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441 - Lumbar Myxopapillary Ependymoma as Red Herring for Diabetic Amyotrophy in a Patient with Progressive Lower Extremity Weakness and Dysethesias

Thursday, February 27, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

AR

Angela Ryck, MD

Resident Physician
University of Virginia
Charlottesville, Virginia, United States

Co-Author(s)

RC

Reid Collis, MD

Resident Physician
University of Virginia School of Medicine - - Charlottesville, VA
Charlottesville, Virginia, United States
DM

Dylan McCaleb, MD

Resident Physician
University of Virginia Health Systems
Charlottesville, Virginia, United States

Corresponding Author(s)

MW

Michael D. Warwick, MD

Assistant Professor
University of Virginia
Charlottesville, Virginia, United States

Case Diagnosis: Diabetic amyotrophy in the setting of poorly controlled type 2 diabetes mellitus and low back pain

Case Description: 68-year-old female runner with untreated T2DM (A1c 13) presented with 1-month history of low back pain, progressive left lower extremity pain, numbness, and weakness, and weight loss. MRI revealed a 1-cm L2/L3 myxopapillary ependymoma with moderate stenosis, which following hyperglycemic treatment, was resected 7-months later. Post-operatively, she experienced worsening right and unimproved left lower extremity pain and weakness. Upon evaluation one year later, she remained non-ambulatory with 0-1/5 strength of L4/L5 myotomes bilaterally, 2/5 strength of right L2/3 myotomes, and dense sensory impairment to the proximal thighs. Electrodiagnostic studies demonstrated widespread sensorimotor axonal loss affecting the lumbosacral nerve roots, plexus, and peripheral nerves, right worse than left, in this clinical setting, consistent with diabetic amyotrophy.

Discussions: Diabetic amyotrophy is a rare proximal neuropathy presenting with asymmetric lower extremity pain, weakness, sensory impairment, and weight loss followed by contralateral lower extremity involvement to various degrees. Progressive worsening for months to two years may occur followed by gradual, often incomplete recovery. Risk factors, as in this patient, include initiation of hyperglycemic treatment. Diagnosis remains clinical while labs, imaging, and electrodiagnostics may support the diagnosis and rule out other causes. In this case, only MRI was performed and no other diagnoses were entertained. Post-operative MRI additionally demonstrated no findings to explain the patient’s continued progression to incomplete paraplegia. While treatment is supportive, steroids, IVIG, and PLEX may provide clinical benefit.

Conclusions: In diabetic patients with progressive lower extremity pain, weakness, and dysesthesias, detailed history and exam may provide insight into less common etiologies including diabetic amyotrophy with EMG/NCS providing additional diagnostic utility. As pain and disability may be severe, prompt, accurate diagnosis is crucial to optimize long-term outcomes and avoid unnecessary surgical intervention.