Case Study: Ongoing Pain Leads to Diagnosis of Diabetic Amyotrophy

It’s common. It’s prevalent. And it’s very difficult to manage. Diabetic neuropathy affects over 60 percent of patients with diabetes. As the incidence of diabetes continues to grow, physicians will have to deal with this progressive complication and its life-threatening comorbidities at an increasing rate.

“We don’t have effective ways of treating the pain caused by diabetic neuropathy, which greatly impacts the patient’s quality of life,” explains Melissa Li-Ng, MD, Interim Institute Chair for Cleveland Clinic’s Endocrinology & Metabolism Institute. “In light of the opioid crisis, we’d rather not use opioids. Some of our nonopioid medications for diabetic neuropathy, including antidepressants, have terrible side effects such as impaired memory, weight gain, difficulty concentrating and urinary retention.”

Even in the diagnostic phase, diabetic neuropathy can even be difficult to pinpoint — especially in community settings with low patient volumes. “Sometimes it can present as a digestive condition or a spinal problem, leading specialists down the wrong path,” notes Dr. Li-Ng. “That is why it’s always good to get input from another specialist to reach the right conclusion.”

Dr. Li-Ng treated a patient with a specific type of diabetic neuropathy who had suffered for six months without an accurate diagnosis or effective treatment.

Presentation

Dr. Li-Ng’s patient was a 50-year-old female with type 2 diabetes. Starting in August 2017, the patient developed severe pain in the abdomen and leg as well as unintentional weight loss. The patient was a high-functioning executive who was unable to work for six months due to pain and fatigue.

The patient had a history of uncontrolled diabetes for eight years without any other complications. In October 2017, her hemoglobin A1C was 13 percent (the goal is < 7 percent for optimal control). By January 2017, she had lowered her hemoglobin A1C to 6.7 percent. Although she had better control of her diabetes, she was still experiencing excruciating pain.

At home in Michigan, she consulted a neurologist, a rheumatologist and a pain specialist. She was prescribed several medications, including opioid pain medicine. However, her symptoms continued to progress for six months, leaving her unable to walk, eat or sleep.

Diagnosis

In January 2018, the patient referred herself to a spine specialist at Cleveland Clinic to investigate her back pain, leg weakness and burning pain in her left leg. After meeting with the spine specialist, she consulted neurologist Nimish Thakore, MD, who suspected diabetic amyotrophy, a distinct form of diabetic neuropathy.

The neurologist contacted Dr. Li-Ng, who was able to see the patient the next day. After the visit, Dr. Li-Ng confirmed that the patient had diabetic amyotrophy.

Treatment

After conferring with Dr. Thakore, Dr. Li-Ng started the patient on a course of high-dose steroids while keeping her blood sugars well-controlled. (As demonstrated in this case, diabetic amyotrophy can occur in patients with well-controlled diabetes.) The treatment allowed Dr. Li-Ng to manage the patient’s nerve inflammation and improve her function. The patient was also tapered off her pain medication.

Outcome

After just three months of treatment, the patient was feeling much better. She was able to return to work and playing golf. After returning to a normal diet, she went back to her baseline weight. “She’s doing great and feels like she’s got her life back,” notes Dr. Li-Ng.

Since she was an out-of-state patient, she was able to attend all follow-up appointments using virtual visits. This was especially important at the beginning of her treatment when her pain would have made long-distance travel nearly impossible. Dr. Li-Ng continues to manage the patient’s diabetes with virtual visits.

Discussion

Physicians should remember that diabetic neuropathy can present in various forms and does not only cause burning or tingling in the feet or hands. In addition to causing pain, it can affect the gastrointestinal tract, causing slow digestion, nausea, vomiting and diarrhea. The first step to a proper diagnosis is to check for an infection and rule out conditions such as Crohn’s disease in patients with gastrointestinal symptoms, keeping in mind that diabetic neuropathy can lead to gastroparesis or diabetic enteropathy. Diabetic neuropathy can also affect a patient’s heart rate, causing resting tachycardia.

“The sad part is that if our patient’s condition had been recognized and treated properly from the beginning, her inflammation and pain levels would not have reached the point they did, which severely restricted her lifestyle,” says Dr. Li-Ng.

Coordination of care is a vital part of diagnosis and treatment. Because Dr. Li-Ng was located within the same health system as the neurologist, they were able to collaborate and quickly develop a primary treatment plan as well as a backup treatment plan.

“Because diabetes is a multidisciplinary problem, not just an endocrinology issue, it often requires a multidisciplinary approach to rule out other diseases and treat complications,” explains Dr. Li-Ng. “Our high volume of patients and our Diabetes Center allow us to collaborate across disciplines to provide expert care for our diabetes patients.”