Diabetes Care Volume 37, March 2014 e45

Diplopia as the Presenting Charlotte G. Krol, Frederikus A. Klok, and Eelco J.P. de Koning Symptom of Type 1 Diabetes

Diabetes Care 2014;37:e45–e46 | DOI: 10.2337/dc13-2244

Neuropathy is a common complication was the diagnosis. Given his normal nerve, sparing the superomedial- of diabetes, in which cranial nerve BMI and rapidly progressive symptoms, concentrated pupillomotor fibers and palsies are rare and associated with type 1 diabetes was considered the thereby pupil function, in contrast to long-standing poorly controlled type 2 most likely diagnosis. Therefore, and palsies due to other diagnoses (4,5). diabetes. We report a case of a young because cranial mononeuropathy Differential diagnoses include patient with oculomotor nerve palsy as requires rapid correction of infectious diseases, aneurysms, the presenting symptom of type 1 hyperglycemia, insulin therapy was inflammatory disorders, tumors, diabetes. initiated immediately. Normoglycemia trauma, and surgery (4). Diabetic A 36-year-old previously healthy was achieved with a basal-bolus reg- oculomotor nerve palsies typically Sudanese man was referred to our imen and a daily dose of 0.67 units/kg recover over weeks to months emergency department because of within a few weeks. Four months after without sequelae. Management is ’ progressive diplopia of his right eye for the initial diagnosis, the patient socu- supportive, including optimal glycemic 7 days. At the emergency department, lomotor nerve palsy had improved controlaswellasminimizationofother he also reported weight loss, fatigue, dramatically, with almost complete risk factors for ischemia, including control of blood pressure and lipid excessive thirst, and polyuria in the resolution of symptoms. levels (2). previous few weeks. His family history Cranial mononeuropathies are rare and revealed type 2 diabetes in his father. most frequently occur in older In conclusion, isolated oculomotor On physical examination, there was individuals with long-standing, poorly nerve palsy may be the presenting ptosis and reduced abduction of his controlled type 2 diabetes with vascular symptom in a patient with new-onset right eye. Pupil function was normal. and neuropathic complications (1–3). type 1 diabetes. Clinicians should HisBMIwas23kg/m2. Laboratory Symptoms of oculomotor nerve palsy consider a diagnosis of diabetes in examination showed a random glucose consist of an abrupt onset of patients presenting with otherwise level of 23 mmol/L and a C-peptide debilitating severe diplopia and a unexplained, isolated cerebral eLETTERS level of 0.26 nmol/L. GAD antibodies, decrease of visual acuity. Physical mononeuropathy. insulin antibodies, and antibodies examination shows paralysis of against insulinoma-associated adduction, elevation, depression, and – OBSERVATIONS antigen-2 were not detectable. ptosis. Pupil abnormalities can occur, Duality of Interest. No potential conflicts C-reactive protein level, leukocyte and heavy ocular pain is reported. of interest relevant to this article were count, and creatinine level were within Diabetic oculomotor nerve palsies reported. normal limits, and his pH was 7.40. The usually occur without other cranial Author Contributions. C.G.K. and F.A.K. wrote urine dipstick tested positive for nerve palsies (4). The nerve injury is the manuscript. E.J.P.d.K. contributed to the ketones, but negative for albuminuria. thought to be caused by either nerve discussion. All authors approved of the final The results of fundoscopy, chest X-ray, ischemia or infarction of the nuclei in manuscript. C.G.K. is the guarantor of this work and, as such, had full access to all the data in the and magnetic resonance angiography the mesencephalon. In patients with study and takes responsibility for the integrity of the brain were normal. Acute diabetic oculomotor nerve palsy, of the data and the accuracy of the data oculomotor nerve palsy due to diabetes infarction occurs in the core of the analysis.

Department of Endocrinology and Metabolism, Leiden University Medical Centre, the Netherlands Corresponding author: Charlotte G. Krol, [email protected]. © 2014 by the American Diabetes Association. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details. e46 Diplopia and Type 1 Diabetes Diabetes Care Volume 37, March 2014

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