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Infectious Emergencies in Patients With Diabetes

Aside from the severe increases in blood sugar, development of infections among people with diabetes is the most common cause of consultation in the emergency room. Patients with diabetes are particularly predisposed to infections. A study showed that people with diabetes are 200 times more likely to be hospitalized for infectious disease and are 90 times more likely to die from infection. This increased risk of dying from infections may be mediated by diseases of the heart and blood vessels.

Many individual infections are more common in people with diabetes, including lung infection (pneumonia), kidney infection (pyelonephritis), skin and soft tissue infections, including the “diabetic foot”, and fungal infections.

Other infections occur almost exclusively in diabetics, like invasive external ear infections (otitis externa), fungal infections involving the nasal passages (rhinocerebral mucormycosis), and infections causing swelling of the gallbladder (cholecystitis) and kidney (pyelonephritis). Some infections are more severe when they occur in diabetic patients and are associated with more complications.

Infections may precipitate increases in blood sugar and, conversely, the high blood sugar of diabetes may facilitate infection. This is because the immune system is depressed, affecting the activity of the cells involved in containing the infection. The antioxidant systems in the body are also compromised in patients with high blood sugar. These impairments are exacerbated by high blood sugar levels but are reversed by normalization of blood glucose levels.

Head and Neck Infections
Head and neck infections almost exclusively seen in diabetic patients that are associated with more disease states and death include invasive middle ear infections (otitis media) and nasal fungal infections which may extend to the brain (rhinocerebral mucormycosis).

Invasive otitis media is an uncommon but potentially life-threatening infection. It slowly invades from the external ear canal into adjacent soft tissues, and bone and eventually spreads across the base of the skull. It occurs primarily in elderly diabetic patients. Patients report weeks to months of severe ear pain, discharge from the external ear, and hearing loss. Surgery is an essential part of therapy. Intravenous antibiotics should also be started at once.

Rhinocerebral mucormycosis is a life-threatening fungal infection. Patients present with facial or ear pain and nasal stuffiness. They may also experience generalized feeling of discomfort and fever. Treatment consists of surgical removal of contaminated tissue of the involved sinuses and prolonged intravenous therapy with antifungal drugs. If untreated, this disease condition is universally fatal. However, if recognized early, there is a 20 percent survival rate.

Pulmonary Infections
Overall, any infection involving the lungs and the airways in diabetic patients is associated with increased mortality. Diabetic persons are four times more likely to die from pneumonia or flu than are nondiabetic persons. Specific infections, such as those caused by the bacteria Staphylococcus aureus are more frequent in diabetes. According to one study, up to 30 percent of diabetics are nasal carriers of S. aureus as compared with 11 percent of healthy individuals. On the basis of their high nasal carriage rate, diabetic persons are thought to be at an increased risk for S. aureus pneumonia.

The more common bacteria that cause pneumonia, such as Streptococcus pneumoniae, Legionella, and influenza are associated with more disease states and death. Antiviral drugs are recommended treatment for influenza. The good thing is diabetic persons have a normal response to vaccines. Because of their increased susceptibility to complications, routine immunization against bacteria that cause pneumonia and influenza is recommended for all diabetic patients.

Infections of the Urinary Passages
The presence of bacteria in the urine without any symptom is three times more common among diabetic than nondiabetic women. However, there is no difference in the development of symptomatic urinary tract infection (UTI), time to onset of symptoms, infection of the kidneys (pyelonephritis), or need for hospitalization.

The symptoms and signs of infection of the urinary bladder (cystitis) in the diabetic patient are the same as for nondiabetic patients. However, because of the high incidence of unsuspected upper tract UTI in diabetic persons, the recommendation is to consider prolonged treatment with antibiotics. In addition, owing to the incomplete bladder emptying associated with cystitis in conjunction with the high glucose concentrations in the urine, fungal infection (Candida albicans) may also be seen.

Infections involving both kidneys (pyelonephritis) is twice as common in patients with diabetes and predisposes to a more severe infection of the upper urinary tract. Swelling of the kidneys is almost exclusively an infection of diabetics and carries a grave prognosis. Treatment includes rapid supportive measures and intravenous antibiotics. The overall death rate is 30 percent and surgical removal of the affected kidney is the treatment of choice in most patients.

Abdominal Infections
Although infection of the gall bladder (cholecystitis) is probably no more common in patients with diabetes than in the general population, sudden severe infection is more common. The early symptoms similar to those with cholecystitis due to gallstones are present in 50 percent of patients. Even with surgical removal of the gall bladder and the use of antibiotics, this virulent infection is associated with gangrene and perforation of the gallbladder and has a 15 percent death rate.

Skin and Soft Tissue Infection
Diabetic patients develop skin infections more often than their nondiabetic counterparts. Numbness of the hands and feet, blockage of the blood vessels, and high blood sugar all predispose diabetic patients to skin and soft-tissue infections. Blood glucose levels higher than 250 mg/dL significantly increase a patient’s risk for soft-tissue infection. Other factors that predispose to the development of skin infections include a past history of inflammation involving the structures under the skin (cellulitis), swelling of the leg, blockage in the blood supply to the legs, ringworm infection, and dry skin.
Necrotizing fasciitis is a deep-seated, life-threatening infection of the tissue under the skin with progressive destruction ofunderlying fat and muscle. The chance of having this infection is increased in diabetes, alcoholism, and intravenous-drug users. Symptoms include pain out of proportion to skin findings and numbness of the overlying skin. It starts as a violet discoloration of the skin that progress to become vesicles and blisters. Immediate aggressive surgical removal of the contaminated tissue is necessary as are intravenous antibiotics.

Diabetic Foot infections
Foot infection is the most common soft tissue infection associated with diabetes. Complications involving the nerves (neuropathy) and blockages in the blood supply to the feet play major roles in this disease. More serious complications include bone involvement (osteomyelitis), amputation, and death. Infection usually begins after just minor injury or trauma and may progress to cellulitis, death of a portion of the soft tissue, and extension into the underlying bone.
Outpatient management of foot ulcers begins with surgical removal of the dead tissue and administration of antibiotics. In moderate-to-severe cellulitis that places the limb at risk, the patient should be hospitalized for antibiotic therapy and surgical intervention.

Prevention of foot ulcers involves a multidisciplinary team approach. Daily foot care should be included in patient education, and proper foot care habits, such as protective footwear and pressure reduction, should be reinforced. As in most diabetes-related infections, good blood sugar control plays an important role.

Given all these limb-threatening and even life-threatening conditions requiring emergency intervention, vigilant measures should be instituted to prevent infection in diabetic patients.

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