A 25y old female with type 1 DM since 12 years presented with postural light headedness, blurred vision, profuse sweating, palpitations for one month duration. The onset was gradual but worsened in the last few days resulting in 2 syncopal episodes. There was no history of a viral illness. There was no limb weakness but had reduced sensation in the legs. She was on protophane and Novorapid and had good hypoglycaemia awareness. Her HbA1c was 8.2% and did not have any complications of diabetes.
On examination her pulse rate was 100/minute and there was a postural drop 50-60 mmHg in the blood pressure. Her motor examination was normal except for areflexia. There were reduced sensation I the lower limbs distally. Autonomic function tests suggested acute sympathetic and parasympathetic system dysfunction. Nerve conduction studies showed severe sensorimotor poly radiculopathy with demyelination.
She was treated with Intravenous immunoglobulin as for autonomic variant of Guillain Barre Syndrome. After one dose she developed headache and blurred vision with reduced visual acuity. Ophthalmologic examination showed disc oedema , macular oedema and pre proliferative retinopathy and was treated with intraocular bevacizumab . MRI did not show any space occupying lesion the opening pressure during lumbar puncture was 20cmH2O CSF proteins were 0.83 g/L with no oligoclonal bands. There was no increased white cells. Autoimmune antibodies including anti-neuronal antibodies were negative. Postural hypotension was treated with fludrocortisone the patient developed supine hypertension and fluid retention. Fludrocortisone was ceased and midodrine was started. .She was discharged after 1 month l and was still symptomatic on discharge.
Nerve conduction studies one month afterwards showed improving of the sensorimotor polyneuropathy.

Conclusion- This is a rare case of acute autoimmune autonomic neuropathy in a type 1 diabetic. Causes other than diabetic autonomic neuropathy needs to be considered in atypical presentations.