A 36-year-old woman with a history of insulindependent diabetes mellitus since the age of 2 years was admitted to the medical intensive care unit in a state of diabetic ketoacidosis. Previous complications of her severe, long-standing diabetes included chronic renal insufficiency, peripheral arterial insufficiency necessitating left below-knee amputation for peripheral gangrene, severe diabetic retinopathy with markedly impaired visual acuity, dense peripheral neuropathy, and necrobiosis lipoidica diabeticorum. Two weeks prior to admission, the patient noted a large crust on her right thumb overlying the dorsal distal phalanx. On the day of admission, she presented for evaluation of the thumb lesion, and a roentgenogram showed that she had lytic changes in the distal phalanx that were consistent with osteomyelitis. Her serum glucose concentration was noted to be 3.33 mmol/L (59 mg/dL) with positive serum ketones at a 1:2 dilution. Insulin was administered by continuous intravenous infusion, and fingerstick blood glucose concentrations were
Cropley TG. The Diagnostic Challenge of Diabetic Hands. Arch Dermatol. 1993;129(1):40–41. doi:10.1001/archderm.1993.01680220052008
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