|Year : 2016 | Volume
| Issue : 2 | Page : 106-110
Tropical diabetic hand syndrome among diabetic patients attending endocrine clinic of Ahmadu Bello University Teaching Hospital, Shika Zaria, North Central Nigeria
Innocent Onoja Okpe1, Kenneth Ezenwa Amaefule2, Ismail Lawal Dahiru2, Yaqub Lawal1, Ademola Odunayo Adeleye1, Beatrice Bello-Ovosi1
1 Department of Medicine, Endocrine Unit, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Orthopedic and Trauma Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Submission||14-Nov-2015|
|Date of Acceptance||13-May-2016|
|Date of Web Publication||21-Jun-2016|
Dr. Innocent Onoja Okpe
Department of Medicine, Endocrine Unit, Ahmadu Bello University, Zaria
Background: Tropical diabetic hand syndrome (TDHS) is a known complication affecting patients with diabetes mellitus in the tropics. However, there has been no previous report on the condition from the Northern Nigeria. This study assessed the prevalence of the syndrome among diabetic patients attending the endocrine clinic of Ahmadu Bello University Teaching Hospital (ABUTH), North Central Nigeria. Materials and Methods: A retrospective cohort study was employed for the study from January 2010 to May 2013. All patients with incomplete treatment records were excluded from the study. Data analysis was done with Statistical Packages for Social Sciences (SPSS) version 20.0 and presented as tables and charts. Results: Of the total 894 cases reviewed, the prevalence of diseases condition was 12 (1.3%), with female to male ratio of 2:1. Majority (75.0%) of the initiating events were minor trauma, followed by spontaneous blisters and subsequent rupture (16.7%) and the least (8.3%) was burns. The mean interval between onset of disease and presentation in the hospital was 22.9 days. Staphylococcus aureus was the main microbial isolates (75.0%) and majority (88.9%) were sensitive to ciprofloxacin. Mortality rate among the patients was 25.0% while amputation and healing with fixed flexion deformity of digits accounted for 33.3% and 58.3%, respectively. Conclusion: TDHS is a significant complication among diabetic patients in ABUTH, and the most common initiating risk factor was minor trauma. Mortality rate among the patients was also high. Hence, there is a need for intensive education of diabetic patients on the benefits of early diagnosis and treatment and avoidance of trauma.
Keywords: Nigeria, prevalence, tropical diabetic hand syndrome, Zaria
|How to cite this article:|
Okpe IO, Amaefule KE, Dahiru IL, Lawal Y, Adeleye AO, Bello-Ovosi B. Tropical diabetic hand syndrome among diabetic patients attending endocrine clinic of Ahmadu Bello University Teaching Hospital, Shika Zaria, North Central Nigeria. Sub-Saharan Afr J Med 2016;3:106-10
|How to cite this URL:|
Okpe IO, Amaefule KE, Dahiru IL, Lawal Y, Adeleye AO, Bello-Ovosi B. Tropical diabetic hand syndrome among diabetic patients attending endocrine clinic of Ahmadu Bello University Teaching Hospital, Shika Zaria, North Central Nigeria. Sub-Saharan Afr J Med [serial online] 2016 [cited 2018 Jan 16];3:106-10. Available from: http://www.ssajm.org/text.asp?2016/3/2/106/184378
| Introduction|| |
Tropical diabetic hand syndrome (TDHS) is a complication affecting patients with diabetes mellitus in the tropics.  The clinical presentation of TDHS is variable and encompasses localized cellulitis with variable swelling with or without ulceration of the hands, to progressive fulminant hand sepsis, and gangrene affecting the entire limb which may be potentially fatal. TDHS is less well recognized than foot infections and not generally classified as a specific diabetes complication. 
Although TDHS has been occurring over the years, the first reported case in Nigeria was in 1984 by Akintewe et al. where a prevalence rate of 4.0% was documented.  Similar hand sepsis has been recorded from the Western countries,  but not in recent years, and the disorder is now virtually confined to the tropics. ,,
In most studies reported in Africa, middle-aged females predominate. ,,, However, most studies in the Western countries have documented male predominance. , The female predominance in most African studies was thought to be due to the fact that African women are more involved in domestic work which exposes them to frequent hand trauma. ,, Even though the females predominates, cultural practices in most African countries contribute to the late presentation of females with severe hand infections. ,,
In view of its geographical localization and typical clinical features, it is referred to as the TDHS.  There is often a history of antecedent minor hand trauma (e.g., scratches or insect bites). Other risk factors include poor glycemic control, delayed presentation, low socioeconomic status, malnutrition, and applications of herbal remedies to the wounds. ,,,,,, The development of the hand ulcers may or may not be associated with any evidence of neuropathy or arterial insufficiency. 
TDHS can develop into a rapidly progressive, synergistic gangrene (Meleney's gangrene) confined to the superficial fascia that can result in death within days of onset of symptoms. , Previous small series or case reports indicate the severe consequences of TDHS, including permanent disability and death. ,, Staphylococcus aureus is mostly reported as the most common organism isolated in TDHS. , This was adduced to the fact that S. aureus is a common skin flora and could easily infect skin ulcers.  Appropriate treatment for the majority of patients includes incision and drainage of the wound, debridement, amputation, and broad-spectrum antibiotics. , There has been no previous report on the TDHS from the Northern Nigeria. Therefore, the aim of this study was to determine the prevalence of diabetic hand syndrome among diabetic patients attending the endocrine clinic of Ahmadu Bello University Teaching Hospital (ABUTH), North Central Nigeria.
| Materials and Methods|| |
ABUTH, Shika-Zaria is a tertiary health facility with about 1000 bed capacity, 2892 staff strength, and total annual admission turnover of about 10,000 patients. The institution provides general outpatient services, specialized and subspecialist care, and 24 h accident and emergency services among others. In addition, inpatient care is offered in the main clinical specialties. The endocrinology unit has inpatient bed space of 24. The department currently has one professors/chief consultants, two consultants/senior lecturers, four senior registrars, and two registrars.
Study Design and Study Population
A retrospective cohort study of all available secondary data of all diabetic patients admitted into the endocrine unit of the institution was obtained from the medical records department of the hospital. The period under review covers from January 2010 to May 2013. All diabetic patients registered for treatments in the endocrine unit were included in the study and patients with incomplete records were excluded. Information extracted included a sociodemographic characteristic of the patients, history of the disease condition, physical examinations findings, investigation results, treatments, and follow-up records. Outcome measures considered among the eligible cases was diabetic hand syndrome.
Data were extracted, checked for errors, and entered into Statistical Packages for Social Sciences (SPSS) version 20.0 (Illinois, Chicago) version 20.0 for analysis. Descriptive statistics were used to summarize the independent variables of interest and presented as tables and charts.
Ethical approval was obtained from the Health Research Ethics Committee of the ABUTH before the commencement of the study.
| Results|| |
Sociodemographic Characteristic of Patients and Prevalence of Tropical Diabetic Hand Syndrome
[Table 1] represents the sociodemographic characteristics of patients and the prevalence of diabetic hand syndrome. Of the total 894 diabetic patients registered in the units, 474 (53.0%) were males and 420 (47.0%) were females. Overall, the patients were between 24 and 75 years, with mean age 43.4 years (standard deviation [SD] = ±12.2 years). Twelve (1.3%) had TDHS. This constitutes a mean hospital incidence of 3.5 persons per year. Eight (66.7%) of the 12 cases of TDHS were females and four (33.3%) males. The proportion of females and males with TDHS was 1.9% and 0.8%, respectively, with a mean age of 35.3 (SD = ±7.6) years and 51.5 (SD = ±11.2) years for males and females, respectively. All the female cases were full-time homemakers while the male cases indulged in tailoring, bricklaying, and trading.
|Table 1: Prevalence of diabetic hand syndrome by sex of the patients (n=897) |
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Initiating Events for Tropical Diabetic Hand Syndrome
Among the 12 patients who had TDHS the left hand was involved in nine (75.0%) of the cases and the right hand in three (25.0%). Majority (75.0%) of the initiating events were minor trauma (repeated scratching, itching, cutting nails, removing redundant skin, washing clothes, and cooking) followed by spontaneous blisters/bullae and subsequent rupture (16.7%) and the least (8.3%) was burns [Figure 1].
|Figure 1: Initiating events of tropical diabetic hand syndrome among diabetic patients|
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Summary of the History and Investigation Results
Most of the patients presented late to the hospital with a mean interval between onset of disease and presentation of 22.9 days (range: 14-30 days). The mean onset to presentation interval for the patients that died and for those that survived were 27.3 days and 17.4 days, respectively. This delay in presentation is due to initial visit to traditional medicine practitioners or prior use of traditional medications at home in eight (66.7%) of the patients. Diabetic ketoacidosis was the mode of presentation in four (33.3%) of the cases. Mean blood glucose level at presentation was 32.4 (range: 27.8-38.5) mmol/L. The mean duration of diabetes was 5.9 (range: 2-12) years. Seven (58.3%) of the cases were hypertensive for a mean duration of 8.4 (range: 4-20) years. None of the cases smoked cigarette or any form of tobacco. The mean body mass index of the cases was 31.9 (range: 23.3-35.6) kg/m 2 . Peripheral neuropathy (hands and feet) was found historically and/or by examination in seven (58.3%) of the cases. Bilateral reduction of brachial and radial pulses was found in only one (8.3%) of the patients. Digital gangrene was however found in two (16.7%) of cases. X-ray of hand shows osteomyelitic features in three (25.0%) and evidence of gas formation in one (8.3%) of cases.
S. aureus alone or mixed with other bacteria was isolated in nine (75.0%) of the cases and was sensitive to ciprofloxacin in eight (88.9%), ceftriaxone in six (66.7%), cloxacillin in two (22.2%), and gentamicin in one (11.1%) of cases. Sensitivity for clavulanic acid + amoxicillin was done for seven of the S. aureus isolates of which six (85.7%) were found to be resistant. Polymicrobial isolates (Staphylococcus sp., Klebsiella sp., Pseudomonas sp.) were found in five (41.7%) of the cases.
Amputation of one or more digits occurred in four (33.3%) of the cases [Figure 2]a. Healing with fixed flexion deformity of digits was recorded for seven (58.3%) of the patients [Figure 2]b. Three (25%) of the cases died within a mean of 2.7 (range: 1-4) days of admission while the mean duration of hospital stay for the survivors was 51 (range: 38-71) days.
| Discussion|| |
In our study, the prevalence of diabetic hand syndrome among the diabetic patients seen in the endocrine unit of ABUTH during the period under review was 1.3%. This is comparable to a proportion of 1.6% obtained by Unachukwu and Anochie in 2002  but lower than the 4% reported by Akintewe et al. in 1984  from other parts of Nigeria. The sociodemographic characteristics of our study population are similar with other studies in the tropics. In our study, a higher proportion (66.7%) of TDHS was in females. This is consistent with cases observed in most African studies ,, but it is at variant with similar studies in the Western countries where male predominance was recorded. , The female predominance in our study is likely related to reasons reported for similar findings in other tropical studies. ,, Furthermore, all the females in our study are full-time homemakers [Table 1] and majority of them reported minor trauma as the initiating risk factor for developing TDHS [Figure 1]. Full-time homemakers are more likely to be more involved in domestic work and that may expose them to frequent hand trauma.
Regarding interval between onset of diabetic hand syndrome and presentation at hospitals, our study showed that most of the patients presented late to the hospital with a mean interval of 22.9 days. A potential explanation may lie in the source of income of the patients since all the female patients in our study are full-time homemakers and the males are predominantly low-income earners. By extension that may have also accounted for the use of traditional medicine practitioners as the first point of call by our patients. By implication, it is possible that most of the patients presented in the hospitals with complications which may have accounted for the 25.0% mortality rate. The aforementioned explanations are consistent with reports from other studies where late presentation with severe hand infections was attributed to cultural practices. ,
In addition to the high mortality rate, our study has demonstrated a high morbidity rate associated with TDHS. The mean duration of intervals from onset of symptoms to presentation in the hospital among those that survived and those that died varies between 27.3 days and 17.4 days, respectively. Amputation of one or more digits [Figure 2] accounted for 33.3% of complications while healing with ﬁxed ﬂexion deformity of digits [Figure 3] was found among 58.3% of the patients. All these render these patients handicapped, unemployed, and dependent aggravating the socioeconomic crises in their various communities. The short duration of hospital stay of patients that died portends the severity of their hand infections at presentation. Similar high morbidity and mortality rates have been reported in previous studies. ,, The mean duration of hospital stay for the survivors was lengthy 51 (range: 38-71) days and this takes its toll economically and psychosocially on these patients and the health care facilities managing them.
The development of hand ulcers may or may not be associated with any evidence of neuropathy or arterial insufficiency.  This is supported by our study where 58.3% and 8.3% were found to have peripheral neuropathy and clinically significant peripheral arterial disease, respectively. S. aureus was the most common organism isolated in our study (75%) which agrees with most previous reports. , This has been adduced to the fact that S. aureus is a common skin flora and could easily infect skin ulcers.  The S. aureus isolated in our patients were highly sensitive to ciprofloxacin and ceftriaxone. However, amoxicillin and clavulanic acid resistance were found to be high.
| Conclusion|| |
TDHS is a diabetic complication prevalent among female diabetic patients in North Central Nigeria, and the leading initiating factors were minor trauma from manual works, poor glycemic control, poor hand care, malnutrition, and low socioeconomic status. Its high complication rate is further worsened by prior intervention by traditional healers and delayed presentation to the hospital.
The importance of education of diabetics on the danger posed by this scourge in terms of permanent disability, economic and psychosocial implications, and even death cannot be over-emphasized. Prevention strategies include patient and staff education that focuses on good glycemic control, proper hand care, nutrition, and the importance of seeking medical attention immediately following hand trauma regardless of the severity of the injury, or at the earliest onset of hand-related symptoms, such as redness or swelling.
The authors acknowledge the management of ABUTH for approving this study. We also thank the staff of our records department for their patience and support.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]