Diabetic Neuropathy: Rare Presentation as a Painful Pseudoabdominal Mass
A 57-year-old male electronic engineer presented with severe burning dysesthesia and pain in D4-12 distribution on the right side of his chest and abdomen. He also experienced troublesome allodynia leading to decreased sleep, excessive day time sleepiness and fatigue. The symptoms according to him started 6 months prior to his present visit after he had a chest tube insertion for drainage of pleural effusion. On the basis of pleural fluid analysis he was subsequently diagnosed to have pulmonary tuberculosis and was started on antituberculous treatment.\nHe had elevated blood sugar at that time with fasting blood sugar (FBS) 246 mg/dl and postprandial blood sugar (PPBS) 360 mg/dl with glycated hemoglobin (HbA1c) 9.2%. He was first diagnosed to have diabetes 3 years ago and was on irregular treatment for the same. He was initiated on insulin therapy and discharged. A week later he noticed a right abdominal bulge especially after taking a heavy meal or while trying to get up from a lying posture. This was associated with a burning pain over the right lower chest and upper abdomen. The protrusion gradually increased in size.\nHe was extensively investigated for his “painful abdominal mass” including a gastrointestinal scopy and ultrasonography (USG) abdomen, however no abnormality could be detected. Meanwhile his blood sugar remained uncontrolled, he stopped insulin and changed to herbal medications. On initial evaluation at our hospital, his HbA1c was 8.9%. He was initially investigated by our gastroenterology department for his painful abdominal swelling. Since all results were within normal limits he was referred to neurology department for further evaluation. Meanwhile he also developed a right proximal lower limb weakness associated with wasting of thigh muscles leading to buckling at right knee joint. He had no relief of his painful abdominal sensory symptoms.\nOn examination there was a healed scar at the site of intercostal drain insertion in right fifth intercostal space on the anterior axillary line. All peripheral pulses were felt. Right thigh girth was 2 cm less compared to left side. He had weakness of hip adduction, knee extension, and hip extension all on the right side. The right abdominal muscles were weak with a protrusion of the abdomen mimicking a mass []. Abdominal reflexes were absent in all quadrants. Right knee jerk was absent and sensation to crude touch was diminished by 20% on the right side extending from D4 dermatome to right knee.\nOn investigations, he continued to have high blood sugars on admission. FBS 423 mg/dl and PPBS 384 mg/dl with HbA1c 8.9%. Cerebrospinal fluid (CSF) revealed normal sugar with protein 79 mg/dl and 2 cells/mm3, mononuclear. Magnetic resonance imaging (MRI) cervical, dorsal, and lumbosacral spine with contrast showed mild cervical canal stenosis at C3-C6. No evidence of spinal arachnoiditis. Nerve conduction velocity study (NCV); right femoral compound muscle action potential (CMAP) amplitudes were reduced and paraspinal electromyography studies (EMG) revealed denervation potential from thoracic and lumbar segments. Toxicological screening for herbal medication revealed no heavy metals. USG abdomen was normal.