Diabetic Dermopathy

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Is there evidence of:

Fall in visual acuity (2 lines or more on Snellen chart) Established maculopathy (edema of macula, hard exudates on macula) New vessels (at periphery or disc) Rubeosis iridis

Advanced diabetic retinopathy (e.g. retinal detachment)

Immediate referral to an ophthalmologist

Is there evidence of:

Fall in visual acuity (2 lines or more on Snellen chart) Established maculopathy (edema of macula, hard exudates on macula) New vessels (at periphery or disc) Rubeosis iridis

Advanced diabetic retinopathy (e.g. retinal detachment)

Urgent referral to an ophthalmologist (within 1 week)

Is there evidence of:

Hard exudates close to macula

Florid and increasing number of retinal hemorrhages

Preproliferative changes

Non-urgent referral to an ophthalmologist (within a few weeks)

Is there evidence of: Cataract

Routine referral to an ophthalmologist (within a few months)

Figure 102 Once diabetic retinopathy has been identified, referral to an ophthalmologist may be indicated. This table shows the types of diabetic eye disease requiring such referral and the urgency with which it should be undertaken

A classification of diabetic neuropathies

Symmetrical polyneuropathies

Symmetrical diffuse sensorimotor neuropathy

Painful small-fiber neuropathy

Acute painful diabetic polyneuropathy

Autonomic neuropathy

Focal and multifocal neuropathy

Entrapment and compression neuropathies Cranial nerve palsies

Proximal motor neuropathy

(Diabetic amyotrophy)

Hyperglycemic neuropathy

Diabetic Amyotrophy

Figure 104 Transverse semi-thin sections of resin-embedded sural nerve biopsy specimens stained with thionin and acridine orange. (a) appearance of a normal nerve. (b) nerve from a patient with diabetic neuropathy shows loss of myelinated nerve fibers and the presence of regenerative clusters. The walls of the endoneural capillaries are thickened. Diabetic neuropathy is a common complication that usually manifests as a sensory, motor or combined symmetrical polyneuropathy. Acute painful neuropathy and diabetic amyotrophy both cause acute pain in the thighs or legs associated with muscle wasting and weight loss. Painful neuropathy may respond to tricyclic drugs, especially amitriptyline, or anticonvulsants, such as gabapentin mm &

Figure 103 Diabetic neuropathy is a common and often disabling complication of diabetes. Distal symmetric polyneuropathy is the most common form of diabetic neuropathy and can be either sensory or motor and involve small fibers, large fibers or both. Large-fiber neuropathies can involve sensory or motor nerves or both resulting in abnormalities of motor function, vibration perception, position sense and cold thermal perception with commonly a 'glove and stocking' distribution of sensory loss. Small-fiber neuropathy is manifest by pain and paraesthesiae but may develop into a chronic painful neuropathy. Mononeuro-pathies and entrapment syndromes are common. Proximal motor neuropathies (diabetic amyotrophy) have more complex etiologies but are usually associated with great pain and disability. Autonomic neuropathy is rare and leads to a wide variety of symptoms correlating with the affected autonomic nerve damage. After 20 years of diabetes, around 40% of patients will have diabetic neuropathy

Figure 104 Transverse semi-thin sections of resin-embedded sural nerve biopsy specimens stained with thionin and acridine orange. (a) appearance of a normal nerve. (b) nerve from a patient with diabetic neuropathy shows loss of myelinated nerve fibers and the presence of regenerative clusters. The walls of the endoneural capillaries are thickened. Diabetic neuropathy is a common complication that usually manifests as a sensory, motor or combined symmetrical polyneuropathy. Acute painful neuropathy and diabetic amyotrophy both cause acute pain in the thighs or legs associated with muscle wasting and weight loss. Painful neuropathy may respond to tricyclic drugs, especially amitriptyline, or anticonvulsants, such as gabapentin

Diabetes Cutaneous Signs Amyotrophy

Figure 106 This diabetic patient has an ulnar neuropathy. Such entrapment neuropathies are commonly seen in diabetic patients, the commonest being carpal tunnel syndrome. It has been postulated that diabetic nerves may be more susceptible to mechanical injury

Figure 105 Diabetic right third cranial nerve palsy. The right eye is deviated outwards and downwards, and there is associated ptosis. Pupillary sparing is often encountered. Third nerve palsy is the most commonly seen cranial neuropathy of diabetes, although fourth, sixth and seventh nerve lesions have also been reported as well as intercostal and phrenic nerve lesions. These lesions usually improve over time

Figure 106 This diabetic patient has an ulnar neuropathy. Such entrapment neuropathies are commonly seen in diabetic patients, the commonest being carpal tunnel syndrome. It has been postulated that diabetic nerves may be more susceptible to mechanical injury

Postural Hypotension

Figure 107 Clinical features of diabetic autonomic neuropathy. Many diabetic patients have evidence of autonomic dysfunction, but very few have autonomic symptoms. The most prominent symptom is postural hypotension. Erectile dysfunction, common in diabetic men, is not always due to autonomic neuropathy. Late manifestations other than postural hypotension include gustatory sweating, diabetic diarrhea, gastric atony and reduced awareness of hypoglycemia. Symptomatic autonomic neuropathy may be associated with a poor prognosis

Diabetic Neuropathy Classification

Figure 108 This diabetic patient had known diabetic neuropathy and had been repeatedly given foot care advice in his diabetes center. Despite this, he walked over a hot surface in a Mediterranean country in a summer month. By the time he realized that there was a problem he had sustained extensive burn injuries to both feet requiring urgent medical attention

Figure 108 This diabetic patient had known diabetic neuropathy and had been repeatedly given foot care advice in his diabetes center. Despite this, he walked over a hot surface in a Mediterranean country in a summer month. By the time he realized that there was a problem he had sustained extensive burn injuries to both feet requiring urgent medical attention

Diabetic Neuropathy Penis
Figure 109 In spite of his diabetes and neuropathy and with good care from the podiatrist, this patient's burns healed remarkably quickly, fortunately with no adverse sequelae
Enterra Gastric Neurostimulator

Figure 1 10 Intractable vomiting due to diabetic gastroparesis is notoriously difficult to treat. This patient was successfully treated by the surgical implantation of the Enterra™ Gastric Neurostimulator (GES) system (Medtronic Inc, Minneapolis, USA). This novel experimental approach may prove to be an effective treatment strategy in such rare but difficult-to-treat patients

Diabetic Dermopathy TreatmentPenile Constrictor Ring

Figure 111 A vacuum system for management of diabetic impotence. Placing the cylinder over the penis and creating a vacuum with the pump produces an erection which can be maintained by placing constrictor rings over the base of the penis. Studies have shown that many patients prefer this non-invasive technique to other, more invasive, methods

Figure 111 A vacuum system for management of diabetic impotence. Placing the cylinder over the penis and creating a vacuum with the pump produces an erection which can be maintained by placing constrictor rings over the base of the penis. Studies have shown that many patients prefer this non-invasive technique to other, more invasive, methods

Corpus Cavernosum Pump
inhibitor of PDE S

Figure 112 Oral treatment of erectile dysfunction with sildenafil is effective in about 60% of patients with diabetes. Sildenafil selectively inhibits phosphodiesterase type 5 (PDE 5), thereby increasing levels of cyclic GMP within the corpora cavernosa. This enhances the natural erectile response to sexual stimulation

Diabetic Penis PainAlprostadil

Figure 113 Erectile dysfunction in diabetes may be treated by self-injection of the vasoactive drug alprostadil (Caverject, Pharmacia, Peapack, NJ, USA) prostaglandin E1 into the corpus cavernosum of the penis. The resultant smooth muscle relaxation allows increased blood flow into the penis, and penile erection will occur whether or not sexual stimulation is present

Penile Ischemia

Figure 114 An alternative method of administering alprostadil is by transurethral application of a narrow (1.4 mm) pellet of synthetic prostaglandin Ei directly into the male urethra. Although this removes the need to inject alprostadil, there is still an incidence of penile pain, and controversy exists as to the efficacy of this procedure

Figure 114 An alternative method of administering alprostadil is by transurethral application of a narrow (1.4 mm) pellet of synthetic prostaglandin Ei directly into the male urethra. Although this removes the need to inject alprostadil, there is still an incidence of penile pain, and controversy exists as to the efficacy of this procedure

Obesity Glomerulopathy

Figure 1 15 Hyalin deposition in the glomerular tuft in a patient with diabetic glomerulopathy. Other characteristic histopathologic changes of diabetic nephropathy are an increase in glomerular volume, basement membrane thickening and diffuse mesangial enlargement (often with nodular periodic acid-Schiff-positive lesions). Diabetic nephropathy develops in around 35% of type 1 diabetes mellitus (DM) cases and in less than 20% of type 2 DM cases. It is defined as persistent proteinuria (albumin excretion rate >300mg/day) associated with hypertension and a falling glomerular filtration rate. Established nephropathy is preceded by years of microalbuminuria (albumin excretion rate 30-300 mg/day) which is negative on reagent-strip testing for albumin. Vigorous control of blood pressure and the use of angiotensin-converting enzyme inhibitors have been shown to delay the rate of progression of diabetic nephropathy. Periodic acid-Schiff stain

Type Diabetes Untreated Pictures
Time (months)

Figure 116 Once renal failure has become established in diabetes, there is an inexorable decline in renal function which, if untreated, leads to end-stage renal failure. The decline in renal function is linear when plotted as the inverse of serum creatinine over time. Modern treatment strategies attempt to slow the deterioration of renal function by vigorous anti-hypertensive regimens. Angiotensin-converting enzyme inhibitors may be especially effective because they reduce intraglomerular pressure and, unless renal failure is advanced, it is still worthwhile to attempt to achieve improved glycemic control

Outward Signs Kidney Failure

Figure 117 This neuropathic ulcer on the medial aspect of the foot in a diabetic patient shows the characteristic punched-out appearance on heavily calloused skin. The neuropathic foot is numb, warm and dry with palpable pulses. Charcot arthropathy complicates the neuropathic foot and presents with warmth, swelling and redness (shown here). Ulceration occurs at areas of high pressure in the deformed foot, especially over the metatarsal heads. Minor trauma such as ill-fitting or new shoes, or the presence of a small undetected object in the shoe, can result in serious foot ulceration. Treatment is by bedrest, debridement and appropriate antibiotics to treat secondary infection. Special shoes and plaster casts (to allow mobility while taking pressure off the ulcer) are also useful

Figure 117 This neuropathic ulcer on the medial aspect of the foot in a diabetic patient shows the characteristic punched-out appearance on heavily calloused skin. The neuropathic foot is numb, warm and dry with palpable pulses. Charcot arthropathy complicates the neuropathic foot and presents with warmth, swelling and redness (shown here). Ulceration occurs at areas of high pressure in the deformed foot, especially over the metatarsal heads. Minor trauma such as ill-fitting or new shoes, or the presence of a small undetected object in the shoe, can result in serious foot ulceration. Treatment is by bedrest, debridement and appropriate antibiotics to treat secondary infection. Special shoes and plaster casts (to allow mobility while taking pressure off the ulcer) are also useful

Chronic Ulcer With Foreign Body

Figure 118 Deeply penetrating diabetic neuropathic ulcer over the metatarsal head caused by a foreign body. Foot education, especially in those patients with documented neuropathy, is essential for preventing such lesions and should be undertaken by chiropodists, diabetic specialist nurses and diabetic physicians. Diabetic patients should not put their feet in front of fires or on radiators. Their feet should also be regularly inspected for early ulceration and their shoes carefully checked for foreign objects before being worn

Figure 118 Deeply penetrating diabetic neuropathic ulcer over the metatarsal head caused by a foreign body. Foot education, especially in those patients with documented neuropathy, is essential for preventing such lesions and should be undertaken by chiropodists, diabetic specialist nurses and diabetic physicians. Diabetic patients should not put their feet in front of fires or on radiators. Their feet should also be regularly inspected for early ulceration and their shoes carefully checked for foreign objects before being worn

Radiographs Foreign Objects
Figure 119 Three radiographs of the same neuropathic foot taken 1 month apart. Progressive damage to the foot has led to complete disorganization of the midtarsal joints without osteoporosis. These are typical appearances of a Charcot joint
Charcot Foot

Figure 120 Radiographs of the feet of a diabetic patient showing a neuropathic ulcer over the metatarsal heads of the left foot. Destruction of the left second metatarsal head and associated soft-tissue swelling are secondary to osteomyelitis complicating the ulcer. A fracture on the base of the fifth metatarsal is also present. The right foot shows Charcot disorganization of the midtarsal joints

Figure 120 Radiographs of the feet of a diabetic patient showing a neuropathic ulcer over the metatarsal heads of the left foot. Destruction of the left second metatarsal head and associated soft-tissue swelling are secondary to osteomyelitis complicating the ulcer. A fracture on the base of the fifth metatarsal is also present. The right foot shows Charcot disorganization of the midtarsal joints

Atrophic Charcot Foot Images
Figure 121 Osteomyelitis in the diabetic foot with destruction of the base of the third metatarsal (right) and a periosteal reaction in the shafts of the adjacent metatarsals accompanied by osteoporosis
Ankle Marrow Edema With Small Effusion
Figure 122 Sagittal magnetic resonance image of the hind foot of a diabetic patient showing marrow edema of the calcaneus consistent with acute osteomyelitis. There is also fluid deep to the plantar fascia consistent with cellulitis. An ankle effusion is also present
Ankle Joint Effusion
Figure 123 Magnetic resonance image of a diabetic foot showing disorganization of the talo-calcaneonavicular joint with erosions of the articular surface. Such appearances in a diabetic patient are typical of a Charcot joint
Talocalcaneonavicular Joint

Figure 124 The reduction of weight-bearing forces is an essential part of the treatment of significant neuropathic ulceration and can be achieved, on a short-term basis, by the use of a total-contact lightweight plaster cast designed to unload pressure from the ulcer and other vulnerable areas while allowing continued mobility. For the long term, however, equal redistribution of weight-bearing forces over the sole of the foot is achieved by the use of special footwear and insoles

Figure 124 The reduction of weight-bearing forces is an essential part of the treatment of significant neuropathic ulceration and can be achieved, on a short-term basis, by the use of a total-contact lightweight plaster cast designed to unload pressure from the ulcer and other vulnerable areas while allowing continued mobility. For the long term, however, equal redistribution of weight-bearing forces over the sole of the foot is achieved by the use of special footwear and insoles

Figure 125 Off-loading pressure from diabetic foot ulcers is essential to allow healing. Total contact plaster casts may be used, but are not free from problems. A more recent alternative is the Aircast Pneumatic Walker™ with a Diabetic Conversion Kit. It is a light-weight removable plastic brace lined with inflatable chambers to promote off-loading. Experience to date has shown that such a boot greatly increases the immediate off-loading capacity of the diabetic foot clinic

Topical Preparation Recipes

Figure 126 A topical preparation of becaplermin (Regranex™) has been recently introduced as an adjunct in the treatment of full-thickness, neuropathic, diabetic foot ulcers. Becaplermin is recombinant human platelet-derived growth factor. Experience to date with this product is limited and it is very expensive. Accurate cost-benefit analyses are awaited

Figure 126 A topical preparation of becaplermin (Regranex™) has been recently introduced as an adjunct in the treatment of full-thickness, neuropathic, diabetic foot ulcers. Becaplermin is recombinant human platelet-derived growth factor. Experience to date with this product is limited and it is very expensive. Accurate cost-benefit analyses are awaited

Dorsal Foot Ulcers

Figure 127 Distal gangrene in a diabetic ischemic foot (dorsal view)

Dorsal Foot Ulcers

Figure 128 Plantar view of the same foot as in Figure 127 shows the common diabetic complications of ischemia and neuropathy, both of which may lead to ulceration. The ischemic foot is cold, pulseless and subject to rest pain, ulceration and gangrene (shown here). Ischemic ulceration usually affects the margins of the foot and may be amenable to angioplasty or reconstructive arterial surgery

Figure 127 Distal gangrene in a diabetic ischemic foot (dorsal view)

Figure 128 Plantar view of the same foot as in Figure 127 shows the common diabetic complications of ischemia and neuropathy, both of which may lead to ulceration. The ischemic foot is cold, pulseless and subject to rest pain, ulceration and gangrene (shown here). Ischemic ulceration usually affects the margins of the foot and may be amenable to angioplasty or reconstructive arterial surgery

Childhood Diabetic Amputation

Figure 129 The same foot as in Figures 127 and 128 after amputation of the second toe. A good result has been obtained. However, a large proportion of diabetic patients with critical ischemia or gangrene of the lower limbs undergo major amputation. Thus, the importance of adequate screening and preventive measures to avoid these operations cannot be overemphasized

Figure 129 The same foot as in Figures 127 and 128 after amputation of the second toe. A good result has been obtained. However, a large proportion of diabetic patients with critical ischemia or gangrene of the lower limbs undergo major amputation. Thus, the importance of adequate screening and preventive measures to avoid these operations cannot be overemphasized

Diabetes Arterial Calcification
Figure 130 Digital arterial calcification in a diabetic foot. Peripheral vascular disease is a particularly common vascular complication of diabetes and about half of all lower limb amputations involve diabetic patients
Foot Calcification

Figure 131 Angiogram showing occlusion of the right popliteal artery at the adductor canal in a diabetic patient with peripheral vascular disease (left). There are many collateral vessels and the artery reconstitutes distally below the knee. The opposite side (right), which is normal, is shown for comparison

Figure 131 Angiogram showing occlusion of the right popliteal artery at the adductor canal in a diabetic patient with peripheral vascular disease (left). There are many collateral vessels and the artery reconstitutes distally below the knee. The opposite side (right), which is normal, is shown for comparison

Calcified Arteries Leg Young

Figure 132 Calcification accompanying medial sclerosis of the distal lower limb arteries. In diabetes, the distal blood vessels are often affected by both atheroma and medial sclerosis with calcification. This must be borne in mind if reconstructive vascular surgery or percutaneous transluminal balloon angioplasty is contemplated for symptomatic peripheral vascular disease. The initial success rate with angioplasty is reduced in diabetic patients

Figure 132 Calcification accompanying medial sclerosis of the distal lower limb arteries. In diabetes, the distal blood vessels are often affected by both atheroma and medial sclerosis with calcification. This must be borne in mind if reconstructive vascular surgery or percutaneous transluminal balloon angioplasty is contemplated for symptomatic peripheral vascular disease. The initial success rate with angioplasty is reduced in diabetic patients i

Figure 133 Bone scan of the spine (posterior view) in a poorly controlled type 2 diabetes mellitus patient shows the florid increase in activity in adjacent vertebrae typical of osteomyelitis t

Bone Scan Vertebral Collapse

L SPINE E2 Jan 1991 at 15:18

Figure 134 Bone scan showing osteoporotic vertebral collapse in a patient with type 1 diabetes mellitus, which has been associated with a generalized reduction in bone density (diabetic osteopenia). It is probably more common in those patients exhibiting poor metabolic control and is due to reduced bone formation rather than increased resorption. A slightly increased risk of susceptibility to fracture results from this abnormality

L SPINE E2 Jan 1991 at 15:18

Figure 134 Bone scan showing osteoporotic vertebral collapse in a patient with type 1 diabetes mellitus, which has been associated with a generalized reduction in bone density (diabetic osteopenia). It is probably more common in those patients exhibiting poor metabolic control and is due to reduced bone formation rather than increased resorption. A slightly increased risk of susceptibility to fracture results from this abnormality

Figure 135 Many abnormalities of the skin are found in diabetic patients. Some may not be specific to diabetes. Acanthosis nigricans is a skin manifestation of insulin resistant states, while vitiligo is a cutaneous marker of autoimmunity. Eruptive xanthomata are associated with significant hypertriglyceridemia. Necrolytic migratory erythema occurs in patients with a glucagonoma and associated diabetes and is very rare. The rashes of insulin allergy, lipoatrophy and lipohypertrophy are all associated with exogenous insulin administration

Atheroma Leg Rash
Figure 136 Vitiligo, autoimmune destruction of melanocytes, is commonly seen in patients with type 1 diabetes, itself an autoimmune condition

Necrobiosis lipoidica diabeticorum Diabetic dermopathy Diabetic bullae

Bacterial and Candida infection Acanthosis nigricans Vitiligo

Eruptive xanthomata Necrolytic migratory erythema Insulin allergy Lipoatrophy Lipohypertrophy

Insulin Allergy

Figure 137 A typical lesion of necrobiosis lipoidica diabeticorum on the shin. These lesions are usually non-scaling plaques with yellow atrophic centers and an erythematous edge, and predominantly affect diabetic women. They vary considerably in size, and are often multiple and bilateral. Necrobiosis may occur in non-diabetic subjects

Figure 137 A typical lesion of necrobiosis lipoidica diabeticorum on the shin. These lesions are usually non-scaling plaques with yellow atrophic centers and an erythematous edge, and predominantly affect diabetic women. They vary considerably in size, and are often multiple and bilateral. Necrobiosis may occur in non-diabetic subjects

Necrobiosis Lipoidica
Figure 138 Necrobiosis may become severe and ulcerative, causing great distress in affected patients. Spontaneous regression may occur and treatment tends to be unsatisfactory. Skin grafts may become complicated by recurrence within the graft or at an adjacent site
Ulcerative Osteomyelitis
Figure 139 Granuloma annulare. Although this skin condition is occasionally seen in diabetic patients, several large studies have failed to reveal a significant association between the two disorders, both of which are relatively common
Granuloma Annulare Stress
Figure 140 Diabetic dermopathy. These pigmented pretibial patches are often seen in diabetic patients, but are not pathognomonic of the disease. There is a male preponderance and the lesions are discrete, atrophic, scaly or hyperpigmented. The underlying cause is not known
Diabetic Dermopathy

Figure 141 Migratory necrolytic erythema. This rash is associated with glucagon-secreting pancreatic tumors (or occasionally zinc deficiency). Such rashes tend to wax and wane in cycles of 1-2 weeks. Diabetes is presumed to be due to increased glucagon-stimulated hepatic gluconeogenesis. Weight loss, diarrhea and mood changes are frequent features, but death is usually due to massive venous thrombosis. Treatment is by zinc supplementation, or somatostatin or a somatostatin analog

Figure 141 Migratory necrolytic erythema. This rash is associated with glucagon-secreting pancreatic tumors (or occasionally zinc deficiency). Such rashes tend to wax and wane in cycles of 1-2 weeks. Diabetes is presumed to be due to increased glucagon-stimulated hepatic gluconeogenesis. Weight loss, diarrhea and mood changes are frequent features, but death is usually due to massive venous thrombosis. Treatment is by zinc supplementation, or somatostatin or a somatostatin analog

Diabetic Bullae

Figure 142 Bullous lesions rarely occur in diabetes, and can only be diagnosed when other bullous disorders have been excluded. They usually occur suddenly with no obvious history of trauma and may take a long time to heal. The lower legs and feet are usually affected, and there is a male preponderance

Figure 142 Bullous lesions rarely occur in diabetes, and can only be diagnosed when other bullous disorders have been excluded. They usually occur suddenly with no obvious history of trauma and may take a long time to heal. The lower legs and feet are usually affected, and there is a male preponderance

Hyperkeratotic Prayer Nodules

Figure 143 Acanthosis nigricans is uncommon. These brown hyperkeratotic plaques with a velvety surface occur most frequently in the axillae and flexures, and on the neck. Acanthosis is associated with insulin resistance caused by genetic defects in the insulin receptor or postreceptor function, or the presence of antibodies to the insulin receptor

Figure 143 Acanthosis nigricans is uncommon. These brown hyperkeratotic plaques with a velvety surface occur most frequently in the axillae and flexures, and on the neck. Acanthosis is associated with insulin resistance caused by genetic defects in the insulin receptor or postreceptor function, or the presence of antibodies to the insulin receptor

Figure 145 Balanitis secondary to diabetes mellitus is a candidal infection of the distal end of the penis and is common at the time of presentation of diabetes in men

Figure 144 Candidiasis is a common fungal infection in diabetic patients. Although particularly common in the vagina or perineum (pruritus vulvae), under the breasts (intertrigo) and on the tip of the penis (balanitis), it may occur elsewhere. The yeasts thrive in glucose-containing media and, hence, control of blood-glucose levels helps to eradicate this troublesome infection. Antifungal creams may be necessary until glucose levels are controlled, but oral antifungal agents are rarely required

Antifungal Creams Penis

Figure 144 Candidiasis is a common fungal infection in diabetic patients. Although particularly common in the vagina or perineum (pruritus vulvae), under the breasts (intertrigo) and on the tip of the penis (balanitis), it may occur elsewhere. The yeasts thrive in glucose-containing media and, hence, control of blood-glucose levels helps to eradicate this troublesome infection. Antifungal creams may be necessary until glucose levels are controlled, but oral antifungal agents are rarely required

Diabetic Foot InfectionDiabetic Dermopathy

Figure 146 Severe bacterial infection in a poorly controlled diabetic patient. Although it is widely believed that diabetic patients are more prone to infection than non-diabetic subjects, it is unclear whether diabetic patients have an increase in the rate of infection in general. Diabetic patients are susceptible to certain infections, including tuberculosis, urinary tract infections and infections due to unusual micro-organisms such as osteomyelitis, mucor-mycosis and enterococcal meningitis. Diabetes is thought to impair several aspects of cellular function necessary to combat infection

Figure 146 Severe bacterial infection in a poorly controlled diabetic patient. Although it is widely believed that diabetic patients are more prone to infection than non-diabetic subjects, it is unclear whether diabetic patients have an increase in the rate of infection in general. Diabetic patients are susceptible to certain infections, including tuberculosis, urinary tract infections and infections due to unusual micro-organisms such as osteomyelitis, mucor-mycosis and enterococcal meningitis. Diabetes is thought to impair several aspects of cellular function necessary to combat infection

Malignant Otitis Externa

Figure 147 Malignant otitis externa. This infection, which can be extremely serious, is almost always due to Pseudomonas species, as was the case here. Affected patients usually have poorly controlled diabetes. This elderly diabetic patient has a seventh cranial nerve palsy as a complication. Antipseudomonal antibiotics and an early surgical opinion are advised

Figure 147 Malignant otitis externa. This infection, which can be extremely serious, is almost always due to Pseudomonas species, as was the case here. Affected patients usually have poorly controlled diabetes. This elderly diabetic patient has a seventh cranial nerve palsy as a complication. Antipseudomonal antibiotics and an early surgical opinion are advised

Lipoproteinemia

Figure 148 Eruptive xanthomata. Type V hyper-lipoproteinemia with an increase in very-low-density lipoproteins (VLDLs) and chylomicrons is often associated with glucose intolerance. This lipoprotein abnormality is accentuated by obesity and alcohol consumption, and may lead to acute pancreatitis and peripheral neuropathy

Figure 148 Eruptive xanthomata. Type V hyper-lipoproteinemia with an increase in very-low-density lipoproteins (VLDLs) and chylomicrons is often associated with glucose intolerance. This lipoprotein abnormality is accentuated by obesity and alcohol consumption, and may lead to acute pancreatitis and peripheral neuropathy

Diabetic Cheiroarthropathy

Figure 150 Diabetic cheiroarthropathy or limited joint mobility is characterized by an inability to extend fully the metacarpophalangeal and proximal interphalangeal joints when the tips of the fingers and palms of the hands are opposed in the so-called prayer sign. Although it may be seen in adult-onset type 1 and 2 diabetes mellitus (DM), it is most commonly seen in children and young adults with type 1 DM. The development of this abnormality is linked to the duration of diabetes. When present, other diabetic complications are likely to coexist

Figure 150 Diabetic cheiroarthropathy or limited joint mobility is characterized by an inability to extend fully the metacarpophalangeal and proximal interphalangeal joints when the tips of the fingers and palms of the hands are opposed in the so-called prayer sign. Although it may be seen in adult-onset type 1 and 2 diabetes mellitus (DM), it is most commonly seen in children and young adults with type 1 DM. The development of this abnormality is linked to the duration of diabetes. When present, other diabetic complications are likely to coexist

Erythematous Candidiasis Duration
Figure 151 Dupuytren's contracture is common in patients with diabetes mellitus. Conversely, in patients presenting with Dupuytren's contracture, a high prevalence of diabetes is found. The exact nature of the link between the two conditions remains unclear
Diabetic Dermopathy

Figure 152 Macrosomic baby of a diabetic mother. In diabetic women, blood concentrations of fuel substrates (glucose, amino acids and fatty acids) are raised and their delivery to the fetus increased. The elevated glucose and amino-acid levels stimulate fetal P-cells to hypersecrete insulin. The increased insulin secretion and nutrient availability promote fetal growth which, in turn, leads to macro-somia. Vaginal delivery may be impossible in cases of gross macrosomia. Strict glycemic control is mandatory in diabetic pregnancy and requires frequent attendance at a joint obstetric/antenatal clinic. The increased motivation of pregnancy appears to help most diabetic mothers achieve excellent diabetic control

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