Case 143: Peripheral Neuritis and Retinopathy Following Rapid Control of Diabetes Treated Successfully with Boot?

At age 22, this lady was referred for control of her diabetes on March 21st, 1985. She had been treated from age 7 to 17 at a Philadelphia university diabetes clinic. At age 17 she came under the care of a suburban diabetes specialist who began her on pump therapy. She began a liberalized diet believing her pump substituted for her pancreas. Subsequently, she was hospitalized on a half dozen occasions for acidosis, most often without explanation. She developed leg spasms at night and some fluid retention that her doctors could not explain. Her gynecologist referred her for a second opinion regarding her diabetes.

On physical examination, she presented as a pretty young girl weighing 119 lb. and standing 64.5 inches tall. Her blood pressure was 115/78 with a pulse of 76 supine and 110/75 with a pulse of 96 standing. She had acetone on her breath. Her vision was 20:20 in each eye. Her retinal disk borders were sharp. The retinal A:V ratio was 2:3. The eyes were slightly sunken. Her Achilles tendon reflex appeared slightly delayed. Her dorsalis pedis and posterior tibial pulses were palpable. She had a white vaginal discharge and reddening of her vulva and intragluteal cleft. The rest of her physical examination was unremarkable. Her blood sugar was 568 mg/dl and her serum acetone positive to the 4th dilution. She had diabetic ketoacidosis and a pelvic yeast infection. She refused admission to the hospital and was treated as an outpatient successfully and was able to go to work the next day.

She was switched to a four-injection per day insulin program taking NPH at breakfast and bedtime and variable amounts of regular insulin before meals according to her blood glucose level. Her diabetes was easily controlled. Her weight initially increased from 119 to 140 pounds as she retained water; her legs felt heavy, tight and distinctly uncomfortable. By May 26th, her weight had decreased back to 125 pounds, but the discomfort in her legs was worse having become a sharp burning pain. She cried all night long. Her family became quite distraught. Vitamins, Benadryl, Tylenol and antidepressants offered no relief. EMG's on March 20th on both the median and peroneal nerves were abnormal and pointed to a diffuse peripheral neuropathy. She was given Percocet but took the entire 50 pill prescription over a few days. The possibility of drug abuse was obvious. Along with her pain, she developed significant orthostasis; her supine pressure of 137/85 fell to 105/80 standing and her pulse rose from 105 to 130. She was noting blurry vision and having difficulty seeing the numbers on her syringe to take her insulin; diabetic retinopathy was now apparent with the ophthalmoscope. She was advised that it was possible vascular lesions like those in her eyes might be present around the nerves in her legs and explain her leg pain. An experimental treatment with the Circulator Boot was offered. Thin platinum electrodes were placed in her foot and in her arm to measure subcutaneous oxygen tensions by the polarographic method before and after boot therapy; a modest rise was found in the foot and not in the arm. She hence was offered a trial of boot therapy which she accepted perhaps 3-4 times a week. She noted pain relief after the treatment but the pain returned after several hours. She was admitted to the Bryn Mawr Hospital where she again had EMG's before and after boot therapy; the latter showed an improvement in nerve conduction times in her pain free period after boot therapy. The subcutaneous PO2 measurements were again repeated with a rise in PO2 noted both after boot therapy and after the administration of nasal oxygen. Her program was changed to include boot therapy during the day and nasal O2 and methadone at night. She was transferred to the Clinical Research Center at the Hospital University Pennsylvania where under the study of Dr. Britton Chance, she had a 31 P NMR spectroscopy study. In this study, the relative concentrations of intracellular phosphorylated metabolites [including ATP, phosphocreatinines (PCr), inorganic phosphate (Pi), and phosphomonoesters (PME)] in the living cell are examined. Her legs were studied on two consecutive days before and after the application of the Circulator Boot to one of her legs. She was asked to do 25 plantar flexions within the magnet. The Pi/PCr ratio was used to quantitate the overall metabolic state of the muscle. The PME/ATPB ratio (indicating anaerobic metabolism) depleted to the same value both before and after Circulator Boot therapy. However, "her recovery was much improved in both legs on both days following application of the pump".

Right leg on Day #1: The solid lines are the data for Pi/PCr and changed little after boot therapy. The dotted lines connecting the small pyramids represent the PME/ATPB ratios. It is seen that the latter does not rise as high after exercise, falls faster, and plateaus at a lower level post boot treatment.

Right leg on Day #2: Essentially the same changes were seen on the second day.

Left leg on Day #1: Again the PME/ATPB ratios did not raise as high after exercise and fell more rapidly to lower levels.

Left leg on Day #2: Again similar findings were noted. Anaerobic metabolism was lessened by boot therapy.

Advanced background retinopathy, July 1st 1985.

Her fluorescein angiograms showed innumerable microaneurysms.

The later angiograms showed that the dye had leaked from the vessels to cover much of the retina.

Her leg and visual complaints gradually subsided over the summer and fall. She had become a good diabetic. When seen on follow-up on October 2nd, 1985, for example, the mean ( standard deviation of her serum glucose levels were 103 ( 14.7 (32 tests) before breakfast, 101.8 ( 13.5 (32) before lunch, 105.4 ( 13.1 (31) before supper and 107 ( 12.7 (31) at bedtime. She did equally well over the next few years and had no complaints. Several years ago she was lost to our care, having her care assumed by a primary physician of her HMO. We called her the day her story was prepared for this website. She reports she is doing well and has been reduced to a convenient 2-injection/day program. We asked her to request her current ophthalmologist to forward any retinal photographs he might have to us.... which we, of course, will add here to her story.

Comments: This case is a extraordinary example of sudden deterioration of vision in a poorly controlled diabetic with the institution of tight control. This effect has been previously reported and was seen in the data of the Diabetes Control and Complications Trial. I explain this phenomenon to patients noting that glycosylation products and tissue damage from glycosylation have different lifespans. The damage in the capillary may take several weeks for repair. Fibrinogen, albumen and the various plasma proteins turnover more rapidly. The stiff glycosylated red cell is slowly replaced over several weeks. Relatively viscous blood and stiff red cells cannot leak out of the capillary defects....but normal blood elements can. Thus, this women's blood was normalized before her capillary bed had recovered. Pumping on her leg improved blood flow to her nerves and tissues: her subcutaneous O2 was improved (O2 - polarographic studies) as was her cellular recovery from anoxia (NMR studies). The effect on her legs cannot be attributed only to a direct of effect of the pumping; both legs had improvement on the NMR studies athough only one leg was pumped each day. Pumping, of course, may increase the generation of fibrinolysins, nitric oxide and prostacyclin which all may have systemic effects. The course of her eyes was also unusual. The study, from a boot point of view, was weakened by the decision of the second ophthalmologist to do laser therapy. Her eyes were improving before the laser treatment started. Such a remarkable improvement and course is remarkable in patients treated by laser alone. Over the years we have tried to interest ophthalmologist in the potential systemic effects of boot therapy on the eyes... Yawn... We obviously need more cases to first document an effect and then to find the limits of any benefit. We have had other cases who have noted an improvement in their sight associated with their boot treatments and have another case in progress at present; hopefully, we may be able to add her story to this series later. Our library section provides much literature documenting the effect of boot therapy on leg circulation, which has been covered by Medicare in our region for 16 years. Pumping on legs for the benefit of the eyes and head is not an established service in this country. The Chinese, however, have described benefits to such treatments in their boot clinics. Such effects, of course, are very interesting and add to our understanding about the systemic effects of boot treatments.