Diabetic neuropathic cachexia in a young female
A 42-year-old house wife (P2 + 0, last child birth 24 years ago) was admitted with complaints of generalized body ache of 1 year duration. It was more at night and progressively increasing in severity. The patient had numbness and severe burning sensation over her feet, ascending rapidly to involve her legs and thighs. It was associated with loss of weight (approximately 8 kg), loss of appetite, nausea, frequent vomiting, and altered bowel habits without history of fever or pain abdomen. She was detected to have diabetic 1 year ago and put on oral hypoglycemic agents (OHAs). There was no history suggestive of any acute diabetic complication. Past medical history was nonsignificant. She had undergone cholecystectomy 2 months back (Histopathological examination (HPE) suggestive of chronic cholecystitis without malignant change). She was amenorrhoic for last 2 months. On admission, she was biochemically euthyroid with normal creatinine phosphokinase (CPK) level, negative antinatriuretic factor (ANF), rheumatoid factor, anti-double stranded deoxyriobonucleic acid (dsDNA), and poor glycemic status (HbA1C 16.9%).\nWeight: 36.5 kg, body mass index (BMI): 15.7 kg/m2, blood pressure (BP): 100/70 mmHg, pulse: 70/min, regular, all peripheral pulses palpable, pallor: +, icterus: nil, edema: nil, goiter: Gr I, acanthosis: absent, muscle function test (MFT): 6/6 b/l, ankle brachial pressure index (ABPI): left 0.9, right 1.0. Fundus was normal. Profound symmetrical wasting was noted in all extremities with associated bilateral weakness more in proximal muscle groups of the lower extremities. Reflexes were symmetrically decreased in all extremities with absent ankle jerks. The gait was unsteady due to muscle weakness and paresthesias. Otherwise, systemic examination was normal.\nHemoglobin (Hb): 9.4; total leukocyte count (TLC): 12,400; differential leukocyte count (DLC): neutrophils (N)-78, lymphocytes (L)-18, monocytes (M)-2, eosinophils (E)-2; erythrocyte sedimentation rate (ESR): 86; adequate platelet.\nRenal and hepatic profile was normal except hypoproteinemia (albumin/globulin (Alb/Glb):2.6/2.2) and hypokalemia. Human immunodeficiency virus (HIV) was nonreactive. Serum protein electrophoresis did not show any monoclonal band. Whole body bone scintigraphy and bone marrow aspiration study were normal. Nerve conduction velocity (NCV) revealed symmetrical distal axonal and demyelinating type of sensorimotor polyneuropathy involving lower limbs more than upper limbs. Computed tomography (CT) scan abdomen suggested hepatomegaly with mildly dilated common bile duct (CBD) (post cholecystectomy) along with suspected stricture ileum along with proximal narrowing. Chest X-ray, CT scan brain, ultrasonography (USG) abdomen, upper gastrointestinal (GI) endoscopy, colonoscopy, Ba meal follow through, CT enteroclysis were normal.