Endgames Case Report

A patient with longstanding type 1 diabetes and a swollen, warm, and red foot

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7760 (Published 16 November 2012) Cite this as: BMJ 2012;345:e7760
  1. Nicholas Tentolouris, assistant professor of internal medicine 1,
  2. Frank L Bowling, podiatrist2,
  3. Edward B Jude, consultant diabetologist3
  1. 1Athens University Medical School, Athens, Greece
  2. 2Central Manchester University Hospitals and University of Manchester, Manchester, UK
  3. 3Tameside Hospital NHS Foundation Trust and University of Manchester, UK
  1. Correspondence to: E B Jude, Tameside Hospital NHS Foundation Trust, Ashton under Lyne, OL6 9RW, UK Edward.jude{at}tgh.nhs.uk

A 54 year old man with type 1 diabetes since the age of 13 years was referred to the diabetic foot clinic with a warm swollen right foot of seven days duration. Over the past four years he had had acceptable diabetes control and an average glycated haemoglobin of 57 mmol/mol (7.4%). He had a history of hypertension, microalbuminuria, and background diabetic retinopathy. He did not remember any trauma to his foot, had only mild pain in the affected area, and had no signs or symptoms of systemic infection.

On examination, his right foot was swollen and erythematous over the dorsal aspect. No active foot ulceration or cracked skin was present. He had symmetrical peripheral sensorimotor neuropathy, with loss of protective sensation (inability to feel the 10 g Semmes-Weinstein monofilament, also known as 5.07 gauge monofilament nylon fibre) and intact circulation in both feet.

Questions

  • 1 What is the diagnosis?

  • 2 How would you confirm the diagnosis?

  • 3 How would you manage this patient?

Answers

What is the diagnosis?

Short answer

Acute Charcot neuropathic osteoarthropathy (or acute Charcot foot) should always be considered when a person with diabetes and peripheral neuropathy develops unexplained inflammation in the foot. Refer the patient for urgent diagnosis or exclusion by an expert team. Meanwhile, urge the patient to limit weight bearing on the affected foot until he or she has been assessed.1 2

Long answer

Acute Charcot neuropathic osteoarthropathy (or acute Charcot foot) should always be considered when a person with diabetes complicated by peripheral neuropathy develops unexplained inflammation in the foot. Refer the patient for urgent diagnosis or exclusion by an expert team.1 2 Meanwhile, urge the patient to limit weight bearing on the affected foot until he or she has been assessed. Other potential diagnoses include sprain, cellulitis, deep venous thrombosis, and gout.1 2 3

The classic description of …

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