Diabetic Neuropathy Has Several Clinical Presentations

Peripheral neuropathy is a common complication of diabetes mellitus. The neuropathy may manifest as a
distal sensorimotor polyneuropathy, autonomic neuropathy, mononeuropathy, or mononeuropathy
multiplex. The mononeuropathies may involve cranial nerves (cranial neuropathy), nerve roots
(radiculopathy), or proximal peripheral nerves. Distal, predominantly sensory, polyneuropathy is the most
common form of diabetic neuropathy.
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Pathogenesis:
The pathogenesis of the nerve fiber injury in diabetes is unknown. It has long been held that the metabolic
alterations of diabetes are responsible for the distal symmetric polyneuropathy, and that nerve ischemia
caused by the small-vessel disease is responsible for the mononeuropathies. There is evidence, however,
that local nerve ischemia may also play a significant role in the pathogenesis of the symmetric
polyneuropathy.
Pathology: The distal symmetric polyneuropathy of diabetes is characterized pathologically by a mixture
of axonal degeneration and segmental demyelination, with axonal degeneration predominating. The
axonal loss involves fibers of all sizes, but occasionally preferentially affects the large myelinated fibers
(large-fiber neuropathy) or the small myelinated and unmyelinated fibers (small-fiber neuropathy).
Morphology. In individuals with a distal symmetric sensorimotor neuropathy, the predominant
pathologic finding is an axonal neuropathy. As with other chronic axonal neuropathies, there is often
some segmental demyelination. There is a relative loss of small myelinated fibers and of unmyelinated
fibers, but large fibers are also affected. Endoneurial arterioles show thickening, hyalinization, and
intense periodic acidSchiff positivity in their walls and extensive reduplication of the basement
membrane[18] ( Fig. 27-6 ).

FIGURE 27-6 Diabetic neuropathy with marked loss of myelinated fibers, a thinly myelinated fiber (arrowheads), and thickening of endoneurial vessel
wall (arrow).