In diabetic foot (DF) not all In diabetic foot (DF) not all lesions are due to diabeteslesions are due to diabetes

Thomas KatsarosThomas KatsarosDiabetes Center and Diabetic Foot of the Diabetes Center and Diabetic Foot of the

Dept of EndocrinologyDept of EndocrinologyPublic General Hospital of Athens Public General Hospital of Athens ‘‘G. G.

GENNIMATASGENNIMATAS ’’

MEDICINE is a science of MEDICINE is a science of

uncertaintyuncertainty and an art of and an art of

probabilityprobability

William OslerWilliam Osler(1849(1849--1919)1919)

THIS SHOULD NOT BE THIS SHOULD NOT BE FORGOTTEN!FORGOTTEN!

In a patient with diabetes:In a patient with diabetes:One cannot assume that a foot One cannot assume that a foot

lesion is a diabetic foot lesion lesion is a diabetic foot lesion without considering other without considering other possibilitiespossibilities , such as , such as malignancy etc.malignancy etc.

Other possibilities deserve more Other possibilities deserve more attention!attention!

•• In medical literature one can find In medical literature one can find excellent publications on diabetic foot excellent publications on diabetic foot lesions, but scanty reference is made lesions, but scanty reference is made to other possibilities (with one shining to other possibilities (with one shining exception).exception).

Which could be the other Which could be the other possibilities?possibilities?

•• Group A:Group A: Those located in the diabetic foot Those located in the diabetic foot but not related to other disease: e.g. but not related to other disease: e.g. Malignancies.Malignancies.

•• Group B:Group B: Those related to other diseases Those related to other diseases that have not been diagnosed and may that have not been diagnosed and may cause lesions in the foot. In this case the cause lesions in the foot. In this case the foot lesion may be diagnostic guiding foot lesion may be diagnostic guiding finding( The foot lesion may be the finding( The foot lesion may be the ‘‘ tip of tip of the icebergthe iceberg ’’ ).).

•• Group C:Group C: Those related to already Those related to already diagnosed diseases that may cause diagnosed diseases that may cause lesions in the foot: e.g. Vasculitislesions in the foot: e.g. Vasculitis

Group AGroup A

•• MalignanciesMalignancies1)1) Malignant melanomaMalignant melanoma2)2) Basal cell carcinomaBasal cell carcinoma3)3) Squamous cell carcinomaSquamous cell carcinoma4)4) Caposi sarcoma not due to AIDS.Caposi sarcoma not due to AIDS.

Malignant melanomaMalignant melanomaABCDEEFGsABCDEEFGs

•• The American Academy of Dermatology The American Academy of Dermatology proposed the mnemonic ABCDEs of proposed the mnemonic ABCDEs of melanoma that is very helpful.melanoma that is very helpful.

•• Moreover there some other signs that Moreover there some other signs that are very helpful too.are very helpful too.

•• For nodular melanoma that is regarded For nodular melanoma that is regarded the most dangerous ( Elevated, Firm to the most dangerous ( Elevated, Firm to touch, Growing) touch, Growing)

AsymmetryAsymmetry BorderBorder ColourColour Diameter Diameter >6mm>6mm

Evolution:Evolution: Size, Colour, Symptoms (Itching, Pain), Easy Size, Colour, Symptoms (Itching, Pain), Easy Bleeding, Satellite lesions, shape. And Bleeding, Satellite lesions, shape. And EFGsEFGs

HutchinsonHutchinson ’’s sign, Ugly duckling sign, Fried egg s sign, Ugly duckling sign, Fried egg appearance, appearance,

Patient 1Patient 1

•• Mr RK 55 yrs old. Mr RK 55 yrs old. Type 1 DM for 28 Type 1 DM for 28 years.years.

•• Lesion observed 2 Lesion observed 2 yrs ago and changed yrs ago and changed in size and colour.in size and colour.

•• It was treated as It was treated as mycosis.mycosis.

•• Neuropathy(+)Neuropathy(+)•• Peripheral pulses: Peripheral pulses:

Normal.Normal.

Patient 2Patient 2•• Mrs EP 59 yrs old. Mrs EP 59 yrs old.

DM2 for 10yrs. DM2 for 10yrs. Hba1c=8,5%. She Hba1c=8,5%. She came for glucose came for glucose contol.contol.

•• The lesion was The lesion was observed on clinical observed on clinical examination. The examination. The daughter said it was daughter said it was smaller 1 yr ago.smaller 1 yr ago.

•• No neuropathy, No No neuropathy, No PAD.PAD.

Group BGroup B

•• I will try to present the blue toe I will try to present the blue toe syndrome (BTS). Its knowledge is of syndrome (BTS). Its knowledge is of paramount importance!!paramount importance!!

Foot Lesion = Tip of the icebergFoot Lesion = Tip of the iceberg

Foot lesion e.g BTS

PROBABLE CAUSES OF THE FOOT LESIONS e.g. BTS etc

A Picture’s Meaning can Express Ten Thousand Words

Blue Toe Syndrome (BTS)Blue Toe Syndrome (BTS)

BTS is characterized by sudden onset of BTS is characterized by sudden onset of painful, bluish or purple discoloration of one painful, bluish or purple discoloration of one or more toes and/or livedo reticularis in the or more toes and/or livedo reticularis in the foot. It is due to embolism and can cause foot. It is due to embolism and can cause necrotic lesions.necrotic lesions.

The source of emboli usually is showers of The source of emboli usually is showers of parts of atheromas of the aorta, iliac or parts of atheromas of the aorta, iliac or femoral arteries. femoral arteries.

If the source of emboli is above renal arteries If the source of emboli is above renal arteries lifelife --threatening multithreatening multi --systematic disease may systematic disease may be caused especially ARFbe caused especially ARF . .

Causes of Blue Toe SyndromeCauses of Blue Toe Syndrome1) Cholesterol Embolism:1) Cholesterol Embolism: e.g. e.g. AtheromatousAtheromatous

plaque frequently from infrarenal arteries, AAA plaque frequently from infrarenal arteries, AAA Vascular instrumentation. Vascular instrumentation. The most common The most common causecause..

2) Heart:2) Heart: Atrial fibrillation, Endocarditis, etcAtrial fibrillation, Endocarditis, etc4) Hyperviscosity states 4) Hyperviscosity states (e.g. polycythemia rubra (e.g. polycythemia rubra

vera) vera) 5) Hypercoagulability states 5) Hypercoagulability states (e.g. APS)(e.g. APS)6) Medications:6) Medications: e.g. Warfarin, Heparine.g. Warfarin, Heparin7) Illicit drug: e.g7) Illicit drug: e.g Cocaine, AmphetaminesCocaine, Amphetamines8) Vasculitis8) Vasculitis

Diagnosing the causeDiagnosing the cause

•• History:History: e.g. Recent vascular procedures, e.g. Recent vascular procedures, AntiAnti --coagulation, Fever, weight loss.coagulation, Fever, weight loss.

•• Physical examination:Physical examination: e.g. Unilateral or e.g. Unilateral or Bilateral, AAA, Livedo reticularis, Atrial Bilateral, AAA, Livedo reticularis, Atrial fibrillation etc.fibrillation etc.

•• Imaging:Imaging: DopplerDoppler U/S of AA and U/S of AA and IliofemoralIliofemoralarteriesarteries , Chest XChest X --rays, Transesophageal rays, Transesophageal Echocardography, AngioEchocardography, Angio --CT. CT.

•• Blood panelBlood panel depends on history and clinical depends on history and clinical examination. Eg. Vasculitis, APS, examination. Eg. Vasculitis, APS, Myeloproliferative disease etcMyeloproliferative disease etc

•• Skin biopsy.Skin biopsy.

Patient 3Patient 3

•• In this 58 yrs old patient In this 58 yrs old patient with type 2 diabetes. with type 2 diabetes.

•• The lesion appeared The lesion appeared suddenly one week ago suddenly one week ago and was painful and and was painful and purple. purple.

•• Diagnosis of aneurysm Diagnosis of aneurysm of the abdominal aorta of the abdominal aorta was made with guiding was made with guiding sign these spontaneous sign these spontaneous toe lesions.toe lesions.

Patient 4Patient 4•• Mr. GG 56 yrs old with type 2 DM presented 2 Mr. GG 56 yrs old with type 2 DM presented 2

days after sudden pain in the toes of the left days after sudden pain in the toes of the left foot and purplish discoloration of tips of the foot and purplish discoloration of tips of the toes.toes.

•• There was no history of trauma or wearing There was no history of trauma or wearing unsuitable shoes.unsuitable shoes.

•• Doppler that was performed the same day Doppler that was performed the same day revealed a labile atheroma in the left iliac revealed a labile atheroma in the left iliac artery.artery.

•• Angiologists took care of him byAngiologists took care of him by inserting a inserting a stent and the lesions disappeared after stent and the lesions disappeared after some days.some days.

Patient Patient 55

•• Mr. BG 43 yrs old with type 1 DM for 25 Mr. BG 43 yrs old with type 1 DM for 25 yrs presented with a rash in the feet.yrs presented with a rash in the feet.

•• Dermatologic consultation was asked Dermatologic consultation was asked because he had almost all 5 Pbecause he had almost all 5 P ’’s of the s of the lesions of lichen planus (lesions of lichen planus ( pruritic, pruritic, planar, purple, polygonal papules).planar, purple, polygonal papules).

•• Moreover HCV was ordered.Moreover HCV was ordered.

Group CGroup C

•• Vasculitis: e.g. Polyarteritis nodosa, Vasculitis: e.g. Polyarteritis nodosa, Rheumatoid arthritis etc.Rheumatoid arthritis etc.

•• SyphilisSyphilis•• Reactive arthritis (ex ReiterReactive arthritis (ex Reiter ’’s disease)s disease)•• Sarcoma Caposi due to AIDSSarcoma Caposi due to AIDS•• Other ( The list is extensive)Other ( The list is extensive)

Pyoderma GangrenosumPyoderma GangrenosumCourtesy of Ulcer Dpt of Andreas Sygros Hosp of Dermatology

SummarySummary•• This presentation is an effort to This presentation is an effort to

remind clinicians. remind clinicians.

1) Not to assume that Diabetic 1) Not to assume that Diabetic foot lesion is due to diabetes foot lesion is due to diabetes without considering other without considering other possibilities.possibilities.

2) By careful examination of the 2) By careful examination of the diabetic foot and analysis of all diabetic foot and analysis of all findings it is possible to diagnose findings it is possible to diagnose underlying serious disease and underlying serious disease and probably save the patientprobably save the patient’’s life.s life.

THANK YOUTHANK YOU