Resident Physician HonorHealth Scottsdale, Arizona, United States
Case Diagnosis: Charcot neuroarthropathy
Case Description: A 75-year-old woman with poorly controlled type 2 diabetes and peripheral neuropathy presented to the ED with a swollen, painful right foot, initially diagnosed as cellulitis. An MRI revealed a fluid collection, drained without bacterial growth. She was treated with IV clindamycin and discharged on oral antibiotics. After traveling, her symptoms worsened, and a repeat MRI suggested osteomyelitis. Treated with vancomycin, she developed acute renal failure. A physical exam revealed severe foot deformities, and CT confirmed advanced Charcot neuroarthropathy (CN). She was eventually diagnosed with CN and end-stage renal disease, requiring hemodialysis and surgery. This case highlights the critical need for early recognition of CN in diabetic patients with advanced neuropathy, as the missed diagnosis led to kidney injury and worsening foot damage.
Discussions: CN is a significant cause of morbidity, underscoring the importance of early diagnosis. Studies suggest that combining neurologic tests with a detailed patient history—especially noting retinopathy, nephropathy, and previous foot ulcers—is effective in identifying high-risk CN patients, while vascular exams are less predictive. Misdiagnosis, as shown in several studies, often leads to severe complications, including fractures and the need for major amputation, emphasizing the necessity for early diagnosis, treatment, and referral.
Conclusions: As obesity and diabetes rates rise, CN is becoming more prevalent, making timely diagnosis increasingly important. Diagnosing CN can be challenging due to its similarity to other conditions, but it should always be considered in diabetic patients with peripheral neuropathy presenting with foot edema, redness, and warmth, particularly if pain is absent. Immediate immobilization and non-weight-bearing are crucial until orthopedic follow-up. A multidisciplinary approach, with collaboration between emergency physicians, orthopedic surgeons, and physiatrists, is essential to optimize outcomes for patients with this complex condition.
