Endgames Case Report

A patient with type 2 diabetes and a burning sensation in his feet

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4658 (Published 31 July 2014) Cite this as: BMJ 2014;349:g4658
  1. Ioanna Eleftheriadou, registrar of internal medicine1,
  2. Nicholas Tentolouris, associate professor of internal medicine and diabetes1,
  3. Edward B Jude, consultant diabetologist2
  1. 1Athens University Medical School, Athens, Greece
  2. 2Tameside Hospital NHS Foundation Trust and University of Manchester, Ashton under Lyne OL6 9RW, UK
  1. Correspondence to: E B Jude Edward.jude{at}tgh.nhs.uk

A 64 year old man with type 2 diabetes diagnosed nine years earlier attended the outpatient diabetes clinic because of suboptimal diabetes control. His glycated haemoglobin over the past five years had been 64-77 mmol/mol (8-9.2%; optimal value <53 mmol/mol (7%)). He was being treated for diabetes with gliclazide and metformin. He also received simvastatin and enalapril for dyslipidaemia and hypertension, respectively, and 75 mg acetylsalicylic acid daily for the prevention of primary cardiovascular disease.

He had painful symptoms in his legs, which he described as a burning sensation, with tingling in the feet. He had been experiencing the burning pain for the past six months, especially during the night, and he had to walk about or put his feet in water to find relief. He thought that the symptoms may be related to poor circulation in his legs and he was worried that he might need an amputation.

On examination he could not feel the 128 Hz tuning fork up to his knees bilaterally or the 10 g Semmes-Weinstein monofilaments on two out of three sites on the plantar surface of his feet. Pedal pulses, however, were palpable in both feet.

Questions

  • 1. What is the diagnosis?

  • 2. How would you manage this patient?

  • 3. What are the long term complications?

Answers

1. What is the diagnosis?

Short answer

The patient has painful diabetic peripheral neuropathy.1 Painful symptoms develop as a result of damage to, or dysfunction of, the system that normally signals pain.2 3 Doctors should examine patients with diabetes for symptoms of this condition because most patients are not aware that their symptoms are associated with diabetes.

Long answer

Diabetic peripheral neuropathy is defined as the presence of symptoms and signs of peripheral nerve dysfunction in patients with diabetes after exclusion of other causes.1 It has a prevalence of 30-50% in patients with diabetes, and …

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