Paraparesis as a Presenting Manifestation of Type 2 Diabetes

Abstract

A 60-year-old patient with an insignificant medical history came to our outpatient department with complaints of sudden-onset leg weakness, urinary incontinence, and difficulty in speaking for the past 2 days. He reported no history of trauma, loss of consciousness, headache, vomiting, convulsions, or preceding fever. On examination, he was conscious, with a blood pressure of 170/96 mmHg and a regular pulse of 84 bpm. Spinal palpation revealed no abnormality or tenderness. He had abulia, trans-cortical motor aphasia, and urinary incontinence. Frontal release reflexes—the snout reflex, forced grasping reflex, and glabellar tap—were enhanced. Cranial nerves were normal bilaterally. Sensory loss was present in both lower limbs. Motor examination revealed spastic paraparesis. Bilateral Babinski, Chaddock, and Hoffmann signs were positive. Routine investigations revealed normal hemogram, liver, and renal function test results. However, his fasting and postprandial plasma glucose values were found to be 246 and 350 mg/dl, respectively. To know whether this hyperglycemia represented previously undiagnosed type 2 diabetes or stress hyperglycemia, we ordered an A1C, with a result of 9.6%. The patient was thus identified as having type 2 diabetes. Examination of ocular fundi showed bilateral nonproliferative diabetic retinopathy, urine examination documented proteinuria of 1 g/day, and a nerve conductions velocity study revealed bilateral sensory motor neuropathy. His lipid profile revealed triglycerides of 224 mg/dl, total cholesterol of 160 mg/dl, HDL cholesterol of 29 mg/dl, VLDL cholesterol of 32 mg/dl, and LDL cholesterol of 116 mg/dl. In view of clinical findings suggestive of frontal lobe involvement, we ordered a magnetic resonance imaging (MRI) study of the brain. The MRI showed bilateral, ill-defined, wedge-shaped lesions in the anterior cerebral artery territories that were hyper-intense on T2W imaging (Figure 1). Diffusion-weighted imaging confirmed these lesions to be acute infarcts (Figure 2). Magnetic resonance angiography (MRA) revealed narrowing of the A1 segment of the …