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A 65 year old man with Type 2 DM diagnosed at the age of 52, presents with mild pain on the right sole. He has also recently noticed that his right sock is wet every time he takes off his shoes. He does not recall any trauma. DM control is poor (recent HbA1c 8 percent), treated with oral antidiabetic pills. He lives with his wife and is suffering from hypertension and coronary heart disease. He denies any other symptoms. What is the diagnosis?

It is obvious that the patient has ulceration on the plantar surface of his right foot. The presence of mild symptoms, together with an ulcer, indicates that the patient has a serious degree of sensory loss.

On inspection, there was a purulent ulcer in the area of the 1st metatarsal head. The ulcer was surrounded by a large callus. Peripheral pulses were normal, while the neurologic examination revealed severe peripheral neuropathy with loss of Achilles tendon reflexes and no perception of pain, touch, temperature and vibration sensation up to the middle of the shin. Consequently, it is a neuotrophic ulcer, that is, an ulcer on a foot with neuropathy but normal perfusion (Figure 17.1). An ulcer is termed ischaemic, when there are findings of peripheral arteriopathy, but with normal sensation. Ulcers on the feet of patients with neuropathy and ischaemia are characterized as neuroischaemic (Figures 17.2-17.5).

Neuropathy is the common denominator in up to 85 percent of ulcers in diabetic patients. Neuropathy was present in 87 percent of patients with ulcers in a study (62 percent purely neurotrophic, 25 percent neuroischaemic and 13 percent purely ischaemic). In another study, neuropathy was present in 85 percent of the patients with ulcers (40 percent neurotrophic,

Diabetes in Clinical Practice: Questions and Answers from Case Studies. Nicholas Katsilambros et al. © 2006 John Wiley & Sons, Ltd. ISBN: 0-470-03522-6

Figure 17.1. Neurotrophic ulcer on the head of the right 1st metatarsal of the patient under discussion. Ample hyperkeratosis around the ulcer is observed, while its base has granulomatous tissue.

45 percent neuroischaemic and 15 percent ischaemic). Differentiation of neurotrophic from ischaemic ulcers is shown in Table 17.1.

As regards the pathogenesis of lower extremities ulcerations, it should be noted that these are the result of a combination of factors. Neuropathy or arteriopathy per se, do not cause ulcerations. On the contrary, the principal factor for ulcer occurrence is the combination of neuropathy or arteriopathy together with some trauma, which, due to the presence of neuropathy, goes unnoticed. Trauma can be either endogenous (calluses, anatomical malformations of the feet) or exogenous (inappropriate shoes and soles, foreign bodies inside the shoes, burns). The effects of the various factors that lead to ulcerations are shown in Figure 17.6.

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