Case 1

Tom, a 57-year-old man with a 15-year history of type 2 diabetes mellitus, presents to his primary care provider complaining of sensations of pain alternating with tingling and burning in both feet and ankles. The pain, which is consistently moderate to severe during the day, frequently worsens at night with occasional unpredictable spikes that he describes as "unbearable." These exacerbations do not correlate with any obvious activity nor do they occur at consistent times. The pain was initially limited to his feet, but during the past 6-9 months has spread to his ankles, sometimes experienced as a burning sensation and at other times as tingling. The pain interferes with his ability to walk, socialize with friends, and sleep.

What further information would you seek from the patient?

It is very important to gather information regarding his past medical problems and details of his medications.

Tom is a type 2 diabetic and overweight with a BMI of 32 kg/m2. He is taking metformin 1,000 mg/day and hemoglobin A1c levels are consistently less than 6.5%. He sometimes uses Tylenol 1,000 mg TID or Motrin 600 mg TID for the discomfort but reports no relief. However, he exercises routinely despite the pain.

What do you look for in the physical examination?

The history is suggestive of neuropathic origins of pain. A local examination along with detailed neurological assessment is mandatory. Evaluation of the autonomic nervous system using appropriate tests is also important if you are planning an intervention under anesthesia.

Physical examination revealed normal skin color and temperature. Tom reports no vibration sensation at either great toe when tested with a 128 Hz tuning fork and demonstrates a decrease in vibratory sensation to his knees bilaterally. He experienced discomfort over the dorsum of both feet when tested with a cotton-tipped applicator and experienced the application of an alcohol wipe as a burning sensation. His ankle reflexes were absent bilaterally but present at the knees and upper extremities.

What is your diagnosis? How will you manage this patient?

Tom is suffering from painful diabetic neuropathy. The treatment could be initiated with a tricyclic antidepressant. Other options would be gabapentin and pregabalin.

Tom was started on duloxetine beginning at 30 mg daily, which was increased after 10 days to 60 mg daily. At a 1 month follow-up appointment, Tom reported some improvement in his symptoms, stating that the burning and tingling sensations had lessened, allowing him more mobility during the day but that he continued to have paroxysms of pain at night that frequently disturb his sleep. In discussion with his PCP, Tom agreed to add gabapentin to his medication regimen. He was started on 100 mg three times per day and titrated up to 400 mg three times per day over 30 days. At a 3-month follow-up visit Tom reported the pain as significantly better, he is able to lead an almost normal life. He now sleeps better and free of any night pains.

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