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STUDIES
Year : 1992  |  Volume : 58  |  Issue : 3  |  Page : 173-178

Diabetic dermoangiopathy:A clinico-pathological correlation




Correspondence Address:
MPS Sawhney


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  Abstract 

Skin biopsies from 25 diabetics and an equal number of nondiabetic controls were stained with H and E, PAS, alcian blue and iron hemotoxyline. Thirteen (52 percent) diabetics showed evidence of microangiopathy as compared to 1 (4 percent control). PAS positive thickening of capillary basement membrane and endothelial proliferation each were seen in 44 percent of cases. There was evidence of microangiopathy in 88.8 percent of cases with biopsy from dermopathy lesions as compared to 31.2 percent of other diabetics. Iron deposits were seen in 33.3 percent of cases with dermopathy lesions. No correlations could be established between age and sex of patient, family history, type, severity and duration of diabetes, diabetic retinopathy and neuropathy, skin infection and cutaneous microangiopathy. Higher percentage (69.3 percent) of patients with microangiopathy had poor control of their diabetes as compared to those without it (41.7 percent). All the 3 patients with CVA and hypertension showed microangiopathy.


Keywords: Diabetic dermoangiopathy, Diabetic dermopathy


How to cite this article:
Sawhney M, Talwar O P, Tutakne M A, Rajpathak S D. Diabetic dermoangiopathy:A clinico-pathological correlation. Indian J Dermatol Venereol Leprol 1992;58:173-8

How to cite this URL:
Sawhney M, Talwar O P, Tutakne M A, Rajpathak S D. Diabetic dermoangiopathy:A clinico-pathological correlation. Indian J Dermatol Venereol Leprol [serial online] 1992 [cited 2020 Jun 6];58:173-8. Available from: http://www.ijdvl.com/text.asp?1992/58/3/173/3788



  Introduction Top


The relationship of diabetes mellitus and vascular changes is an enigma even today. In 1959, two reports of electron microscopic (EM) studies of glomeruli of diabetic kidney provided the basis of the understanding of microangiopathy in diabetes mellitus. Bergstrand and Butch as well as Farquhar et al, as quoted by Spiro, [1] suggested thickening of capillary basement membrane (CBMT). The association of microangiopathy as manifested by CBMT with hyperglycaemia was finally established with the work of Bendayan [2] in 1981 in experimental animals.

Retinopathy, nephropathy, neuropathy and dermoangiopathy are various manifestations of diabetic microangiopathy. Diabetic dermopathy is one of the manifestations of microangiopathy with an overall incidence of 50 percent reported in Western literature [3] sub and 17.8 percent in an Indian study. [4]

Skin, muscle and kidney biopsies have been used for demonstration of microangiopathy [5],[6],[7],[8] Most studies have used electron microscope to demonstrate CBMT, others have used light microscopy, particularly since the material stains well with PAS [7],[8],[9]

A clinicopathological correlation was studied in diabetic patients with special reference to microangiopathy and CBMT and the same was compared with the results obtained in healthy controls.


  Materials and Methods Top


Twenty five diabetic patients under treatment and an equal number of age and sex matched non-diabetic controls were included in the study. Detailed history was taken and examination with special emphasis on the examination of the skin, was done. Persons with varicose veins and those with family history of diabetes mellitus were not included in the controls. Routine blood and urine investigations, blood urea, serum creatinine, serum cholesterol, chest x-ray, fundoscopy and fasting and post prandial blood sugar levels were measured in all the diabetics. Other investigations like ECG, urine culture, sputum for AFB etc. were done in cases suspected to have complications of diabetes. Blood sugar levels were also measured in all the controls. In addition, in the diabetics, blood sugar levels during the last 1 to 1 I/2 years were recorded to find out the control of diabetes. Skin biopsy was taken from the lesions of diabetic dermopathy in 9 diabetics and from the front of shin in the rest. Biopsy specimens were stained with haemotoxylin and eosin, periodic acid Schiff (PAS), alcian blue and iron haemotoxylin. Criteria followed for microangiopathy were those followed by Vaishnava et al [8]. Criteria for assessment of the control of diabetes into good, satisfactory and poor were those as followed by Joslin clinic [10] and for severity of diabetes into mild, moderately severe and severe diabetes were those used by Ballot and Roman. [11] Assessment of the diabetic retinopathy was done by an ophthalmologist by fundus examination.

Chi Square test was used as a test of significance.


  Results Top


Eight (88.8 percent) of the 9 patients with biopsy from the lesions of diabetic dermopathy showed evidence of microangiopathy with PAS positive CBMT in all 8 (88.8 percent), endothelial proliferation (EP) in 7(77.7 percent) and iron deposits in 3(33.3 percent). While only 5(31.2 percent) of 16 patients without any lesion of diabetic dermopathy showed microangiopathy, with CBMT in 4 (25 percent), EP in 3 (18.75 percent) and none showing iron deposits.

The difference was statistically significant (DF-1, x2 7.65, P 0.05). Overall incidence of microangiopathy amongst diabetics was 52 percent and of the controls only one (4 percent) showed CBMT and EP and there were no iron deposits, the difference being again statistically significant (DF-1, x 2 14.85, P 0.05). No mucin deposits were seen with alcian blue staining.

Of the 13 patients with cutaneous microangiopathy, 9 were males and 4 were females, the difference being not significant. Ten (77 percent) of the 13 patients with microangiopathy were above the age of 50 years, as .compared to 7 (58.3 percent) out of 12 without cutaneous microangiopathy, though the difference was not statistically significant.

Two (40 percent) out of 5 with insulin dependent diabetes mellitus (IDDM) and 11 (55 percent) out of 20 with non insulin dependent diabetes mellitus (NIDDM) showed microangiopathy. Mean duration of diabetes ± SD in patients with histopathological evidence of microangiopathy was 5 ± 4.5 years as compared to 6 - t 4.9 years in those without it.

in patients with cutaneous microangiopathy 4 (30.7 percent) had fair, 9 (69.3 percent) poor, and none had good control of his diabetic state; while in patients without it 3 (23 percent) had good, 4 (33.3 percent) fair and 5 (41.7 percent) poor control of their diabetes. Similarly 11 (83.6 percent) with mild diabetes and 2 (15.4 percent) with moderately severe diabetes had cutaneous microangiopathy, while 9 (75 percent) with mild and 3 (25 percent) with severe diabetes had no evidence of microangiopathy.

[Table - 1]. shows the association of diabetic cutaneous microangiopathy with other complications of diabetes mellitus.


  Comments Top


Fifty two percent of diabetic patients showed evidence of microangiopathy on histopathological examination of the skin by using PAS staining on light microscopy. Vaishnava et al, [8] Goldenberg et al [ 12] and Hendelsman et al [7] had found the incidence to be 52.5 percent, 60 percent and 79 percent respectively by the same technique, while Chhetri et a1 [6]sub using electron microscopy had found this to be 73.9 percent. PAS positive CBMT and endothelial proliferation each were seen in 44 percent of patients as compared to 42.5 percent and 32.5 percent respectively seen by Vaishnava et al [8] One nondiabetic control (4 percent) with negative family history also showed evidence of microangiopathy. Many reports with microangiopathy like retinopathy, neuropathy and CBMT on skeletal muscle biopsy in the absence of hyperglycaemia have been published. [13],[14],[15],[16],[17],[18]

While 88.8 percent of patients with diabetic dermopathy lesions showed microangiopathy, only 31.2 percent of those without it had microangiopathy, a statistically significant difference, suggesting thereby that detection of these dermopathy lesions indicates that the patient is most likely having underlying microangiopathy. Bauer et al [19] had found no changes of microangiopathy in the lesions of dermopathy, however, Binkley [20] showed them to be lesions of microangiopathy. Bauer et al [19] found positive staining with iron haemotoxylin stain in all the cases of dermopathy, while we found iron positivity in only 33.3 percent of cases.

No correlation could be established between duration of diabetes and microangiopathy, as was reported by some other authors also [6],[7],[8] However some found a strong correlation between the two [21],[22]sub Danowaski et al [21] Jose Barbosa 28 and Williamson et a1 [15[ gave the duration of onset of microangiopathy to be about 10 years as compared to our mean duration of 5 + 4.5 years.

In comparison Kilo et a1 [24] found a prevalence of CBMT of 52 percent at the time of diagnosis of hyperglycaemia, suggesting thereby that chemical diabetes may have persisted for years before it was detected and to correlate . onset of microangiopathy with duration of diabetes is really difficult. No correlation could be established between severity of diabetes and microangiopathy as was seen by others also. [5],[6],[8],[21],[22]

Higher percentage of patients with microangiopathy had poor control (69.3 percent) of their diabetes as compared to those without it (41.7 percent). None of the patients with microangiopathy had good control as compared to 25 percent without it. Pirar [22] in his study of 4,400 patients observed that all complications occured more frequently in those with poorest long term control.

No correlation could be established between age and sex of the patient, type of diabetes, family history of diabetes and microangiopathy. Vaishnava et al [8] had found microangiopathy in all the patients above 50 years, while in this study only 10 out of 17 (58.8 percent) had microangiopathy.

In contrast to others, [7],[8] we could not establish any relationship between other microangiopathies like retinopathy, neuropathy and cutaneous microangiopathy. There was no correlation between CAD and microangiopathy, as had been seen by others. [8] All the 3 patients of hypertension with CVA showed microangiopathy. Hypertension has been suggested to accelerate the progression of microangiopathy due to increased vascular leakage. [25] Infection was not more common in cases with microangiopathy as has been reported by others. [26]

 
  References Top

1.Spire R G. Investigation into biochemical basis of diabetic basement membrane alteration. Diabetes 1976; 25 (Supp1 2): 909-13.  Back to cited text no. 1    
2.Bendayan M, Rosio E A. Hyperglycemia and microangiopathy in the el. Diabetes 1981;30 317-25.  Back to cited text no. 2    
3.Danowaski T S, Sabeh G, Sarver M E, et al. Shin spots and diabetes mellitus. Amer J Med Sci 1966; 251 : 570-5.  Back to cited text no. 3    
4.Sawhney MPS, Tutakne MA, Rajpathak SD, et al. A clinical study of diabetic dermoangiopathy. Ind J Dermatol Venereol Leprol 1990; 56 :18-21.  Back to cited text no. 4    
5.VVilliamson J R, Vogler N J, Kilo C. Microvascular disease in diabetes. Med Clin N Amer 1971; 55 : 847-60.  Back to cited text no. 5    
6.Chhetri M K, Rahman 0 T, Chowdhary N D, et al. Studies on microcirculation in the detection of microangiopathy in diabetes mellitus. J Assoc Phys India 1970, 18 : 607-13.  Back to cited text no. 6    
7.Hendelsman MB, Marrione TG, Ghitman B. Skin vascular alterations in diabetes mellitus. Arch Int Med 1962; 110:70-7.  Back to cited text no. 7    
8.Vaishriava H, Cheriyan P T, Damodaran V N, et al. Microangiopathy in diabetes mellitus. J Assoc Phys India, 1967; 15 : 117-23.  Back to cited text no. 8    
9.Meissner W A, Legg M A. The Pathology of diabetes mellitus. In : Joslin Diabetes Mellitus (Marble A, White P, Bradley R F, et al eds), 11th edn: Philadelphia : Lea and Febiger, 1971; 176.  Back to cited text no. 9    
10.U G D P study. Effect of hypoglycaemic agents on vascular complications in patients with adult onset diabetes. VIII Evaluation of insulin therapy. Final Report. Diabetes 1982, 31 (Suppl 5) : 1-26.  Back to cited text no. 10    
11.Ballet S, Roman L. The exercise test in diabetic patients as studied by radio­electrocardio-graphy. Circulation 1967; 36: 245-54.  Back to cited text no. 11    
12.Goldenberg S, Alex M, Joshi R A, et al. Non­atheromatous peripheral vascular disease of the lower extremities in diabetes mellitus. Diabetes 1959; 8: 261-73.  Back to cited text no. 12    
13.Siperstien M D, Unger R H, Madison L L. Studies of muscle capillary basement membrane in normal sub iects, diabetics and prediabetic patients. J Olin Invest 1968; 47: 1973-99.  Back to cited text no. 13    
14.Ellenberg M. Diabetic nephropathy without manifest diabetes. Diabetes 1962; 11 197-201.  Back to cited text no. 14    
15.Harrower A D B, Clarke B F. Diabetic retinopathy with normal glucose tolerance. Br J Opthalmol 1976; 60 : 459-63.  Back to cited text no. 15    
16.Hutton W. Retinal microangiopathy without associated glucose intolerance. In: Diabetic Retinopathy. (Lynn J, Synder W, Vaiser A eds). : New York : Grune and Stratton, 1974; 81-90.  Back to cited text no. 16    
17.Linner E, Svanborg A, Zelander T. Retinal and renal lesions of diabetic type without obvious disturbance in glucose metabolism in a patient with a family history of diabetes. Am J Med 1965; 39 : 298-304.  Back to cited text no. 17  [PUBMED]  
18.Strauss F G, Argy W P Jr, Schreiner G E. Diabetic glomerulosclerosis in the absence of glucose intolerance. Ann Int Med 1971; 75: 239-42.  Back to cited text no. 18    
19.Bauer M F, Levan N E, Frankel A, et al. Pigmented pretibial patches. A cutaneous manifestation of diabetes mellitus. Arch Dermatol 1966; 93: 283-6.  Back to cited text no. 19    
20.Binkley G W. Dermopathy in diabetic syndrome. Arch Dermatol 1965; 92 : 625-34.  Back to cited text no. 20    
21.Danowashki T S, Fisher E R, Khurana R C, et al. Muscle capillary basement membrane in juvenile diabetes. Metabolism 1972; 21 1125-32.  Back to cited text no. 21    
22.Pirart J. Diabetes mellitus and its degenerative complications, a prospective syudy of 4,400 patients observed between 1947 to 1973. Diabetes Care 1978; 1 : 168 and 252.  Back to cited text no. 22  [PUBMED]  
23.Jose Barbosa. Nature and nurture. The Genetics of diabetic microangiopathy. In : Secondary Diabetes. The Spectrum of Diabetic Syndrome (Podolsky S, Viswanathan M, eds). New York: Raven Press, 1980; 67­75.  Back to cited text no. 23    
24.Kilo C, Volger N, Williamson JR. Muscle capillary basement membrane changes related to ageing and to diabetes mellitus, Diabetes 1972; 21 : 881-905.  Back to cited text no. 24    
25.Parving H H. Increased microvascular permeability to plasma proteins in short and long term juvenile diabetics. Diabetes 1976; 25 (Suppl 2) : 884-9.  Back to cited text no. 25    
26.Baverman J M. Cutaneous manifestations of diabetes mellitus. Med Clin N Amer 1971; 55  Back to cited text no. 26    


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