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onicity of the gastrointestinal tract (gastroparesis) and bladder dilation, sexual impotence, and postural hypotension The most striking examples in our experience have included severe abdominal and limb pain, reminiscent of tabetic crises The basis of this type of involvement is not well understood Duchen and associates, who studied the sympathetic ganglia in diabetic patients with autonomic symptoms, described vacuoles and granular deposits in sympathetic neurons and little if any neuronal degeneration; there was also a loss of myelinated nerve bers in the vagus and splanchnic nerves and the rami communicantes, as well as changes in neurons of the intermediolateral columns of the spinal cord Pathology and Pathophysiology In the mundane symmetrical distal diabetic polyneuropathy, a loss of myelinated nerve bers is the most prominent nding according to Thomas and Tomlinson In addition, segmental demyelination and remyelination of remaining axons are apparent in teased nerve ber preparations The latter ndings are probably too severe and widespread to be simply a re ection of axonal degeneration Occasionally, repeated demyelination and remyelination leads to onion-bulb formations of Schwann cells and broblasts, as it does in the relapsing in ammatory neuropathies Unmyelinated bers are also reduced in number in most specimens Similar lesions are found in the posterior roots and posterior columns of the spinal cord and in the rami communicantes and sympathetic ganglia Under the electron microscope, the basement membranes of intraneural capillaries are seen to be thickened and duplicated There are changes in the microvasculature of the nerves as well, similar to what is seen in other organs and in the skin as noted later However, substantial uncertainties persist about the pathogenesis of the diabetic neuropathies Both the cranial (diabetic ophthalmoplegia) and peripheral mononeuropathies as well as the painful, asymmetrical, predominantly proximal neuropathy of sudden onset have been considered by most neuropathologists to be ischemic in origin, secondary to a vasculopathy of the vasa nervorum that is a property of the diabetic state Obliterative microvascular lesions were well illustrated by Raff and coworkers, and corresponding multiple small infarcts were found in the nerve trunks The observations of Dyck and of Johnson and their associates have suggested that all forms of diabetic neuropathy could have the same microvascular basis These authors described multiple foci of ber loss throughout the length of the peripheral nerves, beginning in the proximal segments and becoming more frequent and severe in the distal segments This pattern of change differs from that observed in diffuse metabolic disease of Schwann cells and in the dying-back type of neuropathy; ie, the ndings suggest an ischemic etiology Fagerberg had earlier noted that the fascicular capillaries and epineural arterioles have thickened and hyalinized basement membranes, similar to the microvascular changes seen in the retina, kidney, and other organs But occlusion of vessels and frank infarction of nerve has not been observed in most cases of polyneuropathy for which reason a vascular pathogenesis remains unsettled in the minds of some pathologists In the past several years an alternative view has been offered, based largely on the work of PJB Dyck and colleagues and of Said and coworkers They have found areas of perivascular in ammation and a suggestion of adjacent damage to nerve fascicles in the proximal asymmetric radicular plexus lesions In Said s report, this necrotizing vasculitis was observed in 6 of 22 patients and a degree of perivascular in ammation in 21, changes not seen in the typical. pdfsharp table example c# c# - PDFSharp заполнение полей формы - Qaru
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