Treatment-induced neuropathy of diabetes complicated by orthostatic hypotension.

Summary: Treatment-induced neuropathy of diabetes (TIND) refers to the acute onset of neuropathic symptoms in patients with poorly controlled diabetes, typically as a consequence of an abrupt change in glucose levels during medical management. We present the case of a 50-year-old female with a long-standing history of poorly controlled type 2 diabetes mellitus (T2DM) complicated by progressive lower extremity weakness and associated paresthesias. Comprehensive workup was unremarkable, and symptoms could not be controlled with muscle relaxant therapies. Further chart review revealed an abrupt drop in HbA1c levels roughly 6 months before her admission. The temporal association between the rapid lowering of HbA1c and the emergence of neurological signs strongly suggested the diagnosis of TIND, which was confirmed by EMG studies. A syncopal episode further complicated the patient's clinical course, and she was found to be orthostatic during hospital admission. The patient was started on duloxetine and given an increased dose of gabapentin, which improved her symptoms.

Learning points: TIND is an acute small-fiber neuropathy caused solely by iatrogenic factors and is often unrecognized as a complication of diabetes management. Neuropathic and autonomic symptoms worsen as both the magnitude and rate of change in HbA1c levels increase. Clinicians should be mindful of complications from rapidly lowering glucose levels and aim for an HbA1c reduction of less than 2 percentage points over 3 months.