a widely accepted definition of diabetic peripheral neuropathy is  the presence of symptoms and signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes  ( boulton 1998 )
. it can be classified into several syndromes each with a distinct pattern of involvement of peripheral nerves .
diabetes being a very common medical condition , one should be aware of the usual as well as its rare presentations .
diabetic neuropathy can manifest in any stage of the disease though it tends to be a delayed manifestation in type 2 diabetes .
it can present as an asymmetrical painful proximal neuropathy or it can be symmetrical and distal .
autonomic neuropathy is a more serious form of nervous system involvement and requires careful monitoring . sometimes in a single individual
a 57-year - old male electronic engineer presented with severe burning dysesthesia and pain in d4 - 12 distribution on the right side of his chest and abdomen .
he also experienced troublesome allodynia leading to decreased sleep , excessive day time sleepiness and fatigue .
the symptoms according to him started 6 months prior to his present visit after he had a chest tube insertion for drainage of pleural effusion . on the basis of pleural fluid analysis
he had elevated blood sugar at that time with fasting blood sugar ( fbs ) 246 mg / dl and postprandial blood sugar ( ppbs ) 360 mg / dl with glycated hemoglobin ( hba1c ) 9.2% .
he was first diagnosed to have diabetes 3 years ago and was on irregular treatment for the same .
a week later he noticed a right abdominal bulge especially after taking a heavy meal or while trying to get up from a lying posture .
this was associated with a burning pain over the right lower chest and upper abdomen .
he was extensively investigated for his  painful abdominal mass  including a gastrointestinal scopy and ultrasonography ( usg ) abdomen , however no abnormality could be detected .
meanwhile his blood sugar remained uncontrolled , he stopped insulin and changed to herbal medications . on initial evaluation at our hospital ,
since all results were within normal limits he was referred to neurology department for further evaluation .
meanwhile he also developed a right proximal lower limb weakness associated with wasting of thigh muscles leading to buckling at right knee joint .
on examination there was a healed scar at the site of intercostal drain insertion in right fifth intercostal space on the anterior axillary line .
he had weakness of hip adduction , knee extension , and hip extension all on the right side .
the right abdominal muscles were weak with a protrusion of the abdomen mimicking a mass [ figure 1 ] .
right knee jerk was absent and sensation to crude touch was diminished by 20% on the right side extending from d4 dermatome to right knee
. abdominal bulge on attempted flexion of neck and upper trunk on investigations , he continued to have high blood sugars on admission .
cerebrospinal fluid ( csf ) revealed normal sugar with protein 79 mg / dl and 2 cells / mm , mononuclear .
magnetic resonance imaging ( mri ) cervical , dorsal , and lumbosacral spine with contrast showed mild cervical canal stenosis at c3-c6 .
nerve conduction velocity study ( ncv ) ; right femoral compound muscle action potential ( cmap ) amplitudes were reduced and paraspinal electromyography studies ( emg ) revealed denervation potential from thoracic and lumbar segments .
in view of the initial clinical findings of painful sensory symptoms with unilateral abdominal weakness and proximal right lower limb lower motor neuron weakness we considered the possibility of a multiple radiculoneuropathy .
since the patient was on antituberculous treatment ( att ) , spinal arachnoiditis secondary to tuberculosis was the initial diagnosis . however , mri spine with contrast and csf study were normal .
on reviewing the history he had uncontrolled sugars from the very onset of his symptoms .
this prompted us to think the second possibility of a diabetic truncal neuropathy with a unilateral proximal radiculoneuropathy involving the right lower limb .
his troublesome abdominal swelling , which was extensively investigated earlier , was due to an abdominal wall weakness , a finding very rarely seen in diabetic truncal neuropathy .
it is not a true hernia as there is no protrusion of viscus through a defect in the abdominal wall on the other hand it is the weak muscle wall which bulges out .
pain is in a radicular distribution and is usually accompanied by allodynia and tend to become worse at night leading to insomnia and excessive daytime sleepiness as in our case .
the pathophysiology of diabetic truncal neuropathy is still a matter of controversy , however being a painful neuropathy an ischemic cause seems to be the most favored hypothesis .
our patient had good symptomatic relief with a combination of gabapentine , tramadol , and amitryptaline . on follow up after 3 months he was totally relieved of pain
however , his abdominal bulge persisted for which he was advised muscle strengthening exercises and abdominal binders .
the clinician should be aware of this uncommon presentation as it can prevent unnecessary investigations .
it is a self - limiting condition and usually resolves spontaneously in 2 - 6 months and has a good prognosis .
 diabetic neuropathy has varied clinical presentations . as clinicians 
 we should be aware of the common as well as rare manifestations of this syndrome . 
 diabetic truncal neuropathy presenting as a painful pseudoabdominal mass can easily mislead clinicians who are unaware of this problem . 
 subsequently , this can lead to unnecessary investigations and discomfort to the patient . 
 a good blood sugar control and judicious use of drugs for neuropathic pain along with physiotherapy usually gives good relief . 
 it is mostly a self - limiting condition . 
Introduction
Case Report
Discussion