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Diabetic thoracoabdominal neuropathy.

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Diabetic
Thoracoabdominal
Neuropathy
E. W. Massey, M D
Sun and Streib [3], in their review of the literature o n
diabetic thoracoabdominal neuropathy, accidentally omitted a large series of this entity. Ellenberg I l l reported 40
patients with “diabetic truncal mononeuropathy” in 1978.
Characteristics of his cases differed in some aspects from
the 5 patients presented by Sun and Streib and the 12 cases
they summarized.
All series suggest that this neuropathy occurs in an older
age group [1-3]. There is an equal sex distribution, although all 5 of Sun and Streib’s patients were female. Most
cases occur in adult-onset diabetics whose disease is of long
duration, although occasionally juvenile diabetics are affected. In Ellenberg’s patients no motor involvement was
seen, the nerve involvement was almost always unilateral
and asymmetrical, and the prognosis was good. Diabetic
peripheral neuropathy was usually associated, as other series suggest as well [2].
Nerve conduction velocities may be abnormal [ 1-31,
usually with alteration in sensory latency or amplitudes
present [2].
Electromyographic evaluation [2] demonstrates involvement of the paraspinal muscles, as Drs Sun and Streib
suggest [3]. If fibrillations or positive waves are limited to
the symptomatic level, they can support the clinical diagnosis of diabetic truncal (thoracoabdominal) mononeuropathy (neuropathy).
Division of Neurology
Duke University Medical Center
Durham, NC 2771 0
the inability to evaluate intercostal muscle strength. Second, specific identification of one particular segmental level
is not possible by electromyographic examination of the
paraspinal muscles [3]. Third, needle electrode examination of paraspinal muscles not infrequently displays short
runs of positive waves and prolonged insertion activity in
healthy subjects. This is probably due to the small size of
the muscles with the inherent relative large end-plate zone
[2]. Other reasons for the need for electromyographic
evaluation of “peripheral” muscles in addition to the paraspinal muscles are cited in our paper.
Finally, in addition to the causes cited by Ellenberg,
hyperesthesia and hyperpathia in dermatomal distribution
may also occur by irritation of ligaments and joints of the
vertebral spine (so-called pseudoradicular syndromes) [ 11.
W e propose that further studies regarding thoracoabdominal pain in diabetics should at least include detailed electromyographic examination and sweat tests; the latter
would be normal in nerve root disease and abnormal in intercostal neuropathy [41.
Department of Neurology
The Universzty of Nebraska
Medical Ctwter
42nd and Dewey Ave
Omaha, NE 681 05
Referentej
1. Brugger A: Vertebral, radicular and pseudoradicular syndromes. Parts I and 11. Acta Rheumatologica, Documenta
Geigy No. 18, 1960, No. 19, 1962
2. Buchthal I:, Rosenfalck P: Spontaneous electrical activity of
human muscle. EEG Clin Neurophysiol 21:321-336, 1966
3. Goodgold J, Eberstein A: Electrodiagnosis of Neuromuscular
Diseases. Baltimore, Williams & Wilkins, 1972
4. Schliack H, Schiffter R: Umschriebene Storungen der
Schweissdriisensekretion als diagnostisches Kriterium. Med
Welt 22:1421-1426, 1971
5. Waxrnan SF, Sabin TD: Diabetic trunkal polyneuropathy. Arch
Neuroi 38:46-47, 1981
1. Ellenberg M: Diabetic truncal mononeuropathy-a
new clinical
syndrome. Diabetes Care 1:lO-13, 1978
2. Massey EW: Diabetic truncal mononeuropathy: electromyographic evaluation. Acta Diabetol Lat 17:269-272, 1980
3. Sun SF, Streib EW: Diabetic thoracoabdominal neuropathy:
clinical and electrodiagnostic features. Ann Neurol 9:75--79,
1981
Reply
Sallie F. Sun, MD, and Erich W. Streib, M D
Adult Arnold-Chiari
Malformation Type I
Associated with an Aseptic
Meningeal Reaction
M. Seth Hochman, MD, and Steven A. Kobetz, M D
We appreciate D r Massey’s comments. I t is evident that the
clinical picture in “diabetic thoracic mononeuropathy” may
be variable [51.
W e want to caution about certain conclusions in Ellenberg’s and Massey’s papers: First, the absence of clinical
weakness of the abdominal or intercostal muscles does not
imply evidence for primary involvement of the sensory
axons. Lack of muscle weakness is the rule in the disease of
one intercostal nerve o r one thoracic nerve root because of
the multisegmental supply of the abdominal muscles and
W e recently encountered an aseptic meningeal reaction in
an adult patient with Arnold-Chiari malformation type I.
To our knowledge, this association has not previously been
reported.
T h e patient is a 37-year-old Jamaican woman with an
18-month history of occipital headache. In April, 1980, the
patient was admitted to the hospital because of productive
cough and fever. Although there was palpable tenderness
in the cervical region, she had no nuchal rigidity. Chest
496 Annals of Neurology Vol 10 No 5 November 1981
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