The aim of the present research was to study the prevalence and severity of vitamin D deficiency in patients with diabetic foot infection. Patients were enrolled in two groups: diabetic patients with foot infection (n 125) as cases and diabetic patients without the infection as controls (n 164). Serum 25-hydroxyvitamin D (25(OH)D) was measured by RIA. Data were presented as means and standard deviations unless otherwise indicated and were analysed by SPSS. Results revealed that 25(OH)D (nmol/l) was significantly lower (40·25 (SD 38·35) v. 50·75 (SD 33·00); P, 0·001) in cases than in controls. Vitamin D inadequacy (25(OH)D , 75 nmol/l) was equally common in cases and controls (OR 1·45, 95 % CI 0·8, 3·0; P¼ 0·32), but cases had a greater risk of vitamin D deficiency (25(OH)D , 50 nmol/l) than controls (OR 1·8, 95 % CI 1·1, 3·0; P¼ 0·02). Risk of severe vitamin D deficiency (25(OH)D , 25 nmol/l) was significantly higher in cases than in controls (OR 4·0, 95 % CI 2·4, 6·9; P, 0·0001). Age, duration of diabetes and HbA1c were significantly higher in cases than in controls and therefore adjusted to nullify the effect of these variables, if any, on study outcome. The study concluded that vitamin D deficiency was more prevalent and severe in patients with diabetic foot infection. This study opens up the issue of recognising severe vitamin D deficiency (,25 nmol/l) as a possible risk factor for diabetic foot infections and the need for vitamin D supplementation in such patients for a better clinical outcome. This could be substantiated by similar data from future studies.

Vitamin D has been recognised as a potent immunomodulator and its deficiency is common in different population groups including patients with diabetic foot infection. Diabetic foot infection reflects the altered immune status of the host. As cytokine regulation plays a significant role in infection and wound-healing processes, the present study aimed to evaluate the association between vitamin D status and inflammatory cytokine profiles in patients with diabetic foot infection. The serum concentrations of vitamin D (25-hydroxyvitamin D), IL-1b, IL-6, TNF-a and interferon-g (IFN-g) were measured in 112 diabetic foot infection cases and 109 diabetic controls. Severe vitamin D deficiency (25-hydroxyvitamin D concentration ,25 nmol/l) was more common in cases than in controls (48·2 v. 20·5 %). Although age, duration of diabetes, HbA 1C (glycosylated Hb) concentration and BMI were similar, cases had significantly higher concentrations of IL-6 (P#0·001), IL-1b (P# 0·02) and TNF-a (P# 0·006) than controls. A significant negative correlation was also observed between 25-hydroxyvitamin D concentration and circulating concentrations of IL-1b (r 2 0·323; P# 0·001) as well as IL-6 (r 20·154; P#0·04), but not between 25-hydroxyvitamin D and TNF-a and IFN-g concentrations. Furthermore, a significant difference in IL-1b (P# 0·007) and IL-6 (P# 0·02) concentrations was observed in patients with severe 25-hydroxyvitamin D deficiency compared with patients with 25-hydroxyvitamin D concentration $25 nmol/l, and this difference was remarkable for TNF-a. In conclusion, severe vitamin D deficiency is associated with elevated inflammatory cytokine concentrations in diabetic patients, particularly in those with foot infection. A 25-hydroxyvitamin D concentration value ,25 nmol/l is suggested as the 'cut-off' for such immunological alterations in patients with diabetes mellitus.