Abstract
Acute painful diabetic neuropathy (APDN) is a distinctive diabetic polyneuropathy and consists of two subtypes: treatment-induced neuropathy (TIN) and diabetic neuropathic cachexia (DNC). The characteristics of APDN are (1.) the small-fibre involvement, (2.) occurrence paradoxically after short-term achievement of good glycaemia control, (3.) intense pain sensation and (4.) eventual recovery. In the face of current recommendations to achieve quickly glycaemic targets, it appears necessary to recognise and understand this neuropathy. Over 2009 to 2012, we reported four cases of APDN. Four patients (three males and one female) were identified and had a mean age at onset of TIN of 47.7 years (±6.99 years). Mean baseline HbA1c was 14.2% (±1.42) and 7.0% (±3.60) after treatment. Mean estimated time to correct HbA1c was 4.5 months (±3.82 months). Three patients presented with a mean time to symptom resolution of 12.7 months (±1.15 months). One patient had an initial normal electroneuromyogram (ENMG) despite the presence of neuropathic symptoms, and a second abnormal ENMG showing axonal and myelin neuropathy. One patient had a peroneal nerve biopsy showing loss of large myelinated fibres as well as unmyelinated fibres, and signs of microangiopathy. According to the current recommendations of promptly achieving glycaemic targets, it appears necessary to recognise and understand this neuropathy. Based on our observations and data from the literature we propose an algorithmic approach for differential diagnosis and therapeutic management of APDN patients.
Highlights
Peripheral neuropathies are well-known complications of diabetes [1]
Since several cases with a similar history and clinical picture have been reported, which is described as diabetic neuropathic cachexia (DNC) and considered a subtype of Acute painful diabetic neuropathy (APDN) [13,14,15]
The design of our study does not allow accurate epidemiological data to be calculated, because of the absence of systematic screening for APDN and possible selection biases, it can be inferred from this number that the incidence of APDN is probably below 1 in 1,000 diabetic patients, which suggests that this condition may be very rare
Summary
Peripheral neuropathies are well-known complications of diabetes [1]. The two most common types are the chronic, slowly progressive, length-dependent, axonal (or dying back) polyneuropathy involving all nerve fibre types, often referred to as distal symmetric polyneuropathy (DSP), and the more recently recognised small fibre neuropathy [2]. APDN was initially reported in 1933 by Caravati [4] as “insulin neuritis” in a woman with diabetes who had acute pain in the lower extremities that appeared 4 weeks after insulin initiation. A recent investigation of TIN in 16 patients suggested a predominantly nociceptive and autonomic small nerve neuropathy [11]. Four decades after the first TIN description, Ellenberg reported a case series of 6 patients with painful diabetic neuropathy, depression and cachexia arising at the time of clinical diagnosis of diabetes [12]. Since several cases with a similar history and clinical picture have been reported, which is described as diabetic neuropathic cachexia (DNC) and considered a subtype of APDN [13,14,15]
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