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 Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 7  |  Issue : 2  |  Page : 138-139

Giant swollen leg in type 2 diabetes


1 Department of Endocrinology, Command Hospital, Panchkula, Haryana, India
2 Department of Surgery, Command Hospital, Panchkula, Haryana, India

Date of Submission28-Sep-2014
Date of Acceptance18-Nov-2014
Date of Web Publication19-Jan-2015

Correspondence Address:
K.V.S. Hari Kumar
Department of Endocrinology, Command Hospital, Chandimandir, Panchkula - 134 107, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7942.149572

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  Abstract 

Type 2 diabetes mellitus is a common metabolic disorder with many short-term and long-term complications. Filariasis is a disfiguring disease seen mostly in tropical countries and is often resistant to all therapeutic interventions. We recently encountered an interesting patient with type 2 diabetes along with massively swollen right limb. We highlight the relevant differential diagnosis and plan to educate the readers about the occurrence of filariasis in diabetes.

Keywords: filariasis, Madura foot, type 2 diabetes


How to cite this article:
Kumar KH, Komala S. Giant swollen leg in type 2 diabetes. Parasitol United J 2014;7:138-9

How to cite this URL:
Kumar KH, Komala S. Giant swollen leg in type 2 diabetes. Parasitol United J [serial online] 2014 [cited 2021 Jan 22];7:138-9. Available from: http://www.new.puj.eg.net/text.asp?2014/7/2/138/149572


  Case report Top


A 49-year-old man, with type 2 diabetes for the past 15 years and poor glycemic control, presented with painless, progressive swelling involving the right leg of 7-month duration. The swelling started from the feet and progressed to involve the entire leg. He gave history of oozing water sores from the dorsum of the foot and denied history of fever during the entire duration and injury to the leg before ulceration. His past medical history revealed complications of diabetes in the form of retinopathy and neuropathy, with no formal evaluation of macrovascular disease. The patient reported taking oral antibiotics (amoxicillin and clavulanic acid for 7 days) and topical dressings for the leg swelling, with no significant relief. Physical examination revealed poor oral hygiene with normal vital parameters and a BMI of 22.4 kg/m 2 . A local examination revealed nonpitting edema over the right leg along with thick and indurated skin ([Figure 1]). The sole of the foot showed multiple oozing plaque-like lesions with a pebbled and verrucous appearance ([Figure 2]). The rest of the systemic examination was normal. Preliminarily, he was diagnosed clinically as a case of elephantiasis nostras verrucosa (ENV).
Figure 1 Giant swollen leg.

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Figure 2 Multiple discharging ulcers over sole of the right foot.

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The differential diagnosis of unilateral massive swelling leg includes lymphedema due to filariasis or malignancy, deep venous thrombosis, lipodermatosclerosis, and lipedema [1] . Multiple ulcerative lesions over the foot are unusual in filariasis and suggest Madura foot. Peripheral blood smear was positive for microfilaria and other investigations revealed polymorphonuclear leukocytosis, negative screen for viral infections, and normal biochemical parameters. Pus culture from the ulcer grew multiple organisms (Staphylococcus aureus, Citrobacter spp., and Acinetobacter spp.). The patient was confirmed as a case of ENV secondary to filariasis on the basis of clinical presentation and demonstration of microfilaria in the blood smear. The growth of multiple microorganisms could be due to the secondary infection of the ulcerative lesions and not the primary contributing factor leading to the ENV. He was treated with parenteral antibiotics, diethylcarbamazine, regular saline dressings, and leg elevation and compression for 6 weeks. His ulcerative lesions showed healing, and the patient was planned for reconstructive surgery at a later date.


  Introduction Top


Type 2 diabetes is a metabolic disorder characterized by hyperglycemia and complications affecting all the systems of the body. Patients with diabetes are prone to cutaneous infections because of multiple factors such as hyperglycemia, vascular compromise, and repetitive injuries. Filariasis is a common parasitic infection in the tropical countries and is caused by roundworms belonging to the species Filarioidea. The disease is divided into three subtypes on the basis of the involvement into lymphatic, ocular, and body cavity filariasis. Lymphatic filariasis is caused by Wuchereria bancrofti and leads to chronic lymphedema. The affected portion of the body is prone to recurrent soft tissue bacterial infections leading to its enlargement. ENV is the term used to describe the grossly disfiguring enlargement of a body part and is classically described in cases of secondary lymphedema. In this report, we present a case of ENV in long-standing type 2 diabetes who presented with giant swelling of the right leg.


  Discussion Top


ENV is a form of chronic lymphedema secondary to infections such as filariasis or noninfectious disorders such as malignancy, obesity, and congestive cardiac failure. It is seen typically over lower extremities due to the gravity dependent mechanism. Other areas involved are the scrotum, upper extremities, and buttocks. The progression of lymphedema to ENV is gradual. The pathogenic mechanism is due to accumulation of protein-rich fluid due to lymphedema, which triggers an immune response and further leads to blockage of the lymphatics [2] . This self-perpetuating cycle propagates and is compounded by recurrent bouts of infection coupled with epidermal thickening and dermal fibrosis.

Skin and subcutaneous infections are common in diabetes. Chronic parasitic infections are proposed to prevent the rise of autoimmune disorders as per the hygiene hypothesis [3] . The prevalence of lymphatic filariasis is less in type 2 diabetes. Parasitic helminthic infection may protect against the occurrence of type 1 diabetes as shown in animal studies. Epidemiological data suggest similar observation in humans also. Helminthic infections confer protection against autoimmune disorders by altering the antigenicity and changing the immunoglobulin profile [4] . The beneficial effects of helminthic infections in preventing autoimmune disorders lead to further research exploring them for prevention of these disorders.


  Conclusion Top


We report an interesting case of ENV in type 2 diabetes. We report this case to highlight the clinical presentation mimicking the Madura foot and to educate the readers about the immune link between helminthic infections and diabetes.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sisto K, Khachemoune A. Elephantiasis nostras verrucosa: a review. Am J Clin Dermatol 2008; 9:141-146.  Back to cited text no. 1
    
2.
Yoho RM, Budny AM, Pea AS. Elephantiasis nostras verrucosa. J Am Podiatr Med Assoc 2006; 96:442-444.  Back to cited text no. 2
    
3.
Cooke A. Review series on helminths, immune modulation and the hygiene hypothesis: how might infection modulate the onset of type 1 diabetes? Immunology 2009; 126:12-17.  Back to cited text no. 3
    
4.
Liu Q, Sundar K, Mishra PK, et al. Helminth infection can reduce insulitis and type 1 diabetes through CD25- and IL-10- independent mechanisms. Infect Immun 2009; 77:5347-5358.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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Abstract
Case report
Introduction
Discussion
Conclusion
Acknowledgements
References
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