Although autonomic dysfunction frequently complicates the clinical course of patients with diabetes, relatively little is known of its underlying neuropathology. Using experimental animal models as a guide, the prevertebral superior mesenteric (SMG) and paravertebral superior cervical (SCG) sympathetic ganglia have been examined in a series of adult autopsied diabetic and non-diabetic patients of various ages using histochemical, ultrastructural, morphometric, and immunohistochemical methods. Quantitative studies demonstrated that markedly swollen argyrophilic terminal axons (neuroaxonal dystrophy) containing large numbers of disorganized neurofilaments developed in the SMG but not SCG as a function of diabetes, increasing age, and gender (males were more severely affected than females). As in experimental animals, diabetic (types I and II) patients developed histologically identical lesions prematurely and in greater numbers than age-matched nondiabetic patients. Morphometric studies showed a small but statistically significant decrease in neuronal density in the SMG but not SCG of diabetic patients. The dimensions of individual sympathetic neurons were not significantly different in aging or diabetes. The pathological lesions identified in the SMG may contribute to the autonomic dysfunction so commonly observed in diabetic patients.