Background: 

<ul>
	<li>A sedentary 68-year-old male who had a 15-year history of impaired glucose tolerance, hypertension and hypercholesterolemia</li>
	<li>Smoking 16 years ago and denies the use of alcohol.</li>
	<li>Treated with ACE inhibitor and statins</li>
	<li>Noticed a burning and tingling in his hands and feet.</li>
	<li>Diminished sense of balance</li>
	<li>He denied fever, chills, nausea, vomiting, chest pain or shortness of breath.</li>
	<li>No recent episode of cough, vertigo or orthostatic hypotension.</li>
</ul>

&nbsp;&nbsp;&nbsp;His physical examination was unremarkable except for some hyperesthesia of both hands and feet as well as decreased vibratory sensation. The patient had no open lesions on either foot, and had intact protective sensation for both feet. Reflexes were normal and pedal pulses were palpable. We noted a slight ataxia.

&nbsp;&nbsp;&nbsp;Laboratory studies revealed:

<ul>
	<li>Fasting blood glucose of 136 mg/dl.&nbsp;</li>
	<li>HbA1c was 7.6% up from 6.8% 9 months earlier.</li>
	<li>A CBC, lipid panel, liver screening and a renal profile were all normal</li>
</ul>

Serum levels of B12, T3, T4 thyroid stimulating hormone (TSH) were within normal limits.

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