Differentiating Diabetic foot from other diseases: Difference between revisions

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{{Diabetic foot}}
{{Diabetic foot}}
{{CMG}}
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==Overview==
[[Diabetic foot]] must be differentiated from other [[disease|diseases]] that cause [[foot]] [[ulcer|ulceration]], [[erythema]], [[swelling]] and [[skin]] lesion, such as [[skin and soft-tissue infections]], [[gas gangrene]], [[cellulitis]], [[deep venous thrombosis]] and [[Inflammatory disorder|inflammatory disorders]].
==Differentiating Diabetic foot from other Diseases==
*[[Diabetic foot]] must be differentiated from other [[disease|diseases]] that cause [[foot]] [[ulcer|ulceration]], [[erythema]], [[swelling]] and [[skin]] lesion, such as:<ref name="pmid20859079">{{cite journal| author=Hess CT| title=Checklist for differential diagnosis of lower-extremity ulcers. | journal=Adv Skin Wound Care | year= 2010 | volume= 23 | issue= 10 | pages= 480 | pmid=20859079 | doi=10.1097/01.ASW.0000383230.16279.b0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20859079  }} </ref><ref name="pmid20535310">{{cite journal| author=Pendsey SP| title=Understanding diabetic foot. | journal=Int J Diabetes Dev Ctries | year= 2010 | volume= 30 | issue= 2 | pages= 75-9 | pmid=20535310 | doi=10.4103/0973-3930.62596 | pmc=2878694 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20535310  }} </ref><ref name="pmid30958663">{{cite journal| author=Boulton AJM, Armstrong DG, Kirsner RS, Attinger CE, Lavery LA, Lipsky BA | display-authors=etal| title=Diagnosis and Management of Diabetic Foot Complications | journal= | year= 2018 | volume=  | issue=  | pages=  | pmid=30958663 | doi=10.2337/db20182-1 | pmc= | url= }} </ref>
**[[Skin and soft-tissue infections]]:
***[[Gas gangrene]]
***[[Cellulitis]]
***[[Vibrio vulnificus]] [[infection]]
***[[Aeromonas hydrophila]] [[infection]]
**[[Trauma]]
**[[Deep venous thrombosis]]
**[[Inflammatory disorder|Inflammatory disorders]]:
***[[Pyoderma gangrenosum]]
***[[Necrobiosis lipoidica]]
<br>
*Below, find a list of [[differential diagnosis]] for [[diabetic foot]]:
{| class="wikitable"
 
|-
 
! rowspan="2" |Diseases
 
! colspan="7" |Symptoms
 
! rowspan="2" |Signs
 
! rowspan="2" |Gold standard Investigation to diagnose
|-
!History
!Onset
!Pain
!Fever
!Laterality
!Scrotal swelling
!Symptoms of primary disease
|-
|[[Diabetic foot]]
|*History of poor [[Diabetes management|glycemic control]] <br> *[[Trauma]] <br> *[[Burn]]
|[[Chronic (medical)|Chronic]]
| + -
| + -
| Unilateral
| -
| Since it is related to [[diabetes]], [[symptoms]] such as [[polyuria]], [[polydipsia]] and [[polyphagia]] could be seen.
| *Shiny [[skin]] <br> *Decreased [[hair]] distribution <br> *[[Ulcer]] <br> *[[Medical sign|Signs]] of [[infection]] <br> *[[Foot]] deformities such as [[charcot joint|charcot foot]] and [[hammer toe]]
| The [[diagnosis]] of [[diabetic foot]] could be done by clinical findings, nevertheless [[Magnetic resonance imaging|MRI]] is essential to exclude the [[osteomyelitis]].
|-
|(Cellulitis-[[Erysipelas|erysipelas-]][[skin abscess]])
|
*Acute painful [[swelling]]
*[[Fever]]
|Acute
| +
| +
|Unilateral
| -
| -
|
*[[Tenderness]], hotness, and may be fluctuation if [[abscess]] formed.
*[[Lymphangitis]] in nearby [[Lymph node|lymph nodes]].
*[[Toxemia]] and [[fever]] in severe cases.
*[[Cellulitis]] involves the deeper [[dermis]] and [[erysipelas]] involves the upper dermis.<ref name="pmid24947530">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL et al.| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= 147-59 | pmid=24947530 | doi=10.1093/cid/ciu296 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24947530  }}</ref>
|
*Usually it doesn't need any laboratory tests to diagnose.<ref name="pmid27434444">{{cite journal| author=Raff AB, Kroshinsky D| title=Cellulitis: A Review. | journal=JAMA | year= 2016 | volume= 316 | issue= 3 | pages= 325-37 | pmid=27434444 | doi=10.1001/jama.2016.8825 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27434444  }}</ref>
*[[Blood cultures]] are warranted for patients in the following circumstances:<ref name="pmid10834819">{{cite journal| author=Woo PC, Lum PN, Wong SS, Cheng VC, Yuen KY| title=Cellulitis complicating lymphoedema. | journal=Eur J Clin Microbiol Infect Dis | year= 2000 | volume= 19 | issue= 4 | pages= 294-7 | pmid=10834819 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10834819  }}</ref>
 
#[[Toxicity|Systemic toxicity]]
#Extensive [[skin]] or [[soft tissue]] involvement
#Underlying [[comorbidities]]
#persistent [[cellulitis]]
 
*In patients with recurrent [[cellulitis]], serologic ''testing for [[beta-hemolytic streptococci]]'' is a good diagnostic tool''.''<ref name="pmid4005155">{{cite journal| author=Leppard BJ, Seal DV, Colman G, Hallas G| title=The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas. | journal=Br J Dermatol | year= 1985 | volume= 112 | issue= 5 | pages= 559-67 | pmid=4005155 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4005155  }}</ref>
|-
 
|[[Lymphatic filariasis]]


{{PleaseHelp}}
|
*History of living in endemic area or travelling to it
|Chronic
|<nowiki>+</nowiki>
| +
|Bilateral
| +
|<nowiki>-</nowiki>
|
*[[Hepatomegaly]]
*[[Lymphedema]]
*[[Elephantiasis]]
*[[Lymphangitis]]
*[[Hydrocele]]
*Scrotal [[elephantiasis]]
*[[Lymphadenopathy|Lymphadenopathies]]
*[[Rhonchi]] may be present in patients with Pulmonary tropical eosinophilia syndrome.
|
'''Preparing blood smears'''


==Overview==
*Thick smears
 
#Thick smears consist of a thick layer of dehemoglobinized (lysed) [[Red blood cell|red blood cells]] (RBCs).
#Thick smears allow a more efficient detection of parasites (increased sensitivity).
 
*Thin smears consist of [[blood]] spread in a layer such that the thickness decrease.
 
'''By the ultrasound''', the following findings can be observed:
 
*Dilated lymphatic channels
*Living worms tend to be in motion which called "filarial dance" sign.
 
|-
 
|[[Chronic venous insufficiency]]
 
|
*History of untreated [[varicose veins]]
*Painful bilateral [[lower limb]] [[swelling]] that increases with standing and decreases by rest and [[leg]] elevation.
|Chronic
|<nowiki>+</nowiki>
| -
|Bilateral
| +
 
(If congenial)
| -
|
*Typical varicose veins
*[[Skin]] change distribution correlate with varicose veins sites in the medial side of [[ankle]] and [[leg]]
*Reduction of [[swelling]] with limb elevation.
|
*[[Duplex ultrasound]] will demonstrate typical findings of [[Venous insufficiency|venous valvular insufficiency]]
|-
|[[Deep venous thrombosis|Acute deep venous thrombosis]]
|
*History of prolonged recumbency
*Classic symptoms of [[DVT]] include acute unilateral [[swelling]], [[pain]], and [[erythema]]
|Acute
| +
| -
|Unilateral
| -
|May be associated with primary disease mandates recumbency for long duration
|
*Dilated [[superficial veins]]
*Difference in [[Calf muscle|calf]] diameter is twice as likely to have [[DVT]](most impotant sign )<ref name="pmid16027455">{{cite journal| author=Goodacre S, Sutton AJ, Sampson FC| title=Meta-analysis: The value of clinical assessment in the diagnosis of deep venous thrombosis. | journal=Ann Intern Med | year= 2005 | volume= 143 | issue= 2 | pages= 129-39 | pmid=16027455 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16027455  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16539361 Review in: ACP J Club. 2006 Mar-Apr;144(2):46-7]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17213086 Review in: Evid Based Med. 2006 Apr;11(2):56]</ref>
*Calf pain on passive [[dorsiflexion]] of the [[foot]] ([[Homan's sign]]) isn't realiable sign.
 
|
*[[Compression ultrasonography]] (CUS) with [[Doppler ultrasound|doppler]] is the diagnostic test of choice
*[[D-dimer]] level is used for unprobable cases
|-
|[[Lipedema]]
|
*Family history especially in women; [[X-linked dominant]] or [[autosomal dominant]] condition.<ref name="pmid20358611">{{cite journal| author=Child AH, Gordon KD, Sharpe P, Brice G, Ostergaard P, Jeffery S et al.| title=Lipedema: an inherited condition. | journal=Am J Med Genet A | year= 2010 | volume= 152A | issue= 4 | pages= 970-6 | pmid=20358611 | doi=10.1002/ajmg.a.33313 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20358611  }}</ref>
*Abnormal deposition of fat and [[edema]] and [[easy bruising]].
|Chronic
| +
| -
|Bilateral
| -
|<nowiki>-</nowiki>
|
*Tender with palpation
 
*Negative '''Semmer sign''' to differentiate from lymphedema.<ref name="pmid23939641">{{cite journal| author=Trayes KP, Studdiford JS, Pickle S, Tully AS| title=Edema: diagnosis and management. | journal=Am Fam Physician | year= 2013 | volume= 88 | issue= 2 | pages= 102-10 | pmid=23939641 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23939641  }}</ref>
*Pinching the [[skin]] on the upper surface of the [[toes]]. If it is possible to grasp a thin fold of [[tissue]] then it is negative result.
*In a positive result, it is only possible to grasp a [[lump]] of [[tissue]].


==Differentiating Diabetic foot from other Diseases==
|
*MRI offers strong qualitative and quantitative parameters in the diagnosis of [[lipedema]] <ref name="pmid9412843">{{cite journal| author=Dimakakos PB, Stefanopoulos T, Antoniades P, Antoniou A, Gouliamos A, Rizos D| title=MRI and ultrasonographic findings in the investigation of lymphedema and lipedema. | journal=Int Surg | year= 1997 | volume= 82 | issue= 4 | pages= 411-6 | pmid=9412843 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9412843  }}</ref>
|-
|[[Myxedema]]
|
*History of untreated [[hypothyroidism]].
*Infiltration of the skin with [[Glycosaminoglycan|glycosaminoglycans]] with associated water retention.
|Chronic
| +
| -
|Bilateral
| -
| +
([[hypothyroidism]] )
|
*[[Pretibial myxedema]]
|
*[[Thyroid function tests|Thyroid function tests.]]
|-
|Other causes of [[generalized edema]]
|
*History of chronic general condition (cardiac-liver-renal)
|Chronic
| -
| -
|Bilateral
| -
|<nowiki>+</nowiki>
|
|
*According to the primary cause ( Echo- [[LFTs]]- RFT)
|}


==References==
==References==
{{reflist|2}}
{{reflist|2}}
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Latest revision as of 18:43, 1 August 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]

Overview

Diabetic foot must be differentiated from other diseases that cause foot ulceration, erythema, swelling and skin lesion, such as skin and soft-tissue infections, gas gangrene, cellulitis, deep venous thrombosis and inflammatory disorders.

Differentiating Diabetic foot from other Diseases


Diseases Symptoms Signs Gold standard Investigation to diagnose
History Onset Pain Fever Laterality Scrotal swelling Symptoms of primary disease
Diabetic foot *History of poor glycemic control
*Trauma
*Burn 		Chronic + - + - Unilateral - Since it is related to diabetes, symptoms such as polyuria, polydipsia and polyphagia could be seen. *Shiny skin
*Decreased hair distribution
*Ulcer
*Signs of infection
*Foot deformities such as charcot foot and hammer toe 		The diagnosis of diabetic foot could be done by clinical findings, nevertheless MRI is essential to exclude the osteomyelitis.
(Cellulitis-erysipelas-skin abscess) Acute + + Unilateral - -
  • Usually it doesn't need any laboratory tests to diagnose.[5]
  • Blood cultures are warranted for patients in the following circumstances:[6]
  1. Systemic toxicity
  2. Extensive skin or soft tissue involvement
  3. Underlying comorbidities
  4. persistent cellulitis
Lymphatic filariasis
  • History of living in endemic area or travelling to it
 Chronic + + Bilateral + -

Preparing blood smears

  • Thick smears
  1. Thick smears consist of a thick layer of dehemoglobinized (lysed) red blood cells (RBCs).
  2. Thick smears allow a more efficient detection of parasites (increased sensitivity).
  • Thin smears consist of blood spread in a layer such that the thickness decrease.

By the ultrasound, the following findings can be observed:

  • Dilated lymphatic channels
  • Living worms tend to be in motion which called "filarial dance" sign.
Chronic venous insufficiency Chronic + - Bilateral +

(If congenial)

-
  • Typical varicose veins
  • Skin change distribution correlate with varicose veins sites in the medial side of ankle and leg
  • Reduction of swelling with limb elevation.
Acute deep venous thrombosis Acute + - Unilateral - May be associated with primary disease mandates recumbency for long duration
Lipedema Chronic + - Bilateral - -
  • Tender with palpation
  • Negative Semmer sign to differentiate from lymphedema.[10]
  • Pinching the skin on the upper surface of the toes. If it is possible to grasp a thin fold of tissue then it is negative result.
  • In a positive result, it is only possible to grasp a lump of tissue.
  • MRI offers strong qualitative and quantitative parameters in the diagnosis of lipedema [11]
Myxedema Chronic + - Bilateral - +

(hypothyroidism )

Other causes of generalized edema
  • History of chronic general condition (cardiac-liver-renal)
 Chronic - - Bilateral - +
  • According to the primary cause ( Echo- LFTs- RFT)

References

  1. ↑ Hess CT (2010). "Checklist for differential diagnosis of lower-extremity ulcers". Adv Skin Wound Care. 23 (10): 480. doi:10.1097/01.ASW.0000383230.16279.b0. PMID 20859079.
  2. ↑ Pendsey SP (2010). "Understanding diabetic foot". Int J Diabetes Dev Ctries. 30 (2): 75–9. doi:10.4103/0973-3930.62596. PMC 2878694. PMID 20535310.
  3. ↑ Boulton AJM, Armstrong DG, Kirsner RS, Attinger CE, Lavery LA, Lipsky BA; et al. (2018). "Diagnosis and Management of Diabetic Foot Complications". doi:10.2337/db20182-1. PMID 30958663.
  4. ↑ Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America". Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.
  5. ↑ Raff AB, Kroshinsky D (2016). "Cellulitis: A Review". JAMA. 316 (3): 325–37. doi:10.1001/jama.2016.8825. PMID 27434444.
  6. ↑ Woo PC, Lum PN, Wong SS, Cheng VC, Yuen KY (2000). "Cellulitis complicating lymphoedema". Eur J Clin Microbiol Infect Dis. 19 (4): 294–7. PMID 10834819.
  7. ↑ Leppard BJ, Seal DV, Colman G, Hallas G (1985). "The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas". Br J Dermatol. 112 (5): 559–67. PMID 4005155.
  8. ↑ Goodacre S, Sutton AJ, Sampson FC (2005). "Meta-analysis: The value of clinical assessment in the diagnosis of deep venous thrombosis". Ann Intern Med. 143 (2): 129–39. PMID 16027455. Review in: ACP J Club. 2006 Mar-Apr;144(2):46-7 Review in: Evid Based Med. 2006 Apr;11(2):56
  9. ↑ Child AH, Gordon KD, Sharpe P, Brice G, Ostergaard P, Jeffery S; et al. (2010). "Lipedema: an inherited condition". Am J Med Genet A. 152A (4): 970–6. doi:10.1002/ajmg.a.33313. PMID 20358611.
  10. ↑ Trayes KP, Studdiford JS, Pickle S, Tully AS (2013). "Edema: diagnosis and management". Am Fam Physician. 88 (2): 102–10. PMID 23939641.
  11. ↑ Dimakakos PB, Stefanopoulos T, Antoniades P, Antoniou A, Gouliamos A, Rizos D (1997). "MRI and ultrasonographic findings in the investigation of lymphedema and lipedema". Int Surg. 82 (4): 411–6. PMID 9412843.
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