Acute Charcot neuropathy: A devastating consequence of diabetes mellitus

INTRODUCTION: Acute Charcot neuropathy (ACN) is a complication of diabetes mellitus. The prevalence of ACN may be up to 13% in diabetic individuals. ACN has a complex etiology. Although it mostly affects middle of the foot, hind-foot joints, the ankle, and forefoot joints; upper limp may also be affected. Here, we present a case with ACN, whose diagnosis was hard to differentiate and manage. CLINICAL CASE: A fifty-nine-year-old female admitted to our emergency department with a complaint of pain, numbness, swelling, edema and erythema on left arm. When questioned, she had a history of type 2 diabetes for 22 years and had impaired glycemic regulation with 12.2% HbA1c level. She had all macro and micro vasculary complications of diabetes. On physical examination, her left arm was swollen, pulses were not palpabl. With a suspicion of acute thromboembolism, doppler ultrasound was performed and USG showed no arterial occlusion, but thrombosis from the basilic vein to the proximal brachial vein was seen. She initiated anticoagulant therapy with heparin. After 2 weeks, her complaints increased and pallor, coldness, and pain with passive movements on the left arm were added. She admitted to our intensive care unit with a diagnosis of compartment syndrome. She was followed in ICU with stable hemodynamics and without oxygen supplementation. She had transient acute kidney injury due to rhabdomyolysis but resolved without hemodialysis. Despite fasciotomy, myonecrosis developed on left arm and transhumeral resection was performed. After this devastating result, the patient transferred to endocrinology clinic. Intensive insulin therapy and appropriate antibiotic treatment were continued. During her stay in our clinic, she had the same complaints and physical examination findings on her left foot. Imaging studies (X-ray, bone scintigraphy) showed no osteomyelitis but acute charcot arthropathy was seen. Her glucose levels were regulated, and antibiotics completed. The physical strengthening and ROM exercises for lower extremity and oral total calorie intake was adjusted. Her HbA1c level was decreased to 6.2% without hypoglycemia and she is stable on follow-up. CONCLUSION: ACN is a devastating complication of diabetic neuropathy with its consequences. The diagnosis may mislead clinicians to cellulitis, acute venous thrombosis, arthritis or gout. Misdiagnosis or delay in diagnosis may result in serious consequences such as infection, ulceration even amputation as in our case. A multidisciplinary approach and close monitoring of the findings may provide huge benefit for the patient.