetic lumbosacral radiculoplexus neuropathies: New insights into pathophysiology and treatment. Muscle and Nerve. 2002;25(4):47791.
22 May 2021 - 26 May 2021