Differentiating Diabetic foot from other diseases

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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

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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

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* Diabetic foot must be differentiated from other diseases that cause foot ulceration, erythema, swelling and skin lesion, such as:[1][2][3]
* Skin and soft-tissue infections:
* Gas gangrene
* Cellulitis
* Vibrio vulnificus infection
* Aeromonas hydrophila infection
* Trauma
* Deep venous thrombosis
* Inflammatory disorders:
* Pyoderma gangrenosum
* Necrobiosis lipoidica

* Below, find a list of differential diagnosis for diabetic foot:

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 painful swelling
* Fever

| Acute  | \+  | \+  | Unilateral  | \-  | \-  |

* Tenderness, hotness, and may be fluctuation if abscess formed.
* Lymphangitis in nearby lymph nodes.
* Toxemia and fever in severe cases.
* Cellulitis involves the deeper dermis and erysipelas involves the upper dermis.[4]

* 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

* In patients with recurrent cellulitis, serologic testing for beta-hemolytic streptococci is a good diagnostic tool.[7]

Lymphatic filariasis |

* History of living in endemic area or travelling to it

| Chronic  | \+  | \+  | Bilateral  | \+  | \-  |

* Hepatomegaly
* Lymphedema
* Elephantiasis
* Lymphangitis
* Hydrocele
* Scrotal elephantiasis
* Lymphadenopathies
* Rhonchi may be present in patients with Pulmonary tropical eosinophilia syndrome.

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 |

* History of untreated varicose veins
* Painful bilateral lower limb swelling that increases with standing and decreases by rest and leg elevation.

| 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.

* Duplex ultrasound will demonstrate typical findings of venous valvular insufficiency

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 diameter is twice as likely to have DVT(most impotant sign )[8]
* Calf pain on passive dorsiflexion of the foot (Homan's sign) isn't realiable sign.

* Compression ultrasonography (CUS) with 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.[9]
* Abnormal deposition of fat and edema and easy bruising.

| 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 |

* History of untreated hypothyroidism.
* Infiltration of the skin with glycosaminoglycans with associated water retention.

| Chronic  | \+  | \-  | Bilateral  | \-  | \+

(hypothyroidism )

* Pretibial myxedema

* Thyroid function tests.

Other causes of generalized edema |

* History of chronic general condition (cardiac-liver-renal)

| Chronic  | \-  | \-  | Bilateral  | \-  | \+  |  |

* According to the primary cause ( Echo- LFTs\- RFT)

## References

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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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)  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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
10. ↑ Trayes KP, Studdiford JS, Pickle S, Tully AS (2013). "Edema: diagnosis and management". Am Fam Physician. 88 (2): 102–10. PMID 23939641.CS1 maint: Multiple names: authors list (link)
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.CS1 maint: Multiple names: authors list (link)