Clinical Overview > Condition/ Syndrome > Diabetic foot syndrome

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Silvia M Becerra-Bayona Facultad de Ciencias de la Salud, Universidad Autónoma de Bucaramanga – UNAB, Bucaramanga, Colombia

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Víctor Alfonso Solarte-David Facultad de Ciencias de la Salud, Universidad Autónoma de Bucaramanga – UNAB, Bucaramanga, Colombia

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Claudia L Sossa Facultad de Ciencias de la Salud, Universidad Autónoma de Bucaramanga – UNAB, Bucaramanga, Colombia
Banco Multitejidos y Centro de Terapias Avanzadas, Fundación Oftalmológica de Santander, Clínica Carlos Ardila Lulle – FOSCAL, Floridablanca, Colombia

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Ligia C Mateus Fundación Oftalmológica de Santander, Clínica Carlos Ardila Lulle – FOSCAL, Floridablanca, Colombia

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Martha Villamil Fundación Oftalmológica de Santander, Clínica Carlos Ardila Lulle – FOSCAL, Floridablanca, Colombia

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Jorge Pereira Banco Multitejidos y Centro de Terapias Avanzadas, Fundación Oftalmológica de Santander, Clínica Carlos Ardila Lulle – FOSCAL, Floridablanca, Colombia

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Martha L Arango-Rodríguez Banco Multitejidos y Centro de Terapias Avanzadas, Fundación Oftalmológica de Santander, Clínica Carlos Ardila Lulle – FOSCAL, Floridablanca, Colombia

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Summary

Diabetic foot ulcer morbidity and mortality are dramatically increasing worldwide, reinforcing the urgency to propose more effective interventions to treat such a devastating condition. Previously, using a diabetic mouse model, we demonstrated that administration of bone marrow mesenchymal stem cells derivatives is more effective than the use of bone marrow mesenchymal stem cells alone. Here, we used the aforementioned treatments on three patients with grade 2 diabetic foot ulcers and assessed their beneficial effects, relative to the conventional approach. In the present study, two doses of cell derivatives, one dose of mesenchymal stem cells or one dose of vehicle (saline solution with 5% of human albumin), were intradermally injected around wounds. Wound healing process and changes on re-epithelialization were macroscopically evaluated until complete closure of the ulcers. All ulcers were simultaneously treated with conventional treatment (PolyMen® dressing). Patients treated with either cell derivatives or mesenchymal stem cells achieved higher percentages of wound closure in shorter times, relative to the patient treated with the conventional treatment. The cell derivative and mesenchymal stem cells approaches resulted in complete wound closure and enhanced skin regeneration at some point between days 35 and 42, although no differences between these two treatments were observed. Moreover, wounds treated with the conventional treatment healed after 161 days. Intradermal administration of cell derivatives improved wound healing to a similar extent as mesenchymal stem cells. Thus, our results suggest that mesenchymal stem cell derivatives may serve as a novel and potential therapeutic approach to treat diabetic foot ulcers.

Learning points:

  • In diabetic mouse models, the administration of mesenchymal stem cells derivatives have been demonstrated to be more effective than the use of marrow mesenchymal stem cells alone.

  • Mesenchymal stem cells have been explored as an attractive therapeutic option to treat non-healing ulcers.

  • Mesenchymal stem cells derivatives accelerate the re-epithelialization on diabetic foot ulcers.

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Anna Luiza Galeazzi Rech Kantonsspital Sankt Gallen, Klinik für Allgemeine Innere Medizin/Hausarztmedizin, Sankt Gallen, Switzerland

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Yvon Stüve Kantonsspital Sankt Gallen, Klinik für Allgemeine Innere Medizin/Hausarztmedizin, Sankt Gallen, Switzerland

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Andreas Toepfer Kantonsspital Sankt Gallen, Klinik für Orthopädische Chirurgie und Traumatologie des Bewegungsapparts, Sankt Gallen, Switzerland

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Katrin E Schimke Kantonsspital Sankt Gallen, Klinik für Allgemeine Innere Medizin/Hausarztmedizin, Sankt Gallen, Switzerland

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Summary

Acute Charcot neuropathic osteoarthropathy (CN) is a clinical entity which can easily go unrecognized in its acute early stages due to lack of awareness and unspecific presentation. However, missing early diagnosis can lead to severe complications. We present the case of a 72-year-old male patient who went through the natural course of the disease unnoticed before the very eyes of his physicians leading to a tragic end. We aim to raise awareness for this rare diabetic complication, emphasizing the necessity of early diagnosis and adequate, interdisciplinary treatment.

Learning points:

  • Clinical signs and symptoms of acute Charcot neuropathic osteoarthropathy (CN).

  • Red flags.

  • Importance of early diagnosis and correct treatment.

  • Diagnostic challenges of acute CN.

  • Awareness of high morbidity and mortality.

Open access
Yasuhiro Oda Nephrology Center, Toranomon Hospital, Tokyo, Japan

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Masayuki Yamanouchi Nephrology Center, Toranomon Hospital, Tokyo, Japan

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Hiroki Mizuno Nephrology Center, Toranomon Hospital, Tokyo, Japan

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Rikako Hiramatsu Nephrology Center, Toranomon Hospital, Tokyo, Japan

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Tatsuya Suwabe Nephrology Center, Toranomon Hospital, Tokyo, Japan

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Junichi Hoshino Nephrology Center, Toranomon Hospital, Tokyo, Japan
Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan

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Naoki Sawa Nephrology Center, Toranomon Hospital, Tokyo, Japan

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Kenichi Ohashi Department of Pathology, Toranomon Hospital, Tokyo, Japan
Department of Pathology, Graduate School of Medicine, Yokohama City University, Yokohama, Japan

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Takeshi Fujii Department of Pathology, Toranomon Hospital, Tokyo, Japan

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Yoshifumi Ubara Nephrology Center, Toranomon Hospital, Tokyo, Japan
Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan

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Summary

We report the renal histology of a 66-year-old man with hypertension, cardiovascular disease, and a 30-year history of type 2 diabetes mellitus with proliferative diabetic retinopathy, diabetic neuropathy, and diabetic foot status post toe amputation. Urinary protein excretion was 1.4 g/gCr, serum creatinine level 0.86 mg/dL, estimated glomerular filtration rate 69 mL/min/1.73 m2, and HbA1c 13–15%, despite using insulin. Light microscopy showed global glomerulosclerosis in 37% of the glomeruli, but the remaining glomeruli were intact. Significant polar vasculosis was present, while arteriolar sclerosis was mild. Electron microscopy revealed a thickened glomerular basement membrane, which is compatible with the early stage of diabetic glomerulopathy. The presented case was unique because glomerular changes seen typically in diabetes were not seen in the patient, despite the long-standing history of diabetes and diabetic comorbidities, while prominent polar vasculosis was found. Polar vascular formation helps preserve the glomeruli by allowing hyperosmotic blood bypass the glomeruli; this decreases intraglomerular pressure and minimizes glomerular endothelial damage.

Learning points:

  • A 66-year-old man with a 30-year history of type 2 diabetes mellitus with poor glycemic control underwent renal biopsy, which showed scarce glomerular changes typically seen in diabetic kidney disease and instead revealed significant polar vasculosis.

  • Past studies demonstrated that the increased small vessels around the vascular hilus in diabetic patients originated from the afferent arterioles and drained into the peritubular capillaries.

  • Polar vascular formation may preserve glomerular function by allowing the blood flow to bypass the glomeruli and decreasing the intraglomerular pressure, which minimizes endothelial damage of the glomerular tufts.

Open access
Alessandro Mantovani Division of Endocrinology, Diabetes and Metabolism, Department of Medicine

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Ilaria Teobaldi Division of Endocrinology, Diabetes and Metabolism, Department of Medicine

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Vincenzo Stoico Division of Endocrinology, Diabetes and Metabolism, Department of Medicine

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Fabrizia Perrone Division of Endocrinology, Diabetes and Metabolism, Department of Medicine

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Marina Zannoni Division of Pathology Unit, Department of Diagnostics and Public Health

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Luca Cima Division of Pathology Unit, Department of Diagnostics and Public Health

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Massimiliano Bruti Division of Plastic Surgery, Department of Surgery, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy

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Lucia Mingolla Division of Endocrinology, Diabetes and Metabolism, Department of Medicine

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Maddalena Trombetta Division of Endocrinology, Diabetes and Metabolism, Department of Medicine

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Enzo Bonora Division of Endocrinology, Diabetes and Metabolism, Department of Medicine

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Summary

After basal cell carcinoma, the cutaneous squamous cell carcinoma (cSCC) is the second most frequent non-melanoma skin cancer worldwide, and, classically, arises from the upper coats of the epidermis of sun-exposed areas or from skin areas constantly exposed to a chronic inflammatory stimulus. The occurrence of cSCC seems to be linked to several factors, including exposure to sunlight (or other ultraviolet radiations), immunosuppression, chronic scarring conditions and some familial cancer syndromes. Although the majority of cSCCs are adequately eradicated by surgical excision, a subgroup of cSCC may be linked with an increased risk of recurrence, metastasis and death. The incidence of type 2 diabetes mellitus is constantly increasing worldwide. Importantly, diabetes mellitus is a strong risk factor for cancers (including cutaneous tumors) and is highly related with poor cancer outcomes. At present, in the literature, squamous cell carcinoma developing in association with diabetic foot ulcers has been already reported in some reports; however, additional data are needed to make the clinicians aware of this rare, although possible, complication. Therefore, we herein report an unusual case of an elderly man with T2DM and a positive oncological history, presenting a cSCC involving the skin overlying the first toe of left foot. The growing cSCC appeared approximately 3 years after the appearance of a diabetic ulcer.

Learning points:

  • Diabetic foot ulcers are an important and severe complication of diabetes mellitus and often can result in foot amputation.

  • Chronic and non-healing diabetic foot ulcers are often observed in clinical practice.

  • Clinicians should always take into consideration the malignant degeneration (e.g., cutaneous squamous cell carcinoma) of any chronic non-healing diabetic foot ulcer in elderly T2DM individuals.

  • Timely surgical resection of a chronic, non-healing diabetic foot ulcer might preclude the development of a cutaneous squamous cell carcinoma.

Open access
Alessandro Mantovani Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy

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Maddalena Trombetta Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy

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Chiara Imbriaco Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy

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Riccardo Rigolon Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy

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Lucia Mingolla Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy

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Federica Zamboni Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy

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Francesca Dal Molin Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy

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Dario Cioccoloni Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy

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Viola Sanga Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy

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Massimiliano Bruti Division of Plastic Surgery, Department of Surgery, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy

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Enrico Brocco Regional Referral Center for the Treatment of Diabetic Foot, Policlinico Abano Terme, Padova, Italy

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Michela Conti Division of Infectious Disease, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy

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Giorgio Ravenna Division of Neurosurgery, Department of Surgery, University and Azienda Ospedaliera Universitaria Integrataof Verona, Verona, Italy

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Fabrizia Perrone Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy

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Vincenzo Stoico Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy

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Enzo Bonora Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy

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Summary

Vertebral osteomyelitis (or spondylodiscitis) is steadily increasing in Western countries and often results from hematogenous seeding, direct inoculation during spinal surgery, or contiguous spread from an infection in the adjacent soft tissue. We present the case of a 67-year-old white patient with type 2 diabetes who went to Hospital for high fever, back pain, and worsening of known infected ulcers in the left foot. Despite intravenous antibiotic treatment and surgical debridement of the foot infection, high fever and lower back pain continued. Bone biopsy and two consecutive blood cultures were positive for Staphylococcus aureus. A spinal magnetic resonance imaging (MRI) was performed, revealing serious osteomyelitis in L4 and L5 complicated by an epidural abscess. Contiguous or other distant focuses of infection were not identified. In this case, diabetic foot could be considered as a primary distant focus for vertebral osteomyelitis. Clinicians should consider vertebral osteomyelitis as a ‘possible’ diagnosis in patients with type 2 diabetes complicated by foot infection that is associated with fever and lower back pain.

Learning points

  • Vertebral osteomyelitis is increasing in Western countries, especially in patients with type 2 diabetes.

  • The primary focus of infection is the genitourinary tract followed by skin, soft tissue, endocarditis, bursitis, septic arthritis, and intravascular access.

  • Diabetic foot could be a rare primary focus of infection for vertebral osteomyelitis, and, however, vertebral osteomyelitis could be a serious, albeit rare, complication of diabetic foot.

  • Clinicians should keep in mind the many potential complications of diabetic foot ulcerations and consider vertebral osteomyelitis as a “possible” diagnosis in patients with type 2 diabetes and foot ulcers associated with nonspecific symptoms such as lower back pain.

  • Early diagnosis and correct management of vertebral osteomyelitis are crucial to improve clinical outcomes.

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