Mr. L, aged 53 years, with a history of recently diagnosed type 2 diabetes mellitus (DM), presented to the foot clinic with a one month history of left foot swelling, redness, and warmth. He was referred by his internist after not responding to various oral antibiotics prescribed for further evaluation and management.
The patient denied any recent or past trauma to his left foot or nausea, vomiting, fever, diaphoresis, chills, palpitations, or shortness of breath for the past month. His work requires him to be on his feet most of the time, and Mr. L was anxious for his foot to recover.
The patient’s medical history included class I obesity, hypertension, hyperlipidemia, recently diagnosed type 2 DM for four years. He had smoked half a pack of cigarettes per day for 15 years. Mr. L attempted unsuccessfully to quit smoking previously without use of smoking cessation medications. He denied any past surgical history.
The patient’s medication profile included amoxicillin and clavulanic acid (Augmentin) 875 mg by mouth twice daily, metformin 500 mg by mouth twice daily, simvastatin 20 mg by mouth twice daily, and enalapril 10 mg by mouth twice daily.
Mr. L reported that he did not perform glucose self-monitoring at home and was unaware of his glycemic control. However, he denied symptoms of hyperglycemia including polyuria, polydipsia, and blurred vision.
His internist provided recent labs performed 11 days prior, and a left foot MRI performed four days prior with the following results:
- Hemoglobin A1C (HbA1c): 7.4%
- Basic Metabolic within normal limits (blood urea nitrogen (BUN) 17, creatinine 1, glucose 94)
- Complete Blood Count (CBC) with Differential within normal limits (white blood count was 6.5)
- Liver function tests within normal limits
- Magnetic resonance imaging (MRI)
Left foot dorsal dislocation of the cuneiforms and dorsal and lateral dislocation of the 4th and 5th metatarsals with high grade tear of the posterior tendon proximal to the navicular.
- Vital Signs: 130/74, 82, 20, 98.6F
- Weight: 235 pounds
- Height: 6’1”
- Body mass index: 31
A focused examination revealed an obese man without signs of distress. The patient was alert, oriented, and conversant. Bilateral lower extremity with palpable pedal pulses, dorsalis pedis, and posterior tibial pulses two plus equally, capillary refill less than two seconds, bilateral calf soft and nontender to palpation, bilateral groin nonpalpable lymph nodes.
The patient’s left foot was warm to touch, whereas his right foot had a tactile temperature within normal limits. The skin temperature on his left foot was six degrees Celsius warmer than the right foot. Left foot with two plus nonpitting edema and no erythema. Right foot no edema or erythema. Bilateral foot with skin intact. Absent monofilament forefoot 4/10 bilaterally, indicated diminished sensation.
The patient was diagnosed with acute Charcot arthropathy (CN) of the left foot.