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persistent hyperglycemia, or elevation of the hemoglobin A-1c test The survey by Sumner and colleagues makes a case for such an association but we remain uncertain about the relationship between glucose intolerance alone and polyneuropathy About 15 percent of patients with diabetes have both symptoms and signs of neuropathy, but nearly 50 percent have evidence of peripheral nerve damage as judged by nerve conduction abnormalities The duration of diabetes is perhaps the most important factor in frequency of polyneuropathy Somewhat fewer than 10 percent of patients have clinically evident neuropathy at the time of discovery of diabetes but this gure rises to 50 percent after 25 years (The presence of diabetic retinopathy is also associated with a higher incidence of neuropathy) It is not surprising, therefore, that neuropathy is most common in diabetic people older than 50 years of age; it is uncommon in those under 30 and rare in childhood Dyck and colleagues (1993) studied 380 diabetics 27 percent with type 1 (insulin-dependent) forms and 73 percent with type 2 (noninsulin-dependent); symptomatic polyneuropathy was found in 15 percent of the rst group and 13 percent of the second The percentages were far higher when patients were selected electrophysiologically Several fairly distinct clinical syndromes have been delineated: (1) the most common, a distal, symmetrical, primarily sensory polyneuropathy affecting feet and legs more than hands in a chronic, slowly progressive manner; (2) acute diabetic ophthalmoplegia that affects the third, and less often, the sixth cranial nerve; (3) acute mononeuropathy of limbs or trunk including a painful thoracolumbar radiculopathy; (4) a rapidly evolving, painful, asymmetrical, predominantly motor multiple neuropathy affecting the upper lumbar roots and the proximal leg muscles (socalled diabetic amyotrophy); (5) a more symmetrical, proximal motor weakness and wasting, often without pain and with variable sensory loss pursuing a subacute or chronic course; (6) an autonomic neuropathy involving bowel, bladder, and circulatory re exes; and (7) a painful thoracoabdominal radiculopathy These forms of neuropathy often coexist or overlap, particularly the autonomic and distal symmetrical types and the subacute proximal neuropathies Most of the types of neuropathy listed above are thought to be due to ischemia or infarction of nerves or nerve fascicles, due to a diabetic microvasculopathy All but the rst are special types of mononeuropathy multiplex The polyneuropathy is associated with small blood vessel disease (affecting the vaso nervorum) but possibly also with a poorly understood metabolic abnormality; however, other theories of causation abound In recent years, an in ammatory process has been postulated as yet another mechanism of peripheral nerve damage These aspects are discussed further on Distal Polyneuropathy The distal, symmetrical, primarily sensory form of polyneuropathy is the most common type Although it is usually a chronic process, sometimes unnoticed by the patient, we include it here in order to provide a complete tabulation of the diabetic neuropathies The main complaints are persistent and often distressing numbness and tingling, usually con ned to the feet and lower legs, and worse at night The ankle jerks are absent, and sometimes the patellar re exes as well As a rule, sensory loss is con ned to the distal parts of the lower extremities, but in severe cases the hands are involved and the sensory loss may even spread to the anterior trunk, giving rise to confusion in diagnosis (Said et al) Trophic changes in the form of deep ulcerations and neuropathic degeneration of the joints (Charcot joints) are encountered.

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