INNOVARE CIENCIA Y TECNOLOGÍA VOL. 11, NO. 2, 2022

Disponible en CAMJOL

INNOVARE Ciencia y Tecnología

Sitio web: www.unitec.edu/innovare/

Autor corresponsal: josemanuel00011@hotmail.com, Universidad Nacional Autónoma de Honduras, Tegucigalpa, Honduras

Disponible en: http://dx.doi.org/10.5377/innovare.v11i2.14790

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

, Óscar Daniel Osorto Mejía

Facultad de Ciencias Médicas, Universidad Nacional Autónoma de Honduras, UNAH, Tegucigalpa, Honduras

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

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.

114

J. M. Osorto Mejía, et al.

INNOVARE Revista de Ciencia y Tecnología Vol. 11, No. 2, 2022

On Thursday, January 22, 2020, the patient returned to

the PLH emergency room due to purulent discharge from an

abscess on her right hand. This time affecting the entire back

and palmar region of the hand, with inflammatory changes

that extended to the distal 1/3 of the forearm (Figure 2).

Random glucometry/ of 365 mg/dL was found. The patient

reported a fever of approximately three days of evolution,

accompanied by an inability to pick up objects with the

affected hand, this being her main reason for seeking

medical attention. Two surgical interventions were

performed under blockade of the upper limb (cleaning,

debridement, and abscess drainage on 01/28/2020 and

02/04/2020), broad-spectrum antimicrobial treatment (from

oxacillin to imipenem) to achieve control of the infection, as

well as personalized insulin treatment, using long-acting

insulin 38 I.U. in the morning and 26 I.U. at night,

accompanied by rapid-acting insulin 10 I.U. at 7:00 a.m., 10

I.U. previous lunch and 10 I.U. prior dinner. The patient was

hospitalized for 24 days in the General Women's Ward,

performing 2 to 3 daily dressings using hydrogen peroxide,

chlorhexidine gluconate and povidone iodine. Medical

discharge was decided on February 15, 2020, with the

insulin regimen and medical appointment with

endocrinology services.

During her second stay in the PLH, Grade 2 Joint

Mobility Limitation (LMA) was detected, with involvement

of the first finger of the right hand, inability to flex the finger

(interphalangeal, metacarpophalagic and carpometacarpal

joints) and limited flexion of the fifth finger (proximal and

distal interphalangeal joint), favoring the definitive

diagnosis of Diabetic Hand. The diagnoses at the time of

medical discharge were the following: compensated type 1

diabetes mellitus, TDHS in resolution, Grade 2 Joint

Mobility Limitation.

3. Discussion

The first reports of TDHS date back to 1975 in the United

States of America (USA) and in 1984 at Nigeria, with the

African continent being the site with the greatest study of

this pathology (Abbas, 2001). TDHS shares similar risk

factors with diabetic foot syndrome, peripheral neuropathy,

vascular and angiopathy, in addition to being female, insect

bites, poorly controlled diabetes, hand injuries, low

socioeconomic status, residing in coastal areas and late

medical evaluation. Because TDHS is reported infrequently

in the medical literature, both patients and treating

physicians ignore this entity and favor a rapid and extensive

evolution of the infection. Most of the cases observed are in

advanced stages, added to the precarious health care that

worsens the prognosis (Montes de Oca, 2008; Altamirano

Olvera, 2019).

Glycemic control has been adopted as one of the main

triggering factors. Its pathophysiology lies in the high blood

glucose levels experienced by patients, due to poor

medication control and/or poor adherence to treatment. This

leads to peripheral neurological lesions and compromised

immune response. The antimicrobial action of the immune

system is largely overwhelmed by vasoconstriction

secondary to inflammatory changes, generating poor

irrigation of the affected tissues, as well as hypoxia of the

local tissues. TDHS shares most of the pathophysiological

mechanisms of diabetic foot syndrome, but the mechanism

of the initial trauma is related to an unnoticed injury while

the person is carrying out their daily activities.

Complications of diabetes mellitus in the hands are

relatively rare compared to complications in the foot, with a

ratio of 1:20 (Proubasta Renart, 2015; Zyluk, 2015).

Figure 2. Patient´s hand asymmetry due to inflammation.

115

J. M. Osorto Mejía, et al.

INNOVARE Revista de Ciencia y Tecnología Vol. 11, No. 2, 2022

If the patient does not go to medical services, the

infection follows a rapidly progressive course, spreading

through the different virtual spaces found in the hand. Any

adult diagnosed with diabetes mellitus in the tropical regions

of the world, who also observes cellulitis, abscess and/or

gangrene in any region of the hand, will have a diagnosis of

TDHS. It is worth mentioning that this affectation is part of

the diabetic hand syndrome spectrum, which implies any

alteration in the hands of patients diagnosed with diabetes

mellitus, this disease being the main trigger (Okpara et al.,

2015; Öztürk, 2018).

This pathology presents its own clinical characteristics.

As the main criterion, a poorly controlled diabetes mellitus.

Most of adult patients do not remember a daily trauma that

it goes unnoticed (injury by a sharp object, wood splinter or

during nail cutting). It is common to find neurosensory

alterations such as paresthesia and anesthesia, as well as

discovering that most patients sought care from a local

healer, which worsens the prognosis. This increases the

chances of Meleney's gangrene involving extensive upper

limb tissue destruction, culminating in amputation (Okpara

et al., 2015; Proubasta Renart, 2015; Lawal et al., 2013).

There is currently no widely accepted classification of

TDHS. However, Lawal et al. (2013) propose a very useful

classification. They studied 36 patients, all with type 2

diabetes mellitus. Patients were broadly classified into three

groups based on degree of severity and prognosis, starting

with patients presenting with infection of the hand limited to

the skin, subcutaneous cellular tissue, and muscle, the

network of spaces between the metacarpals, including the

virtual space of Parona (61.1%), which corresponded to

group 1. Patients with infection affecting the deep tendons

of the hand, bones, and joints, including data of

osteomyelitis, but without gangrene (13.9%) corresponded

to group 2. Group 3 corresponded to digital and/or hand

gangrene, Meleney's gangrene (13.9%). According to the

study recommendations, all groups require hospital care for

broad-spectrum antibiotic coverage and a decision whether

a surgical procedure will be performed, if necessary (Lawal

et al., 2013).

Physical therapy is recommended during inpatient and

outpatient days. This improves blood flow and enhances the

immune reaction at the site of infection (Lawal et al., 2013).

Multiple studies indicate a speedy recovery in individuals

treated with hyperbaric oxygen therapy, reducing

hospitalization time by up to half of what is usual.

Unfortunately, TDHS predominates in countries with an

inefficient hospital system, causing a huge investment in

resources due to a prolonged hospital stay. The PLH has a

two-compartment hyperbaric chamber that is used as the

main treatment for patients with decompression sickness

(diver's disease), common in this region of the country due

to artisanal pearl fishing. Two daily sessions of 120 minutes

imply a cost of $250 USD. Patients cannot opt for this

therapeutic scheme due to its high cost. The diverse

microbial flora found on the hands (bacteria, fungi, etc.) due

to their use in multiple activities contributes to the rapid

evolution of the disease. The use of secretion culture to

guide antimicrobial therapy is ruled out for this reason. All

these factors may contribute to an opportunistic infection in

the ulcer; therefore, an empirical antibiotic therapy should

be started (Naqash, 2016; Cánaves, 2013).

Depending on the hospital resource, a wide range of

antibiotics can be applied, since many patients turn to local

traditional medicine as their first option to treat their

ailment, increasing the incidence of medical consultations

with patients in states of sepsis and/or septic shock,

requiring admission to the intensive care unit. Within

surgical treatment there is a variety of procedures ranging

from simple cures to the need for partial or complete

amputation of the hand (Lawal et al., 2013). Once the

diagnosis has been established as such, glycemic control

will be through human insulin. The use of oral

hypoglycemic agents as the only treatment is

contraindicated (Ince, 2015; Núñez Parada, 2016; Proubasta

Renart, 2015).

The LMA considerably affects the daily activities of

patients, reducing their quality of life and requiring certain

dependence on third parties. LMA can be classified

according to its level of involvement. Its main method of

prevention is the metabolic control of the patient. Once

established, there are few effective treatments against this

pathology. Strict glycemic control delays the progression of

this disease. Most treatments are not very effective

(Cánaves, 2013). Surgical interventions (fasciotomy,

resection of the A1 pulley, among others) are indicated only

if it affects the patient's daily activities. However, certain

authors recommend surgical treatment as a preventive

measure for possible deformities and complications such as

a pain syndrome due to restricted movement. More research

is needed in this regard to clarify this conflict. Although

there is still no internationally accepted convention for

LMA, active and passive physiotherapy is recommended.

The affected joint may benefit from prolonged use of a

corrective brace. Likewise, the paraffin bath favors

loosening the affected joints (Proubasta Renart, 2015).

4. Conclusion

More studies are needed to validate the different TDHS

classifications found in the literature. This disease, like all

metabolic pathologies, is preventable if its identified and

treated correctly since the beginning. TDHS must be treated

aggressively from its beginning, which implies efficient

health care for all patients diagnosed with diabetes mellitus.

The hyperbaric chamber located in the PLH would be a

highly valuable adjuvant treatment for patients with TDHS

and all pathologies that can be treated in this modality, such

as diabetic foot, Fournier's gangrene, carbon monoxide

poisoning, among others.

116

J. M. Osorto Mejía, et al.

INNOVARE Revista de Ciencia y Tecnología Vol. 11, No. 2, 2022

5. Acknowledgements

To Dr. Óscar Rene Zúñiga (Endocrinologist) and Dr.

Nery E. Linarez (Cardiologist, Hospital General del Sur) for

their invaluable contribution to this study.

6. Author Contributions

JO, SL and OO participated in the literature review, as

well as in the presentation of the case. SL translated the

manuscript to English. All authors read and approved the

final version of the manuscript.

7. Conflicts of Interest

The authors declare no conflict of interest.

8. Bibliographic References

Abbas, Z. G., Lutale, J., Gill, G. V., & Archibald, L. K. (2001). Tropical

diabetic hand syndrome: risk factors in an adult diabetes population.

International Journal of Infectious Diseases, 5(1), 19–23.

https://dx.doi.org/10.1016/s1201-9712(01)90043-8

Altamirano Olvera, C., Caicho Caicedo, O., Ramos Rojas, R., Mediavilla

Ordoñez, D., & Pérez Pérez, E. (2019). Experiencia de un Caso en el

Tratamiento del Síndrome de Mano Diabética por Absceso Dorsal.

Cuidados de Enfermería y Educación en Salud, 4(1), 7–21.

https://revistas.userena.cl/index.php/cuidenf/article/view/1228

Álvarez Correa, L. A., Domínguez Zambrano, A., Solís Rojas, C.,

Hernández Maya, M., & García García, J. A. (2020). Mano diabética en

el Hospital General de México "Dr. Eduardo Liceaga": experiencia en

42 casos. Cirugía Plástica Ibero-Latinoamericana, 46(1), 65-72.

https://bit.ly/3Om64yS

American Diabetes Association [ADA]. (2020). 1. Improving care and

promoting health in populations: standards of medical care in Diabetes

2020. Diabetes Care, 43(1), 7–13. https://dx.doi.org/10.2337/dc20-

S001

Cánaves, Y., & Parón L. (2013). Síndrome de Mano Diabética. Revista

Médica de Rosario, 79(3), 118-125.

http://www.circulomedicorosario.org/revista.php

de Mora, I., López E., Bautista M., Freire F., Freire D., & Bautista, D.

(2019). Complicaciones musculoesqueléticas de la diabetes mellitus.

Revista Cubana de Reumatología, 21(1), 3-5.

https://zenodo.org/record/2553484#.YuG9OnbMK3A

Ince, B., Dadaci, M., Arslan, A., Altuntas, Z., Evrenos, M. K., & Fatih

Karsli, M. (2015). Factors determining poor prognostic outcomes

following diabetic hand infections. Pakistan Journal of Medical

Sciences, 31(3), 532–537. https://dx.doi.org/10.12669/pjms.313.6858

Lawal, Y. Z., Ogirima, M. O., Dahiru, I. L., Girei, B. A., & Salisu, M. B.

(2013). Tropical diabetic hand syndrome: surgical management and

proposed classification. Archives of International Surgery, 3(2), 124-

127. https://www.archintsurg.org/text.asp?2013/3/2/124/122931

Montes de Oca, N. J., Córdoba, G. H., Mondragón, C. M. A., Jaramillo, G.

A., López, O. E., Torres, C. M. L., Ochoa, G. G., & Rogel, R. J. (2008).

Síndrome mano del diabético. Reporte de casos, Toluca, Estado de

México. Revista Mexicana de Angiología, 36(1), 14-20.

https://www.medigraphic.com/cgi-

bin/new/resumen.cgi?IDARTICULO=42740

Naqash, M., Ahmad, F., Baht, A. N., Jalalie, U., & Naja, R. R. (2016).

Tropical diabetic hand syndrome - a case report with a short review.

International Journal of Research in Medical Sciences, 4(12), 5494-

5496. http://dx.doi.org/10.18203/2320-6012.ijrms20164238

Núñez Parada, L. E. (2016). Factores de riesgo conductuales y biológicos

de pacientes con diabetes mellitus tipo 2 complicados y su costo de

acuerdo al número de complicaciones. Hospital Escuela Universitario,

Honduras. enero – abril 2014. Universidad Nacional Autónoma de

Honduras.

https://tzibalnaah.unah.edu.hn/xmlui/handle/123456789/6335?show=f

ull

Okpara, T. C., Ezeala-Adikaibe, B. A., Omire, O., Nwonye, E., & Maluze,

J. (2015). Tropical Diabetic Hand Syndrome. Annals of Medical and

Health Sciences Research, 5(6), 473–475.

https://www.amhsr.org/articles/tropical-diabetic-hand-syndrome.html

Öztürk, A. M., Uysal, S., Yıldırım Şımşır, I., Hüngör, H., & Işıkgöz

Taşbakan, M. (2018). Hand infection in patients with diabetes: a series

of 17 cases and a pooled analysis of the literature. Turkish Journal of

Medical Sciences, 48(2), 372–377. https://dx.doi.org/10.3906/sag-

1712-120

Proubasta Renart, I. (2015). La mano diabética. Revista Iberoamericana de

Cirugía de la Mano, 43(2), 135-141.

https://dx.doi.org/10.1016/j.ricma.2015.09.001

Zyluk, A., & Puchalski, P. (2015). Hand disorders associated with diabetes:

a review. Acta Orthopaedica Belgica, 81(2), 191–196.

http://www.actaorthopaedica.be/archive/volume-81/issue-2/review-

article/hand-disorders-associated-with-diabetes-a-review/

117