Search

Two hundred and fifty six consecutively ambulant diabetic patients attending a Nigerian diabetic clinic for the presence of cheiroarthropathy were examined using standard criteria. Forty eight (19%) had limited joint mobility of the hand, a prevalence higher than the 4% (2/56) observed in a non-diabetic population matched for age and sex. Limited joint mobility was twice as prevalent in the insulin treated (16/50, 32%) than in the non-insulin dependent (32/206, 16%) diabetics. Indices such as age, duration of diabetes, and glycaemic control (as assessed by integrated blood glucose concentration over the previous 12 months and glycated haemoglobin (HbA1c concentrations) were the same in the diabetics with and without limited joint mobility. The prevalence of cataracts (18/48, 38%) and background retinopathy (8/48, 17%) was higher in diabetics with limited joint mobility than in those without (respectively 6-9% and 5-6%); hypertension, peripheral neuropathy, and foot ulcers, however, were about equally common in the two groups of diabetics (with and without limited joint mobility). Nephropathy appeared commoner in diabetic subjects without limited joint mobility. Our results confirm previous observations in Caucasians of an increased prevalence of limited joint mobility in diabetes, especially those receiving insulin treatment, and also showed that limited joint mobility could predict the presence of retinopathy and cataracts in those diabetics. Neuropathy and hypertension were not commoner in our diabetics with limited joint mobility (unlike in the Caucasian population), suggesting that racial factors may underlie the predictive value of limited joint mobility in diabetic microangiopathy.

Two unusual predisposing factors to indolent foot ulceration seen in Nigerian diabetic patients are presented. These are guinea-worm infestation (dracontiasis) affecting the dorsum of the foot and lichenification with fissuring of the sole of the foot during the cool, dry weather of the harmattan season. These two preventable and treatable conditions are widely prevalent in sub-Saharan African countries. While there was severe hyperglycaemia in both cases, one was associated with diabetic ketoacidosis and resulted in limb amputation. Both patients stayed 4-5 months in hospital. A case is made for early recognition and specific management of these lesions to prevent undue morbidity and prolonged hospitalisation.

Foot lesions constitute an important cause of morbidity and mortality in Nigerian diabetics, yet remain poorly characterised. We, therefore, prospectively studied 50 diabetics with 84 major foot lesions over a three-year period at Ibadan, Nigeria. Sixty eight percent of the patients were illiterate and 80% ignorant regarding the importance of footcare. Duration of diabetes was significantly longer in these patients (p less than 0.05) than in age- and sex-matched diabetics without foot lesions. The prevalence rates of neuropathy (68%), foot ischaemia (54%), hypertension (42%) and nephropathy (20%) in diabetics with foot lesions were higher than in previous reported groups of Nigerian diabetics. The initiating factors were predominantly trivial trauma and "spontaneous" blisters. Sixty percent were anaemic at presentation, while short-term glycaemic control was generally poor. Mixed bacterial organisms were cultured in 70% of the cases, with anaerobes presumed present in 33%. Chronic osteomyelitis (38%) and soft tissue changes (35%) were the commonest foot x-ray findings. Some aspects of prevention of foot lesions were discussed.

A total of 160 consecutive diabetic patients were examined for hand and foot ulcers. We found 6 patients with ulcers of the hand. Antecedent trauma, all trivial, was noted in all the patients with ulcers. Five patients with foot ulcers had peripheral neuropathy and 1 patient had occlusive vascular disease. Only 3 of the 10 diabetic foot cases had a history of trauma. The mean age of the patients with hand and foot ulcers was 43 years and 56 years respectively. Staphylococcus was the commonest isolate. Digital gangrene was a more common complication in hand ulcers compared with the foot.

A prospective cross-sectional study of 84 foot lesions in 50 diabetic patients was done in a Nigerian teaching hospital over a three-year period (1982-1984) to assess factors that may influence the choice of treatment and treatment outcome. Age, gender, duration of diabetes, mode of treatment of diabetes and tobacco smoking did not influence whether or not a diabetic with a foot lesion will have major amputation, an unsatisfactory outcome of primary treatment, prolonged hospital stay or will die. Similarly, the presence of foot infections alone, microangiopathy (nephropathy, retinopathy), foot ischaemia alone or neuropathy alone had no relationship to poor prognostic indices. However, when these complications appeared in concert (neuropathy, ischaemia and infection) and when, at presentation, there was associated systemic disease (as shown by anaemia and leucocytosis), severe fasting hyperglycaemia, evident bone destruction and anaerobic superinfection, the outcome of treatment was adverse. In addition, hypertension and infection of the foot were related to need for major amputation. Poor long-term control did not influence prognosis adversely. We therefore suggest that the high morbidity seen with diabetic foot lesions could be reduced by optimizing glycaemic control, using combination antibiotic chemotherapy, vigorously correcting anaemia and encouraging early presentation of even mild lesions before underlying bone disease supervenes.