A 15y10m boy was presented to our hospital (in March 2017) with the complaints of acute, severe, continuous, burning pain affecting soles and both legs, insomnia, loss of body weight and appetite. He described his pain as stabbing and burning. He also perceived contact with bed clothing, socks, shoes or floor as causing extreme discomfort. He could barely move out of bed. He had no symptoms in hands or any other neurological complaints. An. Morbi: type 1 diabetes was diagnosed 7 years ago in 2011, was initiated on Actrapid and Protaphane insulin. First came to our hospital in January 2017. His glycosylated haemoglobin A1c (HbA1c) was 10.77%, fructosamine was 472.88 μmol/l. His compliance and glycaemic control were poor. We changed his insulin to glargine and glulisine to achieve normoglycaemia. He had lessons in the diabetes school. Repeat HbA1c three month after (March 2017) was 8.34%, fructosamine was 322.02 μmol/l. On examination: his height is 145 cm, weight 33.5 kg, BMI 15.9 kg/m2 H-SDS=−3.4 S.D., Tanner stage 2. His vitals and general physical examination were unremarkable. On neurological examination, cranial nerves were normal. On electromyography (EMG): sensory motor axonal polyneuropathy of the lower extremities. He was discharged on carbamazepine (8 mg/k/d) and benfotiamine 150 mg twice daily, NSAID analgesics (for intermittent use) and pregabalin 75 mg/d (in case of severe pain). Gradually over the next six months his pain decreased, but still the patient continued to feel pain. His glycaemic control has remained between optimal and suboptimal. His HbA1c (October 2017) was 8.21%, fructosamine was 290.34 μmol/l. He continuous to take benfotiamine (Benfogamma, Woerwag Pharma) 150 mg twice daily.
Conclusion: In the face of current recommendations for achieving glycaemic targets quickly, a paradoxical occurrence of APDN should be kept in mind. It is important for the paediatric endocrinologists and neurologists to recognize this rare entity for the need to provide adequate analgesia for relief from severe pain. Is this pain completely reversible?
27 - 29 Sep 2018
European Society for Paediatric Endocrinology