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Reflex sympathetic dystrophy syndrome (RSDS), a complex clinical syndrome characterized by pain and swelling of an affected extremity, is most commonly seen after trauma. We report the case of a woman with diabetes mellitus and chronic renal failure who presented with RSDS 5 months after placement of an arteriovenous (AV) graft for hemodialysis. The temporal relationship between RSDS and the vascular surgery suggests AV graft placement as the precipitating event for the development of RSDS. Treatment with systemic corticosteroids successfully relieved the patient's symptoms. We believe that RSDS should be included in the differential diagnosis of unexplained limb pain and swelling after AV graft placement.
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PMID:Reflex sympathetic dystrophy syndrome of the hand after placement of an arteriovenous graft for hemodialysis. 188 37

The existence of myelopathy as a complication of diabetes is debatable and, in the few reported cases, spinal involvement has been diffuse. We describe 2 cases of focal myelopathy. Two insulin-dependent, middle-aged men with adult-onset diabetes presented with gradually ascending lower limb pain and numbness without sphincteric symptoms. Examination showed mixed upper and lower motor signs in the lower limbs, with a severe impairment of cutaneous sensation below a sharply demarcated band at the T9-10 level with relative preservation of posterior column function. Myelography was normal. CSF showed mild elevation of protein and in one case showed 23 x 10(6) white cells/L. Nerve conduction studies showed a co-existing, mild sensorimotor neuropathy. There was no evidence of truncal radiculopathy on paraspinal EMG. Extensive investigation for other causes of myelopathy was negative.
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PMID:Diabetic focal myelopathy. 326 39

1. We examined 156 patients 33 years after CO poisoning occurred at the Miike Mikawa Mine, Fukuoka, Japan. The subjects were classified according to age as follows: between 55 and 59 years (n = 14), 60 and 69 years (n = 62), 70 and 79 years (n = 60), and 80 and 87 years (n = 18). The mean age was 69.2 years old. Concerning the duration of coma that occurred soon after the accident, 64 remained comatose from 0 to 6 hours, 46 from 6 to 12 hours and 46 from 12 to 48 hours. 2. Subjective symptoms were observed in 96.8% of the patients. Among them, forgetfulness was noted in 89.7%, followed by irritability in 66.7%, headache in 59.6%, insomnia in 55.8%, limb pain in 46.8%, dull head feeling in 42.9% and dizziness in 36.5%. 3. Intellectual disturbances were observed in 68.6% of the patients, including impression disturbance in 58.3%, memory disturbance in 51.9%, calculation disturbance in 63.5%, thinking disturbance in 61.5% and disorientation in 14.1%. 4. Apathy and disorder of volition and interest which were found in 72.4% were included in personality change because all symptoms persisted for many years. Personality change was classified as follows: weakness of emotion and will (hypobulia) in 54.4%, infantilism in 35.2%, hyperactive, talkactive and lack of inhibition in 18.5%, lack of self-possession and unstable temper in 9.6%, depression in 15.3%, neurosis in 7.6% and schizophrenic state in 2.5%. Among these symptoms of personality change, weakness of emotion and will and infantilism were conspicuous among the patients who remained in a coma for more than 6 hours soon after the accident but showed no relationship with age. 5. Neurological symptoms that were found in 48.7% of the patients were classified as sensory disturbance in 25.6%, peripheral nerve symptoms in 16.0%, pyramidal symptoms in 14.1%, ataxia and cranial nerve symptoms in 7.1%, paroxysmal symptoms in 6.4% and focal symptoms in 4.5%, extrapyramidal symptoms in 21.8% (Parkinsonism in 4.5%, tremor in 10.9% and muscle rigidity in 16.0%) and vegetative symptoms in 37.2%. 6. At the time of investigation, 5 CO poisoning patients were classified as serious cases (3.2%), 20 as comparatively serious (12.8%) medium-degree cases, 28 as comparatively mild (17.9%) medium-degree cases, 37 as comparatively serious (23.7%) mild cases, 42 as comparatively mild (26.9%) mild cases, 24 (15.4%) as having symptoms which were not problematic, and 24 (15.4%) as having symptoms that markedly worsened due to complication. 7. A total of 138 (88.4%) cases had complications were classified as follows: 78 cases (50.0%) of hypertension, 62 cases (39.7%) of cerebral infarction, 24 cases (15.4%) of cardiac disturbance, 21 cases (13.5%) of diabetes mellitus, 14 cases (9.0%) of hepatic disturbance and six cases of silicosis (3.8%). 8. Cranial MRI was carried out for 129 cases (82.7%). Of the abnormal findings identified, cerebral atrophy accounted for 72.0% (93 cases), including moderate and severe cases in 47.2% (61 cases), pallidum lesion for 37.9% (49 cases), lacunar infarction (including cerebral infarction) for 52.7% (68 cases), and hippocampal atrophy for 18.6% (24 cases). Many cases of cerebral atrophy and hippocampal atrophy were observed in patients who remained in the initial coma for more than 12 hours and were 80 years of age or old. The cases of pallidum lesion were observed in patients who remained in the initial coma for more than 6 hours, and no relationship with age was found. The other findings, cerebral atrophy and lacunar infarction showed a slight relationship with age. 9. Among the moderate and serious cases of intellectual disturbance, cerebral atrophy constituted to 62.5%, lacunar infarction 68.7% and pallidum lesion 50.0%. Among the moderate and serious cases of personality change, cerebral atrophy constituted 78.5%, lacunar infarction 35.0% and pallidum lesion 50.0%. Moreover, among extrapyramidal symptoms, pallidum lesion constituted 58.6%, cerebral atrophy 55.1% and lacun
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PMID:[Long-term follow-up study on sequelae of carbon monoxide poisoning; serial investigation 33 years after poisoning]. 1050 96

Ehlers-Danlos syndrome (EDS) is a relatively rare, inherited connective tissue disorder and skin hyperextensibility, joint hypermobility, chronic joint and limb pain, blood vessel and tissue fragility are frequent symptoms. The aims of this study were to describe the degree to which individuals with EDS accept and cope with perceived limitations related to the syndrome, and to determine the relationships between acceptance of disability (AD), sense of coherence (SOC), functional health status and background data. Four questionnaires were mailed: the AD scale Modified (ADM), the SOC Scale, the Sickness Impact Profile (SIP) and a background form. The respondents with EDS were recruited through the EDS National Association in Sweden and the response rate was 74% (69 females and eight males). The Ethical Committee at Huddinge University Hospital (ref. no. 152/95) approved the study. This study has shown that the level of AD and SOC in individuals with EDS is similar to other patient groups, e.g. individuals with ostomy and with diabetes. Further, the SOC was in concordance with that of the general population. Those working full-time accepted their disability to a greater degree than those on sick leave or disability pension. A multiple regression analysis showed that a greater AD was associated with a higher level of SOC and a better functional health status. The SOC and SIP together accounted for 50% of the variance in the ADM. For health promotion in nursing practice it is important to have insight into the problem areas which may influence the overall life situation for an individual with EDS. A key issue for nurses is to identify individuals with low acceptance of their disease and/or low SOC in order to support these persons' adaptation process. Future research on EDS may be directed towards projects focusing on the development and implementation of models to strengthen the level of AD and SOC in this group.
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PMID:Acceptance of disability and sense of coherence in individuals with Ehlers-Danlos syndrome. 1291 24

Acute compartment syndrome has a multitude of aetiologies. Unfortunately, the diagnosis is often delayed, resulting in permanent functional loss. Although spontaneous muscle infarction is an uncommon, yet well-recognized complication of diabetes mellitus, subsequent development of compartment syndrome appears to be rare, with only five case reports identified in the literature. This condition has not been reported in the emergency medicine literature. We report a case of a diabetic gentleman who presented with lower limb pain significantly out of proportion to any obvious injury and had a subsequent diagnosis of acute compartment syndrome. Despite fasciotomies, he had a persistent foot drop. Nontraumatic acute compartment syndrome secondary to diabetic muscle infarction should be considered in any diabetic patient presenting with pain out of proportion to sustained injury.
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PMID:Acute compartment syndrome secondary to diabetic muscle infarction: case report and literature review. 1652 45

Diabetic muscle infarction (DMI) is a rare complication of longstanding, poorly controlled diabetes. Only a few cases have been reported in the literature. The case of a 34-year-old man with a 7-year history of type 2 diabetes mellitus, with sudden onset of left thigh pain, is described here. A final diagnosis of DMI was made, the pathophysiology of which remains unclear. MRI findings were diagnostic and characteristic. The management of this condition is usually symptomatic. Short-term prognosis is very good; however, the recurrence rate is high. Long-term prognosis is poor, with most patients dying from cardiovascular complications of diabetes within 5 years of diagnosis. This case supports the need for a high index of suspicion, when a poorly controlled patient with diabetes presents with non-traumatic limb pain.
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PMID:Diabetic muscle infarction. 1758 55

Spinal epidural lipomatosis (SEL) is a rare disorder characterized by overgrowth of fat in the extradural space, causing compression of the neural elements. It is frequently associated with the administration of exogenous steroids or elevation of endogenous steroids. We present two patients, both with epidural lipamotosis of idiopathic origin. One was 53-year-old man with progressive mid-thoracic and lower limb pain with associated weakness and neurogenic claudication due to thoracic epidural lipomatosis. The second was a 68-year-old male with lumbar epidural lipomatosis. Co-morbidities for the first patient included diabetes and obesity; however, there was no history of steroid administration. An MRI scan revealed thoracic cord compression, with significant stenosis at T4-T9. The second patient complained of progression of longstanding lumbar pain and claudicant symptoms. There was no history of steroid intake. An MRI revealed stenosis at L4-S1 and diffuse anterior lipomatosis. A literature review revealed 49 cases of idiopathic SEL and 62 of secondary SEL. We aimed to delineate the differences between these two relatively distinct entities including their anatomical distribution, clinical presentation and prognostic implications.
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PMID:Spinal epidural lipomatosis--a brief review. 1895 86

Distal limb pain in diabetes mellitus is frequently attributed to hyperexcitability of primary afferents associated with peripheral neuropathy. However, prior studies have demonstrated that, after traumatic nerve injury, hyperexcitability develops not only within primary afferents but also within pain-signalling neurons of the spinal cord dorsal horn and thalamic ventral posterolateral (VPL) nucleus, establishing a basis for tiered central pain generators or amplifiers. In this study we asked whether hyperexcitability develops within thalamic neurons in experimental painful diabetes. Diabetes was induced in adult male Sprague-Dawley rats with streptozotocin (STZ). Behavioral testing for tactile allodynia, performed one week prior to STZ injection and weekly thereafter, indicated that, by six weeks after STZ injection, mechanical allodynia had developed (mechanical withdrawal threshold <4 g, STZ; 21.75 g, control). Thalamic unit recordings were obtained from the VPL nucleus at seven weeks after STZ injection, in rats that met a criterion withdrawal threshold of <4 g, at a time when mean glucose level for control rats was 104.8+/-2.9, and for diabetic rats was 420.1+/-42.0. Our analysis shows that, in this model of diabetic neuropathic pain, thalamic VPL neurons develop hyperexcitability, with increased responses to phasic brush, press, and pinch stimuli applied to identified peripheral receptive fields. VPL neurons from diabetic rats also display enhanced spontaneous activity, independent of ascending afferent barrage, and enlarged receptive fields. These results suggest that aberrant levels of spontaneous activity and hyper-responsiveness of VPL thalamic neurons may contribute to diabetic neuropathic pain.
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PMID:Thalamic neuron hyperexcitability and enlarged receptive fields in the STZ model of diabetic pain. 1928 53

Pain and pain-related interference with physical function have not been thoroughly studied in individuals who have undergone knee-disarticulation amputations. The principal aim of this study was to determine whether individuals with knee-disarticulation amputations have worse pain and pain-related interference with physical function than do individuals with transtibial or transfemoral amputations. We analyzed cross-sectional survey data provided by 42 adults with lower-limb amputations. These individuals consisted of 14 adults reporting knee-disarticulation amputation in one limb and best-matched cases (14 reporting transfemoral amputation and 14 reporting transtibial amputation) from a larger cross-sectional sample of 472 individuals. Participants were rigorously matched based on time since amputation, reason for amputation, age, sex, diabetes diagnosis, and pain before amputation. Continuous outcome variables were analyzed by one-way analysis of variance. Categorical outcomes were analyzed by Pearson chi-square statistic. Given the relatively small sample size and power concerns, mean differences were also described by estimated effect size (Cohen's d). Of the 42 participants, 83% were male. They ranged in age from 36 to 85 (median = 55.1, standard deviation = 11.0). Most amputations were of traumatic origin (74%), and participants were on average 12.4 years from their amputations at the time of the survey. Individuals with transtibial amputation reported significantly more prosthesis use than did individuals with knee-disarticulation amputation. Amputation levels did not significantly differ in phantom limb pain, residual limb pain, back pain, and pain-related interference with physical function. Estimates of effect size, however, indicated that participants with knee-disarticulation amputation reported less phantom limb pain, phantom limb pain-related interference with physical function, residual limb pain, residual limb pain-related interference with physical function, and back pain-related interference with physical function than did participants with transtibial or transfemoral amputations. This study demonstrated that patients with knee-disarticulation amputation used prostheses significantly less than did patients with transtibial amputation. However, no evidence was found that patients with knee-disarticulation amputation have worse outcomes in terms of pain and pain-related interference with physical function; in fact, they may have more favorable long-term outcomes.
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PMID:Pain and pain-related interference in adults with lower-limb amputation: comparison of knee-disarticulation, transtibial, and transfemoral surgical sites. 2010 19

Diabetic muscle infarction (DMI) is a rare complication of longstanding, poorly controlled diabetes. Only a few cases have been reported in the literature. The case of a 34-year-old man with a 7-year history of type 2 diabetes mellitus, with sudden onset of left thigh pain, is described here. A final diagnosis of DMI was made, the pathophysiology of which remains unclear. MRI findings were diagnostic and characteristic. The management of this condition is usually symptomatic. Short-term prognosis is very good; however, the recurrence rate is high. Long-term prognosis is poor, with most patients dying from cardiovascular complications of diabetes within 5 years of diagnosis. This case supports the need for a high index of suspicion, when a poorly controlled patient with diabetes presents with non-traumatic limb pain.
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PMID:Diabetic muscle infarction. 2168 7


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