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CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 4  |  Page : 308-310

Rheumatological manifestation of diabetes: “Namaste” sign


Department of General Medicine, JSS Medical College, Jss Academy of Higher Education (Deemed to be University), Mysuru, Karnataka, India

Date of Web Publication10-Jan-2019

Correspondence Address:
Dr. N Jeswanth Reddy
Flat No-304, Gowrav Residency, K R Mohalla, Lakshmipuram, Mysore - 570 025, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_108_17

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  Abstract 


In addition to the well-known complications such as neuropathy, nephropathy, retinopathy, diabetes mellitus can also result in a variety of rheumatologic manifestations, some of which can significantly affect a patient's quality of life. Diabetic cheiroarthropathy (DCA), which affects the hands clinically, manifests as painless limited extension of the 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. This is the so-called “Namaste” or “Prayer” sign. This sign gives an indication of metabolic control of diabetes and microvascular disease. We hereby report a middle-age male patient admitted for fever and was incidentally found positive for this sign. Fundoscopy revealed nonproliferative diabetic retinopathy and there was microalbuminuria. The diagnosis is mainly clinical. It is imperative for clinicians to remember that the presence of DCA carries with it a significant relationship with microvasculopathy.

Keywords: Diabetic joint disorder, diabetic stiff hand, hands in diabetes


How to cite this article:
Mahesh M, Reddy N J, Mamatha S, Madhumitha M. Rheumatological manifestation of diabetes: “Namaste” sign. J NTR Univ Health Sci 2018;7:308-10

How to cite this URL:
Mahesh M, Reddy N J, Mamatha S, Madhumitha M. Rheumatological manifestation of diabetes: “Namaste” sign. J NTR Univ Health Sci [serial online] 2018 [cited 2019 Jan 17];7:308-10. Available from: http://www.jdrntruhs.org/text.asp?2018/7/4/308/249820




  Introduction Top


The syndrome of limited joint mobility, diabetic sclerosis, pseudosclerodermatous hand of the diabetic, and diabetic stiff hand are some of the diagnostic terms used in medical literature that refer to diabetic cheiroarthropathy (DCA). It is usually characterized by painless limited extension of the 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.[1],[2] A tight waxy skin surface on the dorsum of the hand usually completes the clinical picture.[3]

DCA occurs in both type 1 and type 2 diabetes mellitus. Some reports suggest an overall prevalence of 30%,[1] while other studies give prevalence ranging from 8 to 50%.[4],[5]


  Case Report Top


A middle-aged male with a 12-year history of type 2 diabetes mellitus was admitted with a diagnosis of uncomplicated urinary infection. During the routine clinical examination, he was found to have incomplete approximation of the digits when he attempted to approximate the palmar surfaces of the proximal and distal interphalangeal joints with palms pressed together and the fingers abducted. He was thus unable to fold his hands in the posture of “welcome” or “prayer” or “namaste” (Namaste = Prayer/Welcome in Sanskrit) [Figure 1].
Figure 1: “Namaste”sign Note the incomplete approximation of the digits when the patient attempted to approximate the palmar surfaces of the proximal and distal interphalangeal joints with palms pressed together

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There was no history of dysphagia, dry eyes, and dry mouth. He denied any changes in the color of his fingers with cold weather. There was no family history of rheumatological disease. There was no evidence of Dupuytren's contracture. Carpal tunnel syndrome was ruled out with negative Tinel's and Phalen's tests. There was no flexor tenosynovitis as evidenced by the absence of palpable crepitus. In view of the above features, DCA was diagnosed clinically.

The glycosylated hemoglobin (HbA1c) was 10.5%. Erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, and collagen vascular workup were normal. He had nonproliferative diabetic retinopathy and microalbuminuria.


  Discussion Top


DCA was initially described in patients with type 1 diabetes[6],[7] but has now been shown to occur in patients with type 2 diabetes mellitus as well. Some authors suggest that it occurs more frequently in type 1 diabetes because of the longer duration of their diabetes.[8]

The genesis of the DCA is multifactorial. One possible mechanism is that the hyperglycemia facilitates glycosylation and crosslinking of collagen. Hence, the collagen proliferates extensively in the skin, subcutaneous tissues, tendons, muscles, and periarticular tissue. These collagen fibers become stiffer. Furthermore, there is decreased collagen degradation. There is ongoing diabetic microangiopathy of the skin and subcutaneous vessels and also thickening of capillary basement membranes. As a consequence, there is low-grade ischemia of the tissues, resulting in fibrosis manifesting as tight waxy skin over the digits. The epidermis and dermis are microscopically deficient in normal skin architecture because of the ischemia.[9]

Rosenbloom et al.[7] demonstrated a strong association between the increasing severity of joint limitation and the increased prevalence of microvascular disease in type 1 diabetes mellitus. They reported a three-fold risk of clinically apparent microvascular disease in patients with DCA. They concluded that limited joint mobility identifies a population that is at increased risk for early-onset microvasculopathy. Subsequent studies have supported this finding.[10],[11] Our patient had evidence of nonproliferative retinopathy, in addition to nephropathy at the time when he presented with symptoms related to her hands.

With improved glycemic control, the symptoms and signs can be ameliorated. Treatment is aimed at good glycemic control with the usage of nonsteroidal antiinflammatory drugs and physiotherapy. If instituted early, treatment can improve patients' symptoms or reverse the clinical picture altogether. Early diagnosis can allow the clinician to make the link with microvascular complications and intervene accordingly.[12]

This case has been reported to emphasize the importance of recognizing this sign, which is easily elicitable if looked for and which gives valuable information regarding patients glycemic control and presence of other significant complications of diabetes.


  Conclusion Top


It is important that clinicians be aware of diabetic cheiroarthropathy and its close relationship with metabolic control of diabetes and microvasculopathy. Patients with diabetes mellitus can be quickly screened for the classic signs of DCA.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fitzcharles MA, Duby S, Waddell RW, Banks E, Karsh J. Limitation of joint mobility (cheiroarthropathy) in adult noninsulin-dependent diabetic patients. Ann Rheum Dis 1984;43:251-4.  Back to cited text no. 1
    
2.
Akanji AO, Bella AF, Osotimehin BO. Cheiroarthropathy and long term diabetic complications in Nigerians. Ann Rheum Dis 1990;49:28-30.  Back to cited text no. 2
    
3.
Knowles HB. Joint contractures, waxy skin, and control of diabetes. N Engl J Med 1981;305:217-9.  Back to cited text no. 3
    
4.
Douloumpakas I, Pyrpasopoulou A, Triantafyllou A, Sampanis C, Aslanidis S. Prevalence of musculoskeletal disorders in patients with type 2 diabetes mellitus: A pilot study. Hippokratia 2007;11:216-8.  Back to cited text no. 4
    
5.
Attar SM. Musculoskeletal manifestations in diabetic patients at a tertiary center. Libyan J Med 2012;719162.  Back to cited text no. 5
    
6.
Lundbaek K. Stiff hands in long-term diabetes. Acta Med Scand 1957;158:447-51.  Back to cited text no. 6
    
7.
Rosenbloom AL, Silverstein JH, Lezotte DC. Limited joint mobility in childhood diabetes mellitus indicates increased risk for microvascular disease. N Engl J Med 1981;305:191-4.  Back to cited text no. 7
    
8.
Pal B, Anderson J, Dick WC, Griffiths ID. Limitation of joint mobility and shoulder capsulitis in insulin- and non-insulin-dependent diabetes mellitus. Br J Rheumatol 1986;25:147-51.  Back to cited text no. 8
    
9.
Buckingham B, Perejda AJ, Sandborg C, Kershnar AK, Uitto J. Skin, joint, and pulmonary changes in type I diabetes mellitus. Am J Dis Child 1986;140:420-3.  Back to cited text no. 9
    
10.
Lawson PM, Maneschi F, Kohner EM. The relationship of hand abnormalities to diabetes and diabetic retinopathy. Diabetes Care 1983;6:140-3.  Back to cited text no. 10
    
11.
Rosenbloom AL. Limited joint mobility in childhood diabetes: Discovery, description, and decline. J Clin Endocrinol Metab 2013;98:466-73.  Back to cited text no. 11
    
12.
Lister DM, Graham-Brown RAC, Burden AC. Resolution of diabetic cheiroarthropathy. Br Med J 1986;293:1537.  Back to cited text no. 12
    


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Abstract
Introduction
Case Report
Discussion
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