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Abstract
Diabetes mellitus (DM) is one of the most common chronic diseases in the United States. It is characterized by increased patient morbidity and mortality due to the many complications that can arise. Certain dermatological findings can be indicative of poorly controlled DM and can be a useful clue to further management. Persons experiencing homelessness (PEH) with DM often have higher rates of diabetic complications than the general diabetic population. Medical providers caring for PEH in the setting of limited resources should carefully evaluate cutaneous disease as a potential indicator of underlying illness. This physical manifestation of illness can serve to guide the next appropriate steps in management. A 41-year-old unsheltered male with an extensive medical history of hypertension, seizures, chronic diarrhea, and cocaine use was seen at a “foot-washing” medical outreach event. He presented with fevers, chills, and multiple painless right lower extremity ulcerated lesions of unspecified origin. A finger-stick glucose measurement was found to be 650 mg/dL. After immediate administration of 10 units of insulin, he was transported immediately to the emergency department and admitted. His month-long hospital course was complicated and involved the amputation of multiple toes. Preemptive outreach and management could have prevented the marked deterioration of his disease and represents the importance of outreach and regular follow-up with the PEH community.
Highlights
Diabetes mellitus (DM) is the most expensive chronic disease in the nation, costing approximately US$327 billion in 2017 [1]
Some of the most feared yet common cutaneous complications are infections. These can occur from pre-existing skin lesions or can occur hematogenously due to impaired immune responses in diabetic patients [4]
We present a case of uncontrolled type 1 DM (T1DM) in an unsheltered patient, which was discovered incidentally through cutaneous findings at a public health outreach event
Summary
Diabetes mellitus (DM) is the most expensive chronic disease in the nation, costing approximately US$327 billion in 2017 [1]. Multiple studies have shown homelessness in general to be associated with substandard DM management [7] This can exacerbate their underlying predisposition toward chronic wounds, infections, and cardiovascular disease. Patients admitted with recurrent episodes of diabetic ketoacidosis (DKA) had significantly higher rates of depression, alcohol and drug use, and homelessness [12] This represents a public health crisis because complications from DM are limited to DKA and the management of chronic wounds and dermatologic conditions. Chronic ulcers, those seen in long-standing, poorly controlled DM have an increased likelihood of infection. Due to the fact that he had multiple underlying acute and chronic health conditions, his hospital course was complicated by multiple infections, and the decision was made to amputate his right second and third toes (Figure 3)
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