E. Lee Murray, MD
CHAPTER CONTENTS
OVERVIEW
Some of the most important endocrine disorders with neurologic manifestations are listed here, and details of most of these disorders are included in the following sections. Disorders discussed elsewhere are so indicated.
•Diabetic neuropathy: Can be polyneuropathy with mainly sensory symptoms, mononeuropathy, mononeuropathy multiplex, ocular motor palsy, or diabetic amyotrophy
•Thyroid ophthalmopathy: Proptosis and diplopia, typically bilateral
•Thyrotoxicosis: Fatigue, weakness, tremor, associated with tachycardia, weight loss
•Hashimoto encephalopathy: Memory difficulty, personality change, symptoms of hypothyroidism, with possibly seizures and/or neurologic deficits.
•Pheochromocytoma: Episodic headache with hypertension, tachycardia, diaphoresis, orthostatic hypotension
•Cushing syndrome: Neurologic presentation of proximal muscle weakness with central obesity, moon facies
•Addison disease: Neurologic symptoms include progressive muscle weakness, occasionally acute, with hyperkalemia, depression, orthostatic hypotension; systemic symptoms of hyperpigmentation, weight loss, nausea, vomiting
•Pituitary tumor: Headache, visual field disturbance, ocular motor deficit, sometimes associated with hormonal derangements
•Pituitary apoplexy: Abrupt onset of headache, visual deficit, ocular motor deficit from pituitary infarction or hemorrhage
•Diabetes insipidus (DI): Polyuria and polydipsia due to loss of antidiuretic hormone (ADH; also known as arginine vasopressin, AVP). Commonly in the setting of cerebral trauma or surgery but can be due to brain tumors
•Syndrome of inappropriate antidiuretic hormone (SIADH): Weakness, depression, confusion, lethargy due to profound hyponatremia; usually caused by acute cerebral lesion (e.g., trauma, infection)
DIABETES MELLITUS
Hospital neurology consultation in patients with diabetes is usually for the following indications:
•Hypoglycemic encephalopathy (Chapter 11)
•Ocular motor palsy (Chapter 33)
•Stroke in a patient with diabetes (Chapters 11 and 16)
•Neurologic symptoms with hyperglycemic state (Chapter 11)
•Seizures with hyper- or hypoglycemic state (Chapters 11 and 19)
Some important disorders in diabetics who come to neurology consultation are discussed here; others are discussed in their respective chapters as indicated.
Diabetic Neuropathy
Diabetes mellitus neuropathic complications:
•Peripheral neuropathy: Mixed polyneuropathy with sensory symptoms predominating but also motor and autonomic manifestations.
•Mononeuropathy: Acute symptomatic neuropathy with involvement of almost any of the arm, leg, or cranial nerves.
•Mononeuropathy multiplex: Almost any nerve can be affected, but most common are ulnar, median, radial, peroneal.
•Ocular motor palsy: Painful CN 3 palsy, pupil-sparing, is the most common. CN-6 palsy can be seen less commonly. Usually unilateral.
•Autonomic neuropathy: Broad range of symptoms including orthostatic hypotension, decreased pupil response, impaired sweating, bladder distention with incomplete emptying, and gastroparesis with abdominal pain, nausea/vomiting, and constipation.
•Lumbar radiculoplexopathy (diabetic amyotrophy): Proximal plexopathy and/or radiculopathy with lumbar involvement producing unilateral weakness in an L2–L4 distribution. Associated with pain in the back extending to the thigh.
Details of the evaluation of neuropathy are found in Chapter 21. Electromyogram (EMG) and nerve conduction studies (NCS) are indicated for most patients with peripheral neuropathy. Some patients have mononeuropathies superimposed on polyneuropathy.
CSF analysis is not needed unless there is concern for an infectious or inflammatory cause.
MANAGEMENT begins with best diabetes care. Note that many of the medications used for diabetic neuropathic pain are not approved by the US Food and Drug Administration (FDA) for that indication.
◦Anticonvulsants, antidepressants; especially amitriptyline, gabapentin, pregabalin, and duloxetine
◦Others include nortriptyline, paroxetine, citalopram, carbamazepine; NSAIDs are sometimes tried.
•Mononeuropathy and mononeuropathy multiplex
◦Occasional patients may benefit from decompression when entrapment is believed to be a significant contributing factor.
◦Pain is managed as for polyneuropathy.
◦Mononeuropathy can be exacerbated by compression, so protection and avoidance can be helpful, especially in patients who have had significant weight loss.
◦Best diabetes management and physical therapy
◦Pain can be managed as for polyneuropathy.
◦Orthostatic hypotension can be managed by elastic hose to thigh or higher, increasing Na intake, midodrine, fludrocortisone; use caution in those with supine hypertension.
◦Pyridostigmine can be used in those with supine hypertension.
◦Droxidopa is another option for orthostatic hypotension.1
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