Repeated Multiple Episodes of Furunculosis in a Young Brittle Diabetic, Successfully Treated

Abstract

We report a 36-year-old male, a brittle diabetic, known case of diabetes mellitus for the last 10 years, noncompliant with medications, and presented with repeated episodes of furunculosis. The patient had a history of fever, headache, and one seizure episode in the last week. The patient has brittle diabetes, uncontrolled hypertension, and acute on chronic kidney injury with Vitamin D deficiency and iron deficiency anemia. The patient responded well to both systemic and local antibiotics, and all the skin lesions healed with adequate blood sugar management.

INTRODUCTION

Diabetes Mellitus is a metabolic condition characterized by persistent hyperglycemia, whose effects are seen on all systems, including the skin. Diabetic skin infections are commonly bacterial or fungal. One such bacterial skin infection is Furunculosis. A furuncle, also referred to as a boil, is a painful, pus-filled lesion forming under the skin when hair follicles become infected with bacteria, usually Staphylococcus aureus, rarely community-associated methicillin-resistant staph aureus (CA-MRSA). Individuals with diabetes are at higher risk for developing furuncles due to several factors, such as impaired immune response, increased skin dryness, and poor wound healing.

CASE REPORT

A 36-year-old male presented with multiple furuncles, in various stages, along with fever, headache, and a history of a seizure episode 1 week prior. Patient has been noncompliant to both antidiabetic and antihypertensive medications.

Past history

The patient had repeated episodes of furunculosis in the past, with the last episode 1 month back. He was diagnosed with diabetes mellitus 10 years ago, hypertension 1 year ago, and chronic kidney disease 2 months prior, not on hemodialysis. He has been noncompliant to his medications.

• Personal history: The patient is a known alcoholic and smoker for the last 16 years

• Family history: No family history of diabetes mellitus or any other significant family history.

Laboratory investigations

Lab Investigation	Patient value (with reference interval)
Hb	8.7 g/dL
TLC	12,800 cells/mm3
Neutrophils	84%
Lymphocytes	14%
Monocytes	2%
Platelets	1.7 lac/mm3
Hematocrit	25%
MCV	69.8 fL
BSL on admission	312 mg/dL
HbA1c	9%
Urea	60 mg/dL
Creatinine	2.4 mg/dL
LFT	Normal
Iron studies	Adjacent to iron studies
Iron	21 µg/dL (65–175)
TIBC	195 µg/dL (250–425)
Transferrin saturation	10.7 (20%–50%)
Ferritin	536 ng/mL (4.63–204)
Serum Calcium	7.4 mg/dL
Serum Vitamin D3	15.5
Urine RM	Protein 2+ (24 h urinary proteins=3208)
C3/C4 (complements)	108/62.7
ANA by IF	Weak positive, nucleoplasm, Granular, 1:100
Swab culture	From right thigh wound: MRSA was isolated

TLC=Total leukocyte count, Hb=Hemoglobin, MCV=Mean corpuscular volume, BSL=Blood Sugar Levels, HbA1c=Glycated hemoglobin, LFT=Liver function tests, TIBC=Total iron binding capacity, ANA=Antinuclear antibody, IF=Immunofluorescence, MRSA=Methicillin-resistant Staphylococcus aureus

Radiological imaging

Radiological Investigation	Finding
USG (A + P)	Bilateral mildly raised renal cortical echogenicity
Renal artery Doppler study	Normal
USG local (right thigh swelling)	Few ill-defined small pockets of collection with internal dense echoes in the subcutaneous plane on the lateral aspect of the right mid-thigh region, with minimal peripheral vascularity-likely suggestive of abscess
ECG	Changes suggestive of LVH
2D echo	Mild concentric LVH, ejection fraction 60%, Grade 2 diastolic dysfunction
MRI brain	Suggestive of chronic ischemic changes

LVH=Left ventricular hypertrophy, MRI=Magnetic resonance imaging, ECG=Electrocardiogram, USG=Ultrasound sonography

General examination

Pulse was 80 beats/min, blood pressure 230/120 mmHg, respiratory rate 16 breaths/min, and saturation 97% on room air.

Pallor was present, along with bilateral lower limb edema and facial puffiness.

There were multiple furuncles present over bilateral lower limbs [Figure 1], with a few of them being purulent [Figure 2]. The largest lesion was a carbuncle [Figure 3], measuring 4 cm × 3.5 cm, located over the lateral aspect of the right thigh.

Figure 1.

At presentation, multiple lesions of diabetic dermatopathy spectrum, present over bilateral lower limbs, in various stages of healing

Figure 2.

A purulent furuncle, located over lateral aspect of the left thigh

Figure 3.

A carbuncle present over lateral aspect of the right thigh

Systemic examinations were unremarkable.

Diagnosis

Uncontrolled diabetes mellitus with accelerated hypertension with diabetic nephropathy, with calcium and Vitamin D deficiency, and iron deficiency anemia with multiple furunculosis.The patient did not require dialysis, and creatinine remained stable at around 2 mg/dL.

Follow-up

Patient is on regular follow-up, furuncles have showed good healing [Figure 4], and there has been no further admission to the hospital.

Figure 4.

Same lesion as in Figure 3, healed posttreatment

DISCUSSION

• Furunculosis caused by S. aureus/MRSA has been studied by various researchers, common in diabetics, type 2 more than type 1. Furunculosis can be chronic, repetitive, and cause a lot of morbidity, and hence, appropriate antibiotic treatment and good skin hygiene are essential

• El-Gilany and Fathy conducted a study for recurrent furunculosis in a hospital in Egypt[1] and reported that most of these patients had nasal carriage of S. aureus, which acts as a reservoir and, in susceptible patients, leads to furunculosis by MRSA organisms. Among the risk factors for developing recurrent furunculosis were diabetes, poor hygiene, and iron deficiency anemia. Our patient had diabetes and iron deficiency anemia, post control of which, the patient had no recurrence of furunculosis

• Demos et al.[2] in their review of recurrent furunculosis found CA-MRSA infections to be associated with a toxin “Panton–valentine–leukocidin (PVL)”

  The same PVL toxin was also reported by Ibler and Kromann[3] in CA-MRSA from Europe

  Jaiswal et al.[4] and Bethe et al.[5] also discuss the significance of PVL, a toxin produced by some strains of S. aureus which slows down leukocyte migration and hence phagocytosis

• Ramakrishnan, et al. in their review[6] spoke of multiple lesions in Diabetic individuals, for example, there may be furuncle: A walled-off collection of pus, painful and firm with systemic features of infection. In the same patient, at the same time, there may be a carbuncle: larger, deeper lesion, involving skin, subcutaneous tissue, and draining through multiple pores. Our patient had both multiple furuncles over both lower limbs and a carbuncle over the lateral aspect of the right thigh

• Mendes et al.[7] also discuss diabetes mellitus and skin, and a condition called bullous diabeticorum which has painless nonpruritic blisters as the main manifestation and is common in patients of diabetes and renal failure. Another condition seen in diabetics on insulin is necrobiosis lipoidica, a painful ulcerative lesion thought to be a manifestation of autoimmune vasculitis in diabetes, and responds to symptomatic treatment, steroids, and emollients. Our patient had diabetic nephropathy and painful furuncles, and a carbuncle

• Edwards et al.[8] in their review of Diabetic manifestations describe patients with carbuncles, bullous erysipelas, and perifollicular abscesses as manifestations of colonization by MRSA

• David et al.[9] and Linz et al.[10] in their overview of complications and prevention of skin conditions in diabetes, they discuss the role of aggressive specific antibiotic therapy. For MRSA, they recommend vancomycin, linezolid initially, and later step-down to tetracyclines, trimethoprim-sulfamethoxazole. For prevention, they recommend application of Mupirocin ointment in the anterior nares which are common sites of Staphylococcus colonization.

  Our patient was treated with antibiotics, local application of mupirocin, and insulin for diabetes control.

Treatment given in hospital

Treatment given	Drugs
Systemic antibiotics	Injection piperacillin–tazobactam (2.25 g – IV – OD) Later switched to injection linezolid (600 mg – IV – BD)
Local antibiotic	Mupirocin (2% w/w) ointment for local application over furuncles
Insulins	Injection aspart (4 units – s/c – TDS) Injection glargine (8 units – s/c – HS)
Antiepileptic	Tablet levetiracetam (500 mg – IV – BD) continued
Antihypertensives	Tablet nifedipine (30 mg – p/o-TDS) Tablet moxonidine (0.3 mg – p/o – BD) Tablet metoprolol (50 mg – p/o – BD) Tablet prazosin (7.5 mg – p/o – TDS)
Iron deficiency	Corrected with IV iron – 1000 mg of ferric carboxy maltose, followed by oral iron supplements
Calcium and Vitamin D supplements	Tablet calcium carbonate 500 mg + Vitamin D3 250 IU daily capsule cholecalciferol 60,000 IU once a week

IV=Intravenous w/w=weight/weight, s/c=subcutaneous, p/o=per oral, IU=International Units

CONCLUSION

Diabetes with furunculosis is a difficult-to-treat condition, especially when repetitive. Our patient, who had been repeatedly admitted for the same, did respond to good control of diabetes, antibiotic treatment, local application of mupirocin, good personal hygiene, correction of iron deficiency anemia, and Vitamin D deficiency. The patient has been on regular follow-up with no further episodes of furunculosis postdischarge. Hence, the emphasis should be on good personal hygiene, tight control of blood sugar levels in diabetes, and treating all associated risk factors like iron deficiency anemia and Vitamin D deficiency.

Clinical implications

Diabetic individuals are prone to skin infections, one of them being furunculosis/boils caused by S. aureus, commonly the CA-MRSA strain, and these tend to happen repeatedly. Prevention would be the best strategy:

• Diabetic persons should maintain high level of personal hygiene, i.e., bathe every day with antiseptic soaps, wear loose-fitting, washed cotton clothes, and whenever they notice a boil under the skin, not to attempt to burst it, instead report to their doctor early

• Mupirocin application in the anterior nares to prevent nasal colonization by Staphylococci and emollient creams to keep skin moist also help prevent furunculosis

• All deficiencies, like iron and Vitamin C, D, and B12, should be corrected early

• Most important parameter is to keep good control over blood sugar levels.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.