AN ExTREME CAuSE OF vISION LOSS AND NEuROPAThY IN A DIAbETIC PATIENT

AYŞE MERvE ÇELIK1, ÜMMÜ MUTLU1, MERvE BAHAR3, EZgI ŞAHIN2, KADIR ULUÇ ANIL2, gÜLŞAH YENIDÜNYA YALIN1, NURDAN GÜL1, ÖZLEM SOYLUK SELÇUKBIRICIK1, AYŞE KUBAT ÜZÜM1, REFIK TANAKOL1, FERIHAN ARAL1

1DEpARTMENT OF INTERNAL MEDICINE, DIvISION OF ENDOCRINOLOgY AND METABOLISM, ISTANBUL FACULTY OF MEDICINE, ISTANBUL UNIvERSITY, TURKEY
2DEpARTMENT OF INTERNAL MEDICINE, ISTANBUL FACULTY OF MEDICINE, ISTANBUL UNIvERSITY, TURKEY 3DEpARTMENT OF OpHTHALMOLOgY, ISTANBUL FACULTY OF MEDICINE, ISTANBUL UNIvERSITY, TURKEY

INTrODUCTION: Diabetes is a chronic disease which can fre- quently lead to vision loss and neuropathy due to microvascular complications when not well controlled. Here we present a case of a diabetic patient presenting with vision loss and neuropathy due to a cause other than diabetes.

CASE: A 60-year-old female patient was admitted to our clinic with complaints of fatigue, loss of appetite, weight loss, severe pain, numbness and loss of strength in the right foot and difficulty in walking for the last month. She presented to a different medical center five months ago due to sudden vision loss in her right eye. Orbital MRI was normal. Due to the findings of fundus examination, her complaint was accepted to be associated with diabetic retinop- athy and intravitreal ranibizumab (anti-VEGF) was injected at that center. However, her vision did not improve. Lumbar MRI revealed a lesion in L4 vertebra. An operation was recommended for it but the patient had refused. In another center, these symptoms were said to be associated with diabetic neuropathy but gabapentin did not resolve her symptoms. She was admitted to our clinic due to her continuing complaints. She had diabetes and hypertension for 20 years. Her treatment included insulin detemir, metformin, rami- pril, gabapentin. Diabetic retinopathy, nephropathy and neuropathy were noted. There were no macrovascular complications. In phys- ical examination; there were decreased breath sounds in the left lung, and muscle strength of the right lower extremity was 3/5.

On laboratory findings, glucose: 263 mg/dl, HbA1c: 9.6%, ESR: 34 mm/h, CRP: 2 mg/l, hemogram, creatinine, liver enzymes, electro- lytes, thyroid function tests were normal.

There was an opacity in the left lung on her chest X-ray. Fundus ex- amination revealed lesions compatible with choroidal metastases bilaterally. Thorax CT showed suspicious multiple lymph nodes, the largest being 27x13 mm in the mediastinum, a 10x6 cm mass-at- electasis complex in the left lung, nodular lesions thought to be metastatic in the bilateral lung parenchyma and pleural effusion in the left hemithorax. Cranial MRI showed multipl foci compatible with metastasis. 18-F-FDG PET/CT revealed that the lesion in the left lung (SUV:7.3) may be the primary focus and there were lesions with increased FDG uptake compatible with metastases in thyroid, bilateral lung parenchyma, liver, left adrenal and various parts of skeletal system. Consultation with neurology suggested paraneo- plastic neuropathy and the repeated lumbar MRI revealed lesions compatible with metastases in D12, L4, and L5 vertebra and the L5 nerve root was observed to be significantly compressed.

Diagnostic transthoracic fine needle aspiration biopsy resulted as primary lung adenocarcinoma. The patient was referred to the on- cology department.

CONCLUSION: Findings like vision loss and/or neuropathy in a diabetic patient should not always be thought as complications of diabetes, as these findings may be due to different causes other than diabetes.

KEYwOrDS: diabetes, retinopathy, neuropathy, malignity, vision loss