Looking for a needle in a haystack: an older diabetic man with cheiroarthropathy loses an insulin pen needle in subcutan
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CASE REPORT
Looking for a needle in a haystack: an older diabetic man with cheiroarthropathy loses an insulin pen needle in subcutaneous tissue Iacopo Iacomelli1 · Chiara Giulietti2 · Mauro Di Bari3 Received: 7 July 2020 / Accepted: 19 August 2020 © Springer Nature Switzerland AG 2020
Keywords Insulin pen · Needle · Detachment · Elderly · Diabetic cheiroarthropathy
Introduction Diabetic cheiroarthropathy (DCA) is an often underestimated complication of diabetes mellitus, characterized by thick, tight, and waxy skin limiting small joints mobility, which has been reported in a range from 8 to 66% in type 1 diabetes mellitus and from 8 to 76% in type 2 diabetes mellitus [1]. The pathogenesis remains not completely understood, and it is the result of complex and multifactorial process. Chronic hyperglycemia causes connective tissue damage (generating non-enzymatic glycosylation of collagen) and microvascular disease; moreover, other mechanisms such as overuse, trauma, and genetic/immunologic factors may play a relevant role. DCA is diagnosed by physical examination: it is usually characterized by stiffness and painless limited extension of proximal metacarpophalangeal joints and/or interphalangeal joints with spontaneous flexion of the fingers. There is decreased ability to fully flex or fully extend the fingers. Patients with positive prayer sign or positive table top test are highly suspected of DCA: prayer sign is described as * Iacopo Iacomelli [email protected] 1
Diabetes Clinic and Geriatric Clinic, Department of Internal and Specialist Medicine, Internal Medicine Unit, Santa Maria alla Gruccia – Valdarno Hospital, Azienda USL Toscana Sud Est, Piazza del Volontariato 2, 52025 Montevarchi, Arezzo, Italy
2
Internal Medicine Unit, San Giuseppe Hospital, Azienda USL Toscana Centro, Empoli, Florence, Italy
3
Geriatric Intensive Care Medicine, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
the inability to close gaps between palmar sides of opposite hands when the patient takes a praying position. Table top test is defined as the inability to wholly contact the hand palmar side on the table. A tight waxy skin surface over the dorsum of the hand usually completes the clinical picture. Among with disease progression, reduced grip strength, dexterity, and function can occur with contracture development. DCA diagnosis is clinical, but it can be supported by ultrasonography and/or magnetic resonance imaging findings, even not specific. Laboratory tests are useful only in detecting other causes. A self-administered questionnaire, such as Disabilities of the Arm, Shoulder and Hand (DASH), can be used to assess the functional disability of patients with this condition: this questionnaire includes 30 items evaluating the function of upper limbs using a 5-point scale. The total score is calculated within a range from 0 to 100. The higher scores represent a higher degree of functional disability. The reduced manual dexterity caused by DCA may determine numerous problem
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