INNOVARE CIENCIA Y TECNOLOGÍA VOL. 11, NO. 2, 2022
Disponible en CAMJOL
INNOVARE Ciencia y Tecnología
Sitio web: www.unitec.edu/innovare/
1
Autor corresponsal: josemanuel00011@hotmail.com, Universidad Nacional Autónoma de Honduras, Tegucigalpa, Honduras
Disponible en: http://dx.doi.org/10.5377/innovare.v11i2.14790
© 2022 Autores. Este es un artículo de acceso abierto publicado por UNITEC bajo la licencia http://creativecommons.org/licenses/by-nc-nd/4.0
Case Presentation
Tropical diabetic hand syndrome, a common but unknown pathology
Síndrome de mano diabética tropical, una patología frecuente pero desconocida
José M. Osorto
a,1
, Sonia Yaneth Lovo
a
, Óscar Daniel Osorto Mejía
b
a
Facultad de Ciencias Médicas, Universidad Nacional Autónoma de Honduras, UNAH, Tegucigalpa, Honduras
b
Facultad de Ciencias Médicas, Universidad Católica de Honduras, UNICAH, Tegucigalpa, Honduras
Article history:
Received: 5 April 2022
Revised: 6 May 2022
Accepted: 22 June 2022
Published: 31 August 2022
Keywords
Diabetes mellitus
Hand
Infection
Palabras clave
Diabetes mellitus
Mano
Infección
ABSTRACT. Introduction. Out of 10 patients with diabetes mellitus, 4 could have significant hand injuries that
require timely medical evaluation. Here we report a rare condition called tropical diabetic hand syndrome (TDHS), its
classification and treatment of a case in the Mosquitia region of Honduras. TDHS is defined as any adult diagnosed
with diabetes mellitus presenting with cellulitis, abscess and/or gangrene in any region of the hand and upper limb.
Case presentation. A 22-year-old woman with diabetes mellitus type 1 attended Hospital de Puerto Lempira on two
occasions in a period of 4 months. She showed up with inflammatory changes in her right hand, which she attributed
to an unnoticed injury while doing her daily activities. Multiple surgical interventions and broad-spectrum antibiotic
treatment were necessary to control the injury. Discussion. The term TDHS is rarely used to designate inflammatory
changes in the hands of diabetic patients living in tropical countries. Compared to the diabetic foot, TDHS occurs in
a 20:1 ratio, and it
’
s not uncommon to see a rapid spread of infection through the hand and forearm compartments,
with Meleney's gangrene its complication. Conclusion. TDHS must be treated aggressively from the beginning given
its rapid evolution to complications. A complementary therapy must be integrated.
RESUMEN. Introducción. De 10 pacientes con diabetes mellitus, 4 de ellos pueden llegar a presentar lesiones
importantes en la mano que requieren evaluación médica oportuna. Aquí reportamos una rara condición llamada el
síndrome de mano diabética tropical (TDHS), su clasificación y tratamiento, mediante la presentación de un caso en la
región de la Mosquitia de Honduras. TDHS se define como cualquier adulto diagnosticado con diabetes mellitus que
presente celulitis, absceso y/o gangrena en cualquier región de la mano y miembro superior. Presentación del caso.
Mujer de 22 años con diabetes mellitus tipo 1. Acudió al Hospital Puerto Lempira en dos ocasiones en el periodo de 4
meses, con cambios inflamatorios en la mano derecha atribuido a una lesión desapercibida mientras hacía sus
actividades diarias. Múltiples intervenciones quirúrgicas y antibiótico de amplio espectro fueron necesarios para
controlar la lesión. Discusión. Rara vez se utiliza el término TDHS para designar los cambios inflamatorios en las
manos de pacientes diabéticos que viven en los países del trópico. En comparación al pie diabético, el TDHS se presenta
en una proporción 20:1, y no es extraño evidenciar una rápida propagación de la infección a través de los
compartimientos de la mano y antebrazo, siendo la gangrena de Meleney su complicación. Conclusión. El TDHS debe
tratarse agresivamente desde su comienzo dada su rápida evolución a complicaciones. Es necesario integrar una terapia
complementaria.
1. Introduction
Diabetes mellitus is an endocrine-metabolic disease
determined by environmental factors, eating habits, physical
activity, and genetic factors, among others. Its main
characteristic is the poor production of insulin by the beta
cells of the pancreas, in some cases the total absence of
insulin production, as well as alterations in the uptake of
insulin by membrane receptors. The person suffering from
this disease has a poor macronutrient metabolism (fats,
proteins, and carbohydrates), as well as levels of insulin
resistance. It produces florid alterations in the organism.
High blood glucose levels (hyperglycemia) dangerously
stand out. Once this pathology is established, fasting
hyperglycemia can be identified and, in many cases, an
extensive evolution of the disease including complications
such as microangiopathic, as well as macroangiopathies,
enteropathies and neuropathies (de Mora, 2019).
The American Diabetes Association (ADA) proposes
diagnostic criteria for diabetes mellitus, which are: fasting
glucose ≥126 mg/dL (with a minimum fast of 8 hours); 2-
J. M. Osorto Mejía, et al.
INNOVARE Revista de Ciencia y Tecnología Vol. 11, No. 2, 2022
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hour plasma glucose ≥200 mg/dL during a glucose tolerance
test. For the test, a load of 75 grams of anhydrous glucose
dissolved in water is applied; glycosylated hemoglobin
(A1C) ≥6.5%. Classic symptoms of hyperglycemia or
hyperglycemic crisis are diagnosed with random glucose
≥200 mg/dL (ADA, 2020).
Along with poor control of this disease, complications
develop, such as diabetic foot syndrome, Fournier's
gangrene, chronic kidney injury, diabetic retinopathy,
reduced immunocompetence, furunculosis, alterations in the
upper limb, among others. The alteration of the hands of
diabetic patients is more common in type 2 diabetes than in
type 1. However, its determining factor is the time of
evolution. In any case, the entity is directly related to the
underlying metabolic alteration (Proubasta Renart, 2015).
Tropical diabetic hand syndrome (TDHS) was first
mentioned as an entity typical of diabetic patients who are
between the Tropics of Cancer in the northern hemisphere
and the Tropic of Capricorn in the southern hemisphere.
However, it is known that this alteration can appear
worldwide, so certain authors prefer to name it within the
spectrum of diabetic hand syndrome. TDHS is defined as
any adult diagnosed with diabetes mellitus presenting with
cellulitis, abscess and/or gangrene in any region of the hand
and upper limb. It is not surprising that most medical
personnel name this problem as "abscess in the hand" or
"inflammatory changes in the hand", being the main
problem its entity identification and study (Álvarez et al.,
2020).
2. Case presentation
A 22-year-old female patient diagnosed with type 1
diabetes mellitus, with an evolution of 13 years from
Yumanta, Gracias a Dios went to the Puerto Lempira
Hospital (PLH) emergency room on Thursday, October 10,
2019, due to an ulcer on her right hand (Figure 1). The base
and edges of the lesion were blackish, which is attributed to
the application of “Sika” on the injury. There were
inflammatory changes in the first finger of the right hand
that extended to the thenar region, second finger and wrist,
with an evolution of approximately one month. The patient
indicated that she went to the PLH, as a suggestion from the
hospital internist. "Sika" is the Misquito name that
corresponds to their traditional medicine, being used to
name ointments, infusions, rituals, etc. In this case it was
used to name an "antiseptic" cream based on herbs and roots.
The patient reported that she was being treated with long-
acting insulin, which was abandoned after two months of
initiation. She didn’t remember the set dose.
Admission to the General Women's Ward was decided to
comply with antibiotic coverage, glycemic control and
surgical treatment for abscess drainage and deep
debridement. Three surgical interventions and 19 days in the
hospital were necessary, with several wound cleanings per
day and staggered antimicrobial treatment, using from
clindamycin and gentamicin, piperacillin plus tazobactam,
to imipenem. Medical discharge was indicated on November
18, 2019, with insulin treatment (long-acting insulin 32
International Units [I.U.] at 7:00 a.m. and 18 I.U. at 10:00
p.m.) and daily ulcer dressings. An appointment was
scheduled in an outpatient consultation with the
endocrinology service, due to metabolic imbalance. The
patient did not show up for scheduled appointments. It is
worth mentioning that the diagnosis was recorded by the
treating endocrinologist.
Figure 1. Patient´s right hand with ulcer in resolution.
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