Pseudoainhum of toes in type 2 diabetes

Abstract

A 43 year old woman known case of type 2 diabetes for 12 years presented with claudication pain and shortening of toes of left leg of 1 year duration. The claudication distance decreased gradually from 3 km to 1 km with no history to suggest rest pain. The pain involved the foot with sparing of thigh and calf muscles. She also noticed gradual shriveling and shortening of toes belonging to left foot. She denied similar complaint in other extremities, exposure to cold or consumption of ergot alkaloids. Past history revealed poor glycemic control (A1c: 9.2%) and microvascular disease in the form of retinopathy and nephropathy. Left foot examination revealed feeble pulse, diminished sensation to pinprick with absent ankle jerk. Toes of left foot were at varying stages of autoamputation with distal ulceration of 2nd toe (Fig. 1a). Radiograph showed resorption of terminal phalanges and osteopenia (Fig. 1b). Doppler study revealed normal major arteries with poor visualization of digital arteries (Fig. 1c). Based on the presentation and findings, she was diagnosed to have Pseudoainhum of toes. Pseudoainhum or Morior is defined as the autoamputation of toes or fingers with shriveling seen in chronic diseases like diabetes [1]. Our patient had features of both macro and microvascular disease with normal major arteries on doppler examination. She was treated with insulin, atorvastatin, ramipril, clopidogrel, aspirin, cilostazole and pentoxifylline. Marginal improvement was observed in the severity of pain and claudication distance with therapy. Ainhum or spontaneous dactylolysis is a disease described in dark skinned individual of autoamputation of small toes [2]. The classical disease is usually preceded by a constricting band or groove encircling the toes. Pseudoainhum is similar process secondary to an identifiable disease independent of skin color. Though the pathogenesis is unclear, various theories like genetic predisposition, angiodysplasia, hyperkeratosis, trauma and environmental factors are proposed for the same [3]. The course of pseudoainhum is characterized by hyperkeratotic skin, fissuring, digital degeneration, skeletal erosion culminating into autoamputation. The differential diagnosis includes localized scleroderma, trauma, frost bite and ergot poisoning. Ainhum and Pseudoainhum are graded into 4 stages according to the stage of pathology [4]. Our patient had all the stages affecting different toes simultaneously. The therapy differs according to the stage of involvement. Oral vitamin A and etretinate are used in early stages and surgical procedures like release of constricting band, skin grafting and amputation are required in advanced stages. K. V. S. H. Kumar (*) : S. Bhasker Department of Endocrinology, Command Hospital, Lucknow 226002, UP, India e-mail: hariendo@rediffmail.com