An Unusual Manifestation of Diabetes Mellitus

Type 2 diabetes mellitus for five years; unexplained 35-lb weight loss three years ago; Bell's palsy on right side many years ago. Glipizide, 10 mg/day. Father died of leukemia at age 65; mother has kidney stones; no diabetes or neuromuscular disease. Insurance salesman; heterosexual, promiscuous, uses condoms; smokes (25 pack years); does not drink. Well-nourished, well developed, not in acute distress; had difficulty rising from a sitting position because of right lower extremity weakness. Blood pressure, 154/74; pulse, 88; temperature, 36.6 degrees C; respiratory rate, 16. Head, eyes, ears, nose, and throat: normal. Neck: normal. Heart: S4. Lungs: clear. Abdomen: mildly obese. Extremities: no cyanosis, clubbing, or edema; atrophy and weakness of right thigh and both calves; wide-based gait; able to walk on toes but not heels. Neurologic responses: cranial nerves intact; deep tendon reflexes, 1 + symmetrically; plantar reflexes, flexor bilaterally. Skin: macular rash in sun-exposed areas. Hemoglobin, 13.2 gm/dL; mean corpuscular volume, 80 micron 3; white blood cell count, 7,200/mm3 (normal differential); platelet count, 137,000/mm3. Serum: electrolytes, normal; blood urea nitrogen, 18 mg/dL; creatinine, 0.8 mg/dL; glucose, 308 mg/dL; total protein, albumin, liver enzymes, and creatine kinase, normal. Urine: 1 + glucose. Venereal disease test: nonreactive; HIV test: negative. Dermatomyositis; heavy-metal poisoning; diabetic amyotrophy. The patient was given 50 mg/day of oral amitriptyline to alleviate the painful paresthesias and was switched to 20 U/day of subcutaneously injected neutral protamine Hagedorn (NPH) insulin to normalize the blood glucose level. Histologic studies of skin and muscle showed sun damage and neuropathic changes, respectively. There was no evidence of vasculitis. Screening for heavy-metal toxins produced negative results.