Case history
Case history #1
A 62-year-old man with diabetes mellitus presents with a 3-day history of progressive left foot swelling, redness, and malaise. He reports noticing a blister on his forefoot several months ago after he started wearing work boots for a new job. He has dressed the area daily with bandages; however, the area has not healed. He also has a history of sensory neuropathy, chronic kidney disease (stage 2), and hypertension. He is a smoker (1 pack per day). Physical exam is notable for fever (100.6°F [38.1°C]) and mild tachycardia (pulse rate of 105 bpm). There is a malodorous left foot ulcer overlying the first metatarsophalangeal joint. Fluctuance and blanching erythema extends 4 cm beyond the ulcer border. The remaining areas of the foot and ankle are notable for moderate pitting edema. The dorsalis pedis pulse is palpable.
Case history #2
A 70-year-old man presents with a 3-month history of a non healing foot ulcer. He is unsure how it began. He reports seeing a podiatrist once in the past, but failed to return for follow-up care. His medical history is notable for diabetes mellitus, remote stroke without residual neurologic deficit, laser photocoagulation for retinopathy, and two previous percutaneous coronary interventions following myocardial infarcts. He stopped smoking cigarettes 3 years ago. Physical exam is notable for a plantar forefoot ulcer beneath the second metatarsal head. There is no associated erythema, swelling, or foul odor. No pedal pulses are palpable.
Other presentations
Patients with Charcot neuro-osteoarthropathy with midfoot collapse may develop ulcers and infections in the midfoot that are associated with structural abnormalities. Heel ulcers occur less frequently in ambulatory patients, and are often due to decubitus pressure in nonambulatory patients debilitated by previous stroke. Leg/calf ulcers (occurring between the knee and the malleoli at the ankle) are generally due to chronic venous insufficiency. Occasionally, infections are initiated by a puncture wound rather than ulceration from repetitive trauma.[Figure caption and citation for the preceding image starts]: Midfoot ulcer in a patient with Charcot neuro-osteoarthropathy (midfoot collapse)From the collection of Dr Neal R. Barshes; used with permission [Citation ends].
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