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Neuropathy in Diabetes
Not a Knee-Jerk Diagnosis
Neuropathic symptoms in patients with diabetes occur commonly and are most often a consequence of the diabetes. Up to 10% of patients with diabetes and neuropathy have an etiology other than diabetes as a cause of their nerve dysfunction. Herein we present a case of vasculitic neuropathy initially misdiagnosed as diabetic neuropathy that led to separate amputations of two toes. This case emphasizes the importance of considering alternative, potentially treatable, causes of peripheral neuropathy in patients with diabetes. (J Am Podiatr Med Assoc 98(4): 322–325, 2008)
The Development of a Charcot Foot after Significant Weight Loss in People with Diabetes
Three Cautionary Tales
Medication to aid weight loss and weight loss surgery are becoming more commonly available for people with diabetes. As a result of profound weight loss, diabetes may go into remission and many biochemical and physical parameters improve. However, some of the end organ damage associated with diabetes may not improve, peripheral neuropathy being an example. We present three cases in people with diabetes and pre-existing peripheral neuropathy who had lost significant weight. They became more mobile and developed a Charcot foot despite their diabetes improving significantly. People who have lost significant weight should continue to monitor their feet because the risks of foot disease remain even if diabetes goes into remission.
Necrotizing fasciitis is a soft-tissue infection characterized by extensive necrosis of subcutaneous fat, neurovascular structures, and fascia. In general, fascial necrosis precedes muscle and skin involvement, hence its namesake. Initially, this uncommon and rapidly progressive disease process can present as a form of cellulitis or superficial abscess. However, the high morbidity and mortality rates associated with necrotizing fasciitis suggest a more serious, ominous condition. A delay in diagnosis can result in progressive advancement highlighted by widespread infection, multiple-organ involvement, and, ultimately, death. We present a case of limb salvage in a 52-year-old patient with type 2 diabetes mellitus and progressive fascial necrosis. A detailed review of the literature is presented, and current treatment modalities are described. Aggressive surgical debridement, comprehensive medical management of the sepsis and comorbidities, and timely closure of the resultant wound or wounds are essential for a successful outcome. (J Am Podiatr Med Assoc 96(1): 67–72, 2006)
Emergency department visits for lower extremity complications of diabetes are extremely common throughout the world. Surprisingly, recent data suggest that such visits generate an 81.2% hospital admission rate with an annual bill of at least $1.2 billion in the United States alone. The likelihood of amputation and other subsequent adverse outcomes is strongly associated with three factors: 1) wound severity (degree of tissue loss), 2) ischemia, and 3) foot infection. Using these factors, this article outlines the basic principles needed to create an evidence-based, rapid foot assessment for diabetic foot ulcers presenting to the emergency department, and suggests the establishment of a “hot foot line” for an organized, expeditious response from limb salvage team members. We present a nearly immediate assessment and referral system for patients with atraumatic tissue loss below the knee that has the potential to vastly expedite lower extremity triage in the emergency room setting through greater collaboration and organization.
Simultaneous pancreas-kidney transplant (SPKT) is an accepted approach and the treatment of choice in patients with type 1 diabetes with accompanying end-stage renal disease. Charcot's neuroarthropathy of the foot (CN) is a fairly common and devastating complication found in patients with long-standing, mostly uncontrolled, diabetes. However, CN has also been identified as a posttransplant consequence of SPKT. Traditional postoperative immunosuppressive therapy, particularly the use of corticosteroids, is acknowledged as an additional risk factor for the development of de novo CN after SPKT. This article describes an unusual case of a patient who presented with full-blown CN deformity after SPKT.
Foot pain and lower-limb neuroischemia in diabetes mellitus is common and can be debilitating and difficult to treat. We report a comparison of orthotic materials to manage foot pain in a 59-year-old man with type 1 diabetes mellitus, peripheral neuropathy, peripheral arterial disease, and a history of foot ulceration. We investigated a range of in-shoe foot orthoses for comfort and plantar pressure reduction in a cross-sectional study. The most comfortable and most effective pressure-reducing orthoses were subsequently evaluated for pain relief in a single system alternating-treatment design. After 9 weeks, foot pain was completely resolved with customized multidensity foot orthoses. The outcome of this case study suggests that customized multidensity foot orthoses may be a useful intervention to reduce foot pain and maintain function in the neuroischemic diabetic foot. (J Am Podiatr Med Assoc 98(2): 143–148, 2008)
The etiology of ulcerations related to increased plantar pressure in patients with diabetes mellitus is complex but frequently includes a component of gastrocnemius soleus equinus. One viable treatment option is percutaneous tendo Achillis lengthening as a means of increasing dorsiflexory range of motion and decreasing forefoot shear forces. This article presents three case reports illustrating the importance of reducing plantar pressure as a crucial component of treatment of diabetic forefoot ulcerations. (J Am Podiatr Med Assoc 95(3): 281–284, 2005)
The number of people with diabetes is expected to reach 592 million in the year 2035. Diabetic foot lesions are responsible for more hospitalizations than any other complication of diabetes. The aims of this study were to examine for the first time a new biocompatible and biodegradable tridimensional collagen-based matrix, GBT013, in humans for diabetic foot ulcer wound healing and to evaluate its ease of use to better define a protocol for a future clinical trial. Seven adult patients with a diabetic foot ulcer of grade 1A to 3D (University of Texas Diabetic Wound Classification) were treated using GBT013, a new collagen-based advance dressing and were monitored in two specialized foot care units for a maximum of 9 weeks. Five of seven wounds achieved complete healing in 4 to 7 weeks. Nonhealed ulcers showed a significant reduction of the wound surface (>44%). GBT013 was well tolerated and displayed positive wound healing outcomes as a new treatment strategy of chronic foot ulcers in diabetic patients.
Neuropathic foot ulcers are a common complication in patients with diabetes. These ulcers are often slow to heal and can lead to infection, further tissue destruction, osteomyelitis, and amputation. These patients pose a challenge to clinicians who must determine the best treatment options while balancing the risks, benefits, and costs. Conservative therapies often present disappointing results, and a number of newer “biologic bandages” have been developed to better assist the healing process. We describe results from diabetic patients with neuropathic foot ulcers treated with a new amniotic membrane–based allograft.
Methicillin-Resistant Staphylococcus aureus Endocarditis from a Diabetic Foot Ulcer
Understanding and Mitigating the Risk
Diabetic foot infections are a common cause of morbidity and mortality in the United States, and successful treatment often requires an aggressive and prolonged approach. Recent work has elucidated the importance of appropriate therapy for a given severity of diabetic foot infection, and highlighted the ongoing risk such patients have for subsequent invasive life-threatening infection should diabetic foot ulcers fail to heal. The authors describe the case of a man with diabetes who had prolonged, delayed healing of a diabetic foot ulcer. The ulcer subsequently became infected by methicillin-resistant Staphylococcus aureus (MRSA). The infection was treated conservatively with oral therapy and minimal debridement. Several months later, he experienced MRSA bloodstream infection and complicating endocarditis. The case highlights the ongoing risk faced by patients when diabetic foot ulcers do not heal promptly, and emphasizes the need for aggressive therapy to promote rapid healing and eradication of MRSA.
