|Year : 2020 | Volume
| Issue : 2 | Page : 156-159
Tropical diabetic hand syndrome: case report of successfully salvaged threatened dominant hand
Department of General Surgery, Navy General Hospital, Colombo; Department of Surgery, General Sir John Kotelawela Defence University, Ratmalana, Sri Lanka
|Date of Submission||21-Apr-2020|
|Date of Decision||12-May-2020|
|Date of Acceptance||28-May-2020|
|Date of Web Publication||11-Sep-2020|
Source of Support: None, Conflict of Interest: None
Tropical diabetic hand syndrome (TDHS) is a less well-recognized complication of diabetes. It is characterized by cellulitis of hand and ends up with limb threatening significant tissue loss, sepsis and in occasion death. When the joint capsule and tendons are exposed in TDHS the digits and the limb and function of the hand are threatened. Loss of thumb of the dominant hand leads to devastating disability. The current case describes successfully managed case of TDHS with threatened thumb and function due to exposed first metacarpophalangeal joint and extensor tendons of the dominant hand.
Keywords: Diabetes, hand, infection, negative pressure wound therapy
|How to cite this article:|
Rajapaksha K. Tropical diabetic hand syndrome: case report of successfully salvaged threatened dominant hand. J Med Trop 2020;22:156-9
| Introduction|| |
Tropical diabetic hand syndrome (TDHS) is characterized by cellulitis, tissue necrosis and fulminant sepsis of the hands of the patients with diabetes mellitus. Disease prevalence documented to be up to 3.2% and most of the reported cases are from tropical countries and coastal areas., TDHS can lead to amputation of digits or whole hand. Salvaging the limb and function of the hand in TDHS is challenging. Treatment options available to preserve threatened limbs in TDHS include glycaemic control antibiotics, wound debridement, amputation, skin grafting, complex reconstructive procedures and physiotherapy.
Current study describes a successfully salvaged case of threatened thumb and function of the right hand affected by TDHS.
| Case presentation|| |
A 42 year old male patient with diabetes mellitus for 15 years and past history of right below knee amputation in the previous year and left multiple toe amputations two years back for diabetic foot disease left with sloughed joint capsule of the right first metacarpophalangeal joint, exposed extensor tendons and first metacarpal bone following debridement of necrotic tissues caused by fulminant hand cellulitis [Figure 1] and [Figure 2]. The patient denied history of trauma or insect bite. He was on insulin therapy but blood glucose was poorly controlled, HbA1c 8%.
|Figure 1: Hand affected with TDHS showing exposed first metacarpal bone (red arrow) and sloughed capsule of metacarpophalangeal joint (yellow arrow).|
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|Figure 2: Hand affected with TDHS showing exposed multiple extensor tendons of the hand.|
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At the initial presentation with cellulitis white cell count of 24000 and C-reactive protein level of 167(mg/l). Hemoglobin level was 8 g/dl and further investigations revealed iron deficiency anemia without a source of bleeding. He was immediately started on intravenous clindamycin 600 mg 6 hourly and amoxicillin and clavallnic acid 1.2 g 12 hourly. Blood cultures prior to antibiotics didn’t yield organisms. Blood glucose level at initial presentation was 12.6 mmol/l and converted to soluble insulin for tight blood glucose control under the guidance of consultant in internal medicine.
On fifth day of antibiotics and soluble insulin, cellulitis progressed to sepsis and subsequently necrosis and abscess formation on the dorsum of the right hand and over the first metacarpophalangeal joint together with non-STEMI. Patient was started on enoxaparin and aspirin. Abscess was immediately drained under sedation and closely observed.
His blood pressure was 134/80 mm/Hg and serum creatinine level was 13.57 mmol/l. Despite attempts to control blood glucose aggressively with insulin, his blood glucose levels were fluctuating between 23.6 mmol/l and 23.6 mmol/l.
Initial pus culture revealed Coliform spp which was sensitive to Amikacin. Intravenous amikacin was administered for 10 days until the sepsis was controlled and white blood cell count and C reactive protein levels were normal.
Excision of nonviable tissues resulted in bare extensor tendons and exposed joint capsule of the first metacarpophalangeal joint. To preserve exposed tendons and joint capsule, negative pressure wound therapy (NPWT) was applied. At the end of seven days of first session of NPWT, the joint capsule too was found to be sloughed and joint was exposed, while the tendons appeared healthy [Figure 3] and [Figure 4]. Cultures performed at this stage revealed Pseudomonas spp which was sensitive to ciprofloxacine. Oral ciprofloxacine was administered for seven days until cultures were negative. Another four cycles of NPWT were applied over four weeks and found granulation tissue over the previously exposed joint [Figure 5]. Dressing was changed to wet to dry dressing with paraffin gauze. Epithelialization was completed at sixth weeks of illness and thumb was preserved [Figure 6]. At the end of the treatment the patient could use his right hand for writing, use axillary crutches and hold the objects. At one year follow-up, there was no recurrent infection in the hand.
|Figure 3: Hand affected with TDHS showing open joint capsule and exposed joints of the first metacarpophalangeal joint (blue arrow) during negative person wound therapy.|
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|Figure 4: Hand affected with TDHS showing good granulation tissues around the extensor tendons.|
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|Figure 5: Hand affected with TDHS showing good granulation tissues cover around the previously exposed joint cavity.|
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|Figure 6: Hand affected with TDHS showing completely healed wound after six weeks.|
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| Discussion|| |
Tropical diabetic hand syndrome (TDHS) remains a major threat to hands and life of the diabetics in tropics. It is characterized by cellulitis, tissue necrosis and fulminant sepsis in the hand and associated with 52% morbidity and up to 19% mortality. Necrosis soft tissues in the dorsum of hand in TDHS often results in exposed tendons, bones and joint capsules. Therefore preservation of digits and function of the hand is challenging.
Fissures in the hand, poorly controlled diabetes, insulin treatment, malnutrition and neuropathy are the independent intrinsic risk factors found in TDHS. In some of the patients the triggering factor for TDHS cannot be identified. Accidental sharp cuts, thorn pricks, insect bites and blunt trauma are identified as triggering factors in some of cases.
The presentation is often delayed due to the poor socioeconomic status and unawareness of the danger of the disease in most of the studies. Often patient may present with advance disease with autoamputation of digits due to inappropriate treatment.
If patient presented early at the stage of cellulitis, broad spectrum empirical antibiotics with anaerobic cover should be started without a delay. The organism identified in the majority of the cases is Staphylococcus aureus., MRSA, Klebsiella, Pseudomonas aeruginosa, Coliform and Enterococcus sp are among the other organisms found in the TDHS.,,,,
Immediate drainage and debridement are required when the patient develops abscess. Debridement can end up with exposed tendons, bones and joint cavities when the tissue damage is extensive.
Covering of exposed tendons, bones and joints with ordinary dressing can lead to spread of the infection to those structures, and eventually require excision of tendons and amputation of the digits, which dramatically impair the function of hand. NPWT has shown benefit when applied over the exposed musculoskeletal structures. To preserve exposed tendons, bone and joint cavity, NPWT with foam was applied over the wound in the current study and benefit of this modern wound care product is shown in this study too. Once the exposed tendons and joint is covered with granulation tissue it can be either covered with split thickness skin graft or can allow to epithelialize.It is noted upon recovery that the current patient had reasonable degree of movements of the right hand which allowed for near normal daily activities including ambulation with axillary crutches. In cases where the movements of the hand and digits are restricted occupational therapy is helpful to optimize the function.
Tight glycemic control, patient education on hand hygiene and seeking medical attention early in the disease are the recommended preventive measures.
In conclusion, limb and digit salvage should be attempted in TDHS, once the life-threatening issues are addressed. NPWT is useful in selected patients with exposed tendons, bones and joints in TDHS to preserve limb and function of the hand.
Author acknowledgeS Dr Priyantha Balasooriya (MD), Consultant in internal medicine for his expert input in the management of this patient.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Okpe IO, Amaefule KE, Dahiru IL, Lawal Y, Adeleye AO, Bello-Ovosi B. Tropical diabetic hand syndrome among diabetic patients attending endocrine clinic of Ahmadu Bello University Teaching Hospital, Shika Zaria, North Central Nigeria. Sub-Saharan Afr J Med 2016;3:106-10. [Full text]
Abbas ZG1, Archibald LK. Tropical diabetic hand syndrome. Epidemiology, pathogenesis, and management. Am J Clin Dermatol 2005;6:21-8.
Mofikoya BO, Ajani A, Ugburo AO, Olusoga O. Surgical outcomes of diabetic hand infections in Lagos, Nigeria. Malawi Med J 2019;31:198-201.
Abbas ZG, Lutale J, Gill GV, Archibald LK. Tropical diabetic hand syndrome: risk factors in an adult diabetes population. Int J Infect Dis 2001;5:19-23.
Raveendran S, Naik D, Raj Pallapati SC, Prakash JJ, Thomas BP, Thomas N. The clinical and microbiological profile of the diabetic hand: a retrospective study from South India. Indian J Endocrinol Metab 2016;20:619-24.
Raimi TH, Alese OO. Tropical diabetes hand syndrome with autoamputation of the digits: case report and review of literature. Pan Afr Med J 2014;18:199.
Yeika EV, Tchoumi Tantchou JC, Foryoung JB, Tolefac PN, Efie DT, Choukem SP. Tropical diabetic hand syndrome: a case report. BMC Res Notes 2017;10:94.
Tiwari S, Chauhan A, Sethi NT. Tropical diabetic hand syndrome. Int J Diabetes Dev Ctries 2008;28:130-1.
Ngim Ewezu Ngim, Paul Amah, Innocent AbangTropical Diabetic Hand Syndrome: report of 2 cases. The Pan African Medical Journal 2012;12:24.
Niu XF, Yi JH, Zha GQ, Hu J, Liu YJ, Xiao LB. Vacuum sealing drainage as a pre-surgical adjunct in the treatment of complex (open) hand injuries: report of 17 cases. Orthop Traumatol Surg Res 2017;103:461-4.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]