By Tedler D. Depaynos, MD

The male patient who came from a neighboring municipality arrived at the Emergency Room (ER) just after daylight. Initially, he was complaining of a wound at his right toe but when the Surgical MD examined the wound, it appeared to be healing well since it was sustained two weeks ago. The patient then showed his right inguinal area which had a large mass that appeared one week after his injury. He said that the mass was initially slightly tender but then the tenderness spontaneously disappeared despite the gradual enlargement of the mass. A week after its appearance, the mass became “reddish” and this was what made the patient rush himself into the ER.
The surgical MD noticed the mass to be “reddish”, non-tender and well circumscribed. He gave the impression of an enlarged lymph node or “lympadenopathy” due to the wound on the right big toe. The surgeon was wondering however why there was no tenderness despite its redness which may be a sign of inflammation. And to think that the patient claimed that he never took any medications!
In general, enlarged lymph nodes are non-tender but if there are signs of inflammation especially tenderness it is usually due to infection. In this case, the surgeon was made to think of other probable causes like Tuberculosis or malignancy although the lymph nodes of the former are usually located at the cervical area and the latter at the supraclavicular area. He however conditioned his patient that a biopsy is in order but first an ultrasound (UTZ) on his right inguinal area should be done. Meanwhile massive antibiotics were given.
The UTZ revealed “several enlarged lymph nodes”, some probably inflamed with “abscess formation”. A very elevated white blood cells (WBC) count result was in consonance with the infection. What was very significant, however, was the massive “glucose” in the patient’s urine which implied diabetis mellitus (DM). More specific lab tests were then done which confirmed the impression.
The patient never knew that he has “uncontrolled diabetis”. He was then referred to Internal Medicine MDs for treatment who also opined that maybe the diabetis is the cause of his enlarging inguinal lymph nodes even though the infection in his left big toe is already controlled. His untreated DM probably lessened his resistance.
DM is a very insidious disease. Patients usually do not feel anything until complications occur usually after 5 to 10 years of being diabetic. And when they occur usually they are irreversible. In this patient, his uncontrolled diabetis was probably making his resistance to ordinary diseases go down.
When the patient was about to be scheduled for surgery, it was observed that the redness and size of the palpable mass has lessened. The massive antibiotics were working fine. This was very obvious to the patient so that he refused to undergo surgery and requested to be discharged with a promise to take his antibiotics diligently at home. He also promised to return for check up regularly for the treatment of his DM he never thought of having. Because of the good response the attending MDs agreed to a conservative management and out-patient treatment.
One of the attending MDs later mentioned that the patient was very uncomfortable in the hospital. It was over flowing with patients and there was no room available so that he was admitted in the corridor where a bed was provided. Practically there was no privacy so he preferred to be at home if possible. He was so joyous that the antibiotics were very effective. **