당뇨병과 연관된 근신경계 질환 2 예 내분비 대사 내과 R1 강성욱 /Prof. 전숙

CASE 1

Chief complaintment Painful swelling of right thigho/s) 3 weeks ago Present illness M/35, 평소 특이 병력 없다가 2002 년에 primary clinic 에서 DM 진단받고 간헐적으로 P.O medication 해오던 자로 3 주전부터 시 작된 painful swelling of right thigh 를 주소로 내원함 (M/35) 임 O 준 Adm via OPD (M/35) 임 O 준 Adm via OPD

Past medical history DM/HTN/TB/Hepatitis (+/-/-/-) DM: 2002 년 진단. Metformin 1000mg 1T bid Trauma or needle injection history on Rt. Thigh(-) Ureter stone (+) : 1999 년, spontaneously resolved Drug Hx (-) Allergy Hx(-) OP Hx (-) Personal history Alcohol (+) : 소주 2~3 잔 X 주 1 회 Smoking (-)

Family hystory stroke Arrythmia, Liver Cirrhosis

Review of system 1. General Fever (-)Chill (-) Fatigue (-)Wt. change (-) 2. Skin Rash(-) Itching (-) 3. Respiratory Cough (-)Sputum (-) Dyspnea (-)Hemoptysis (-) 4. Head&neck Headache (-) Decreased visual acuity (+) 5. Cardiac Chest pain (-) DOE (-)Palpitation (-) 6. GI A/N/V/D/C (-/-/-/-/-) Abdominal pain (-) Melena (-)Hematochezia (-) 7. GU Flank pain (-) Dysuria (-) Urgency (-) 8. Back & Ext PPh edema (+/-) : Rt. Lower Ext. Rt. Thigh pain (+) Heating sensation (+) 9. Endocrine Polyruia (+) Polydipsia (+)

Physical examination Ht cmWt 51.6 kgBMI 18.1 kg/m2 V/S 120/80 – ’C 1. General - Alert consciousness - Acute ill looking appearance 2. Skin - No rash or pigmentation - Normal skin turgor 3. Head and Neck - Normocephaly - No thyroid enlargement or tenderness - No neck vein engorgement 4. Eye/ENT - Isocoric pupil with PLR (++/++) - Pinkish conjunctivae -Whitish sclera - PI (-) PTH (-/-)

Physical examination 5. Thorax - Symmetric chest expansion - Clear breathing sound without rale - Regular heart beat without murmur 6. Abdomen - Soft, flat abdomen - Normoactive bowel sound - tenderness (-) rebound tenderness (-) - No hepatosplenomegaly 7. Back / Extremity - CVA tenderness (-/-) - Rt. Thigh : nonpitting edema (+/-), Td(+), febrile sense(+) palpable mass(+), skin decoloration (-) 8. Neurology - Babinski sign (-/-) V V V V motorsensory 100

Initial lab finding 1. CBC/DC 9,190/ ㎕ – 12.2g/ ㎗ – 36.3% - 565,000/ ㎕ (seg:78.9%) 2. Chemistry Total bilirubin 0.4 mg/dLBUN/Cr 24/0.4 mg/dL Protein/Albumin 6.5/4.1 g/dLNa/K/Cl 132/4.6/95 mEq/L AST/ALT 36/48 IU/LCa/P/Mg 9.1/3.6/2.3 mg/dL ALP/rGT 86/26 IU/LUric acid 2.4 mg/dL CRP 0.3 mg/dLCK/LD 436/197 IU/L Glucose 446 mg/dLHbA1C 14.5% Cholesterol 189 mg/dLTG 46 mg/dL LDL Cholesterol 94 mg/dLHDL Cholesterol 72 mg/dL Apo lipoprotein A1 128 mg/dLApo lipoprotein B 88 mg/dL 3. UA RBC 0~1/HPFWBC 0~1/HPFKetone (-) Protein (+-)Nitrite (-) Glucose (++++)

Chest X-ray

ECG

Problem list #1. Rt. Thigh painful swelling #2. Uncontrolled DM

Initial assessment & plan #1. Rt. Thigh painful swelling S&O) Rt thigh painful swelling, tenderness(+), heating sensation(+), palpable mass(+), skin color change(-) A) Rt. thigh myositis R/O Deep vein thrombosis R/O Lymphoedema P) Diagnostic : Rt. thigh sono Rt. thigh MRI Lower extremity doppler sono D-dimer If needed) autoimmune marker, bone scan Therapeutic : Rest, leg elevation Conservative Mx If needed) antibiotics

Initial assessment & plan #2. DM S) Decreased visual acuity(+), polyuria(+), polydipsia(+), wt loss(-) O) HbA1C 14.5 %, random plasma glucose 445 mg/dL Urine glucose(++++) A) Uncontrolled DM P) Diagnostic : serial GMT check C-peptide activity test auto Ab test DM complication test Therapeutic : Strict glucose control  MDI (long acting insulin qd+ rapid acting insulin tid)

Rt. Thigh Sonography & MRI Rt. Thigh Sonography & MRI & 26

US guided Aspiration US guided Aspiration fluid of intermuscular fascial plane adjacent to vastus lateralis muscle : Clear, watery fluid Gram stain : not found, a few WBC cell

Autoimmune markers & doppler US RA factor (<20) <10 IU/mL C3 (88~201) 143 mg/dL C4 (16~47) 43.9 mg/dL C-ANCA (-) P-ANCA (-) ANA ( 정량 ) (-) Anti-Scl-70 (-) Other Abs N-S No evidance of DVT

Bone scan

Management #1. Diabetic myonecrosis acetaminophen 등 pain control, supportive care

C-peptide activity test & auto Ab test C-peptide activity test Auto Ab test Anti GAD Ab (<1.0)1.40 U/mL Anti IA2 Ab (<0.4)<0.4 U/mL C-peptide(ng/mL) 0min0.1 6min0.3 (<4~10)

DM complication test Microvascular Cx test Fundoscopic finding : hard exudate, multifocal hemorrage, micro aneurysm (Rt>Lt)  sever nonproliferative DR Microalbumin(spot urine) : 152 ug/mg  nephropathy Nerve conduction velocity : decresed in median & ulnar motor & sensory, peroneal motor, post tibial motor, sural sensory  polyneuropathy Macrovascular Cx test : N-S

Management #2. DM 3/22~24 detemir 14 IU qd + lispro 10 IU tid 3/26~4/5 detemir 16 IU qd + lispro 12 IU tid

Final diagnosis 1. Diabetic myonecrosis 2. DM with multiple microvascular complication

CASE 2

Chief complaintment Both lower extremity pain & numbness, tingling sensation o/s) 3months ago Present illness M/41, 2002 년 타원에서 Type 2 DM 진단 받았으나 치료 없이 지 내다가 2010 년 2 월부터 OHA 로 혈당 조절 시작한 자로 내원 3 개 월전부터 상기 증상 생겨 타병원 입원하여 당뇨병성 신경병증 진 단 하에 치료하였으나 통증 지속되어 강동경희대병원 방문 (M/41) 백 O 석 Adm via OPD (M/41) 백 O 석 Adm via OPD

Past medical history DM/HTN/Tb/Hepatitis (+/-/-/-) DM(+) : 2002 년 진단 후 2010 년 2 월까지 치료 하지 않음 년 2 월부터 OHA 복용 시작 Medication Hx OHA : Glimepride 4mg qd, Acarbose 100mg qd DM neuropathy : Imipramine(TCA), Duloxetin(SNRI), Alprazolam(BZD) OP Hx (+) : Laparoscopic appendectomy, 약 10 년전 Personal History Smoking (+) : 10 pack years(0.5 pack/day, for 20 years) Alcohol (-) Occupation : 건축 사업가

History Family hystory DM (+)

Review of system 1. General Fever (-)Chill (-) Wt. loss (+) : 5kg/6mon 2. Skin Rash(-) Itching (+) 3. Respiratory Cough (-)Sputum (-) Dyspnea (-)Hemoptysis (-) 4. Head&neck Headache (-) Sore throat (-) 5. Cardiac Chest pain (-) DOE (-)Palpitation (-) 6. GI A/N/V/D/C (-/-/-/-/-) Abdominal pain (-) Melena (-)Hematochezia (-) 7. GU Flank pain (-) Dysuria (-) 8. Back & Ext both lower extremity: pain, numbness, tingling sensation 9. Endocrine Polyruia (-)Polydipsia (-) Location : thigh ~ toe Character : stabbing pain Pain intensity : continuous pain NRS 6-7 breakthrough pain 5~6 회 /day (NRS 10) Duration : abrupt onset, about 1hour Aggravation factor (-) Relieving factor (-)

Physical examination Ht 169 cmWt 48 kgBMI 16.8 kg/m2 V/S 101/60 – ’C 1. General - Alert conciousness - Chronically ill looking appearance 2. Skin - No rash or pigmentation - Normal skin turgor 3. Head and Neck - Normocephaly - No thyroid enlargement or tenderness - No neck vein engorgement 4.Eye/ENT - Isocoric pupil and PLR (++/++) - Pinkish conjunctivae -Whitish sclera - PI (-) PTH (-/-)

Physical examination 5.Thorax - Symmetric chest expansion - Clear breathing sound without rale - Regular heart beat without murmur 6. Abdomen - Soft, flat abdomen - Normoactive bowel sound - tenderness (-) rebound tenderness (-) - No hepatosplenomegaly 7.Back / Extremity - CVA tenderness (-/-) - Both lower extremity muscle atrophy 8.Neurology - Babinski sign (-/-) V V V V motorsensory Muscle strength knee extension : Gr 5 ankle dorsiflexion : Gr 5 Reflex Achilles tendon reflex : hypoactive Sensation pinprick test : index finger- normal big toe- decreased(both) touch pressure- decreased vibration perception- decreased

Initial lab finding 1. CBC/DC 4,400/ ㎕ – 13.6g/ ㎗ – 39.2% - 236,000/ ㎕ (seg:67.4%) 2. Chemistry Total bilirubin 0.4 mg/dLBUN/Cr 13/0.7 mg/dL Protein/Albumin 7.6/4.7 g/dLNa/K/Cl 143/3.8/107 mEq/L AST/ALT 13/21 IU/LCa/P/Mg 8.6/4.6/1.9 mg/dL ALP/rGT 189/27 IU/LUric acid 3.8 mg/dL CRP 0.07 mg/dLCK/LD 22/278 IU/L Glucose 164 mg/dLHbA1C 6.6% Cholesterol 122 mg/dLTG 45 mg/dL LDL Cholesterol 77 mg/dLHDL Cholesterol 40 mg/dL 3. UA RBC 0~1/HPFWBC 0~1/HPFKetone (-) Protein (-)Nitrite (-) Glucose (-)

Chest X-ray

ECG

Problem list #1. Both lower extremity atrophy, pain, numbness, tingling sensation #2. Known DM

#1. Both lower extremity pain with tingling sensation, atrophy S) Both lower extremity pain, numbness, tingling sensation O) Both lower extremity muscle atrophy & decreased sensation A) Diabetic symmetric polyneuropathy R/O other uncommon diabetic neuropathy P) Diagnostic : electromyography & nerve conduction study if needed) spine MRI Therapeutic : pain control with antidepressants or antiepileptics DIABETIC NEUROPATHY (Harrison’s internal medicine 17 th edition) Symmetric Diabetic Neuropathy Diabetic sensorimotor polyneuropathy Asymmetric Diabetic Neuropathy Cranial neuropathy Radiculopathies and plexopathies Diabetic truncal radiculoneuropathy Diabetic lumboscral radiculoplexopathy(amyotrophy) Uncommon Diabetic Neuropathy Diabetic neuropathic cachexia Insulin neuritis Initial assessment & plan

#2. DM S) Polyuria(-), polydipsia(-) O) HbA1C 6.6%, random plasma glucose 164 mg/dL A) DM P) long acting insulin + OHA(Glimepride 4mg qd, Acarbose 100mg qd if needed) MDI 고려

Nerve conduction study & Electromyography NCS Rt lateral femoral cutaneous nerve : Low motor & sensory nerve action potential amplitude Rt common peroneal nerve : Slow motor & sensory nerve conduction velocity Bilateral plantar nerves : Abscent sensory nerve action potential EMG Mild denervation : Rt vastus lateralis, vastus medialis, iliopsoas muscles Conclusion  Mononeuritis multiplex and Rt chronic lower lumbosacral (L3-S1) polyradiculopathy Lumboscral radiculoplexopathy Polyneuropathy OnsetAbruptInsiduous LocationFocalDiffuse Initial symptomeUnilateralSymmetrical ComplicationRareOften Glycermic controlWell controlledNot well controlled Weight lossFrequentNot frequent DM durationShortLong

MRI – Lumbosacral spine

Management Harrison’s internal medicine 17 th edition

Clinical course #1. Diabetic lumboscral radiculoplexopathy (amyotrophy) Pregabalin 150mg bid Alprazolam 0.25mg bid Pregabalin 300mg bid Alprazolam 0.25mg bid Pregabalin 300mg bid Alprazolam 0.25mg bid Duloxetin 30mg qd PRN) Tramadol IV 50mg

Management #2. DM 7/20~26 detemir 10 IU qd + Glimepride 4mg qd, Acarbose 100mg qd 7/27~8/2 detemir 10 IU qd + aspart 4 IU tid

Final diagnosis 1. Diabetic lumboscral radiculoplexopathy (amyotrophy) 2. DM