Share your views on the case doctors A 53-year-old man came to clinic with type 2 diabetes mellitus, chronic hepatitis B, hepatic cirrhosis, duodenal ulcer, mild splenomegaly, chronic cholecystitis and hepatitis B associated nephropathy. The patient was receiving treatment with insulin degludec 30 IU-0 -0 and insulin aspart 10 IU-14 IU-14 IU, and for the past nine months, he received tenofovir disoproxil 245 mg (0-0-1) for treatment of chronic hepatitis B. The patient was hospitalized for swelling, pruritus and hardening of the skin on the face, ears and hands, which subsequently spread to involve the trunk. Skin complaints began 3 months after the start of therapy with tenofovir. Dermatological examination revealed significant thickening and hardening in the areas of the face, neck, body and extremities, and generalised lichenoid papules were also found Based on clinical data, scleromyxedema, scleredema of Buschke and lichen amyloidosis were considered as possible diagnoses. A skin biopsy showed numerous fibroblasts and irregularly arranged collagen bundles with prominent mucin deposition, consistent with an advanced stage of scleromyxedema. He was diagnosed with Scleromyxedema or Arndt-Gottron (S-AG) syndrome Scleromyxedema or Arndt-Gottron (S-AG) syndrome is a cutaneous mucinosis that mainly affects adults between 30 and 70 years of age and whose aetiology is not fully understood . The disease is defined as a systemic form of Lichen myxedematosus. It is believed that in 80% of patients there is monoclonal gammopathy and there is probably an immune response of B-cells to antigenic mucin deposits in the dermis. Case and images taken from-https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6447340/

Share your views on the case doctors A 53-year-old man came to clinic with type 2 diabetes mellitus, chronic hepatitis B, hepatic cirrhosis, duodenal ulcer, mild splenomegaly, chronic cholecystitis and hepatitis B associated nephropathy. The patient was receiving treatment with insulin degludec 30 IU-0 -0 and insulin aspart 10 IU-14 IU-14 IU, and for the past nine months, he received tenofovir disoproxil 245 mg (0-0-1) for treatment of chronic hepatitis B. The patient was hospitalized for swelling, pruritus and hardening of the skin on the face, ears and hands, which subsequently spread to involve the trunk. Skin complaints began 3 months after the start of therapy with tenofovir. Dermatological examination revealed significant thickening and hardening in the areas of the face, neck, body and extremities, and generalised lichenoid papules were also found Based on clinical data, scleromyxedema, scleredema of Buschke and lichen amyloidosis were considered as possible diagnoses. A skin biopsy showed numerous fibroblasts and irregularly arranged collagen bundles with prominent mucin deposition, consistent with an advanced stage of scleromyxedema. He was diagnosed with Scleromyxedema or Arndt-Gottron (S-AG) syndrome Scleromyxedema or Arndt-Gottron (S-AG) syndrome is a cutaneous mucinosis that mainly affects adults between 30 and 70 years of age and whose aetiology is not fully understood . The disease is defined as a systemic form of Lichen myxedematosus. It is believed that in 80% of patients there is monoclonal gammopathy and there is probably an immune response of B-cells to antigenic mucin deposits in the dermis. Case and images taken from-https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6447340/

A 45 year female pt c/o Alternate day vomiting since 2 months Mild abdominal pain side of rt lumber region radiate to back side since 1 month Loss of appetite since 2 months Burping ( belching) since 1 year Gen weakness Tingling sensation both hand & toes Distanted abdomen since 15 days DM - T2 since 18 years HTN since 5 years UTI since 1 years Past h/o: - pulmonary Koch's 15 years ago Hyponatreamia 2 years ago Dec2018: -BP 140/80 mmHg Nov 2018: -BP 130/90mmHg Oct 2018: -BP 140/90 mmHg 26 Dec 2018 : - sr. Creatinine 1.4 mg/dl 15 Dec 2018 : -sr. Creatinine 2.0 mg/ dl Nov 2018: - sr. Creatinine 1.6 mg/dl HbA1c: - 6.7 BSF: - 110 PP: -205 Sgot: -49 Sgpt: -40 Protein: - 6.2 Albumin 3.1 Globulin: - 3.1 Total Bilirubin 0.6 Direct Bilirubin 0.4 Indirect Bilirubin 0.2 MBG 145.5 Few Bacteria +ve in urine please suggest Rx & diagnosis

DIABETIC NEUROPATHIES. Diabetic neuropathies are a family of nerve disorders caused by diabetes. WHAT CAUSES DIABETIC NEUROPATHY. Nerve damage is likely due to a combination of factors. 1.METABOLIC FACTORS. : hyperglycemia, long duration of diabetes, abnormal blood fat levels and low levels of insulin. 2.NEUROVASCULAR FACTORS : Neurovascular factors leading to damage of blood vessels that carry oxygen and nutrients to nerves. 3.AUTOIMMUNE FACTORS : Causes inflammation of nerves. 4.MECHANICAL FACTORS : Injury to nerves as in carpel tunnel syndrome. 5.INHERITED TRAITS : That increase susceptibility to nerve disease. 6.LIFESTYLE FACTORS : Smoking, alcohol. SYMPTOMS. Symptoms depends on the type of neuropathy and which nerves are affected.Symptoms involve sensory,motor and autonomic nervous system. 1.Tingling, numbness or pain in the toes,feet,legs,hands,arms and fingers. 2.Wasting of muscles of hand or feet. 3.Indigestion, nausea, vomiting, diarrhea,c constipation. 4. Dizziness or fainting due to a drop in blood pressure after standing or sitting up. 5.Problems with urination. 6.Erectile dysfunction. 7.Weakness. TYPES OF NEUROPATHY. Diabetic neuropathy can be classified as 1.Peripheral neuropathy. 2.Autonomic neuropathy. 3.Proximal neuropathy. 4.Focal neuropathy. PERIPHERAL NEUROPATHY. Peripheral neuropathy,also called distal symmetric neuropathy or sensorimotor neuropathy ,is nerve damage in arms and legs.Symptoms are *Numbness or insensitivity to pain or temperature. *A tingling,burning or prickling sensation. *Sharp pains or cramps. *Extreme Sensitivity to touch. *Loss of balance and coordination. Peripheral neuropathy also causes muscle weakness and loss of refle guyxes.Blisters and sites may appear on the numb areas of the foot because pressure or injury goes unnoticed.I f an infection occurs and is not treated promptly,the infection may spread to the bone and the foot may need amputation.Many amputations can be prevented if minor problems are treated in time. AUTONOMIC NEUROPATHY. Autonomic neuropathy affects the nerves that control the heart,blood pressure and blood glucose levels.Autonomic neuropathy also affects internal organs causing problems with digestion,respiration. urination,sexual response and vision. 1.HYPOGLYCEMIA UNAWARENESS. Normally,symptoms such as shakiness,sweating and palpitations occurs when the blood glucose levels drop below <<70 mg/dl.In people with autonomic neuropathy,symptoms may not occur making hypoglycemia to be recognized. 2.HEART & BLOOD VESSELS. Damage to the nerves in the cardiovascular system interferes with the body's ability to adjust blood pressure and heart rate. Due to this,blood pressuremay drop sharply after standing or sitting,causing a person to feel light headed or faint. Damage to nerves that control heart rate makes the heart rate to stay high , instead of rising and falling in response to normal body functions and physical activity. 3.DIGESTIVE SYSTEM. Nerve damage to the digestive system most commonly causes constipation. Damage can also cause the stomach to empty slowly,a condition called GASTROPARESIS. Gastroparesis can lead to persistent nausea and vomiting,bloating and loss of appetite. Gastroparesis also makes blood glucose levels to fluctuate widely ,due to abnormal food digestion. Nerve damage to the OESOPHAGUS MAKES SWALLOWING DIFFICULT. Nerve damage to bowels can cause constipation alternating with uncontrolled diarrhea, 3.URINARY TRACT & SEX ORGANS. Autonomic neuropathy often affects the organs that control urination and sexual functions. Nerve damage can prevent the bladder from emptying completely , allowing the bacteria to grow in bladder and kidneys causing urinary tract infections. When the nerves of the bladder are damaged,urinary incontinence may result because a person may not be able to sense when the bladder is full or control the muscles that release urine. Autonomic neuropathy also leads to decreased sexual response in men and women. A man may have erectile dysfunction or may reach sexual climax without ejaculating normally. A woman may have difficulty in arousal,lubrication or orgasm. 5.SWEAT GLANDS. Nerve damage may cause improper working of sweat glands.It can also result in profuse sweating at night or while eating. 6.EYES. Due to autonomic neuropathy,pupils become less responsive to changes in light.A s a result,a person may not be able to see well when light is turned on In a dark room or have trouble driving at night. PROXIMAL NEUROPATHY. Proximal neuropathy//lumbosacral plexus neuropathy //femoral neuropathy //diabetic amyotrophy causes pain in the thighs,buttocks,hips or legs,usually on one side of the body. FOCAL NEUROPATHY. Focal neuropathy appears suddenly and affects specific nerves,most often in the head,torso or leg. Focal neuropathy is painful and unpredictable.and occurs most often in older adults with diabetes. However,it tends to improve itself over weeks or months and does not cause long term damage. Focal neuropathy can cause *Inability to focus the eye. *Diplopia. *Aching behind the eye. *Bell's palsy. *Severe pain in the lower back and pelvis. *Pain in the front of the thigh. *Pain in the chest and stomach. *Pain on the outside of the shin or inside of the foot. *Chest pain and abdominal pain is mistaken for heart attack or appendicitis. CAN DIABETIC NEUROPATHIES BE PREVENTED. THE BEST WAY TO PREVENT NEUROPATHY IS TO KEEP BLOOD GLUCOSE LEVELS AS CLOSE TO THE NORMAL RANGE AS POSSIBLE.MAINTAINING SAFE BLOOD GLUCOSE LEVELS PROTECTS NERVES THROUGH OUT THE BODY.

A 45 year old female presented with this non healing wound due to toe-ring over second toe anterior aspect of left foot for past 10days. She has been getting injection cefotaxim twice daily from another practitioner. She is a known case of T2DM. Weight - 55 kg Height - 165cm BMI - 20.22 Her present RBS is 260mg/DL I have asked her to get HBA1C, FBS AND PPBS, which I will update soon. Meanwhile sir what antibiotics, OHA and topical application would be best suitable for such patient. @Sepuri Krishna Mohan Sir, I need your valuable advise too.