Non-Tropical Diabetic Hand Syndrome in Peru: A Case Report

Abstract

Background: The diabetic foot is the most studied spectrum in relation to musculoskeletal complications in diabetic patients but upper extremities may be affected, producing from superficial hand injuries to multiorganic failure due to sepsis. Tropical diabetic hand syndrome has been used to describe a potentially dangerous infection in the hand, generally diagnosed in areas of the tropics. Nevertheless, cases have been seen in non-tropical areas in marginal urban areas which are part of the spectrum of Non tropical diabetic hand syndrome.Clinical Case: A 52-year-old woman, from marginal urban area of Lima- Peru with type 2 diabetes mellitus (T2DM) of 6 years in poor metabolic control. She was admitted to the emergency room with two weeks of volume increase, erythema, purulent secretion, flogosis in the fifth finger of the left hand and fever. Initial tests confirmed mild diabetic ketoacidosis and sepsis (pH: 7.29; Glucose: 320 mg / dl, Bicarbonate: 15 mEq/L, Ketone bodies - urine (+), leukocytes 14360 cells/mm3, CRP: 180). Intravenous antibiotic was started. A surgical debridement and amputation of the fifth finger of the left hand was decided. Patient with unfavorable evolution, on the eight day, was admitted to new surgical debridement without clinical improvement. Arterial Doppler Ultrasound and CT angiography confirmed distal arterial insufficiency due to monophasic flow in the left ulnar artery with the presence of collateral circulattion. A third surgical debridement and amputation of the fourth finger of the left hand was done with favorable postoperative clinical evolution.Non tropical diabetic hand syndrome affects predominantly women, between 50 to 60 years, with low socio-cultural level and deficient glycemic control, as in case presented. Other factors include body mass index < 20kg/m2, DM 1 and diabetic neuropathy. Diabetic neuropathy is the most common risk factor in Non tropical diabetic hand syndrome cases, with a prevalence of 88%, while peripheral arterial disease was present in 11% of cases. In this report, neuropathy and peripheral arterial disease were present.Conclusion: Non tropical diabetic hand syndrome is uncommon and underdiagnosed complication of Diabetes Mellitus that has an important clinical repercussion as an important cause of disability. Detailed physical examination of the hands in a patient with diabetes for detection of these cases is highlighted because an early diagnosis and treatment improves prognosis.