Key messages
There are people with incorrectly diagnosed diabetes mellitus all over the world. And in completely extraordinary cases, the diagnosis comes thanks to or because of other problems. An exemplary case was described by the surgeon Gerhard Rümenapf and colleagues of the Upper Rhine Vascular Center at the Diakonissen Foundation Hospital.
The patient and his story
The patient, a 60-year-old man, had stepped on a sea urchin on a beach in Zanzibar during a holiday.Once the thorns were removed, the foot was disinfected and medicated. Despite the absence of fever, the man was prescribed antibiotic treatment.
The data
17 days after the accident, the following tests were carried out at the hospital:
- Right foot painless, swollen and red, 2nd-4th toe necrotic up to the metatarsophalangeal joints.
- Normal leukocytes, elevated C-reactive peptide (68mg/l).
- Blood glucose 476mg/dl and HbA1c value at 12.7.
- Atherogenic risk factors: arterial hypertension and grade I obesity (BMI: 31 kg/m2).
- Inguinal pulse and pulse of the popliteal artery and dorsal artery palpable.
The diagnosis of diabetic foot syndrome and acute neuropathic infection was fairly straightforward although the patient was not aware that he had type 2 diabetes.
Treatment and course
- Emergency surgery and intraoperative diagnosis of peripheral arterial disease of the foot type (PAD).
- Transmetatarsal amputation of necrotic fingers.
- Rapid wound healing.
- Use of compression stockings for diabetes.
- Insulin therapy.
Three months later, further removal of the necrotic metatarsophalangeal joint of the right big toe followed.The man died suddenly after two years, during another vacation; A heart attack was suspected as the cause of death.
Discussion
Sea urchins are common on the coasts of all continents. Their spines are equipped with small spines and sometimes venom glands that can remain in the tissues; In addition, toxins can cause localized necrosis. Wounds caused by sea urchins are painful and especially dangerous because the spines are often colonized by bacteria and can cause acute and chronic inflammation. The remaining spines can cause arthritis and foreign body granulomas.
In these injuries it is important to remove the spines immediately, and debridement of the wound area may also be indicated. This must then be monitored and, according to the vascular surgeons who authored the clinical case, antibiotics are mandatory. The fact that lesions caused by sea urchin spines lead to the initial diagnosis of diabetes mellitus is certainly rare.The painless development of gangrene in the 60-year-old shows that he must have already developed significant diabetic neuropathy in the prediabetes or unrecognized diabetes stage. According to Gerhard Rümenapf and his colleagues, diabetic polyneuropathy with loss of nociception is the most important accelerator in the development of diabetic foot syndrome.
“Diabetic foot syndrome on vacation” usually describes foot injuries that occur during vacations in people whose diabetes mellitus has been known for a long time. The main causes are unaccustomed strain on the feet, the use of unsuitable footwear, burns on the sole of the foot and acute trauma due to walking barefoot.
According to the authors, every week in their vascular surgery departments they discover “several patients with late diabetic complications (diabetic foot, kidney failure, etc.) who were previously not diagnosed as diabetic.”
Laboratory values that usually indicate the severity of inflammation (leukocytes, CRP) may be irrelevant in people with diabetes despite severe inflammation and are therefore not reliable.Clinical evaluation in combination with signs of neuropathy and related PAD, which is present in about 50% of cases, is important.
This article was translated from Univadis.de using several tools, some of which are AI-based. A member of the editorial staff reviewed and edited the content before publication.
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