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Case Illustration

A 57 year old female came to ER with worsening fatigue over the past 48 hours.
She denied any history of fainting nor did she experience any symptoms of
giddiness. There were no complaints of nausea or vomiting, but she told the ER
physician she ate almost nothing for the last 2 days. Any symptoms of increased
body temperature, productive cough, difficulty in breathing, weight loss were
also denied.

The patient had been admitted to Hospital twice due to non-healing wound on
her left foot, with the last admission was 1 month before current ER visit. She did
not experience any pain on her left foot, however she could not stand with both
her feet properly, she needed assistance to be able to walk.
Significant past medical history was uncontrolled Diabetes Mellitus since more
than 10 years, the patient received rapid acting insulin treatment (4
International Units, every 8 hours by subcutaneous injection) after the last
admission.

On physical examination, vital signs were normal, lung, heart, and abdominal
examinations were normal. Distal extremity findings were rocker-bottom left
foot deformity (Figure 1) and deep ulcer extending to tarsal bones without
gangrenous toes (Wagner IV) (Figure 2 and 3).

Routine laboratory findings were as follows : Hemoglobin 8,3 g/dL, White Blood
Cells 15.500 /μL, Hematocrit 28%, Thrombocyte count 589.000 /μL, AST 11 U/L,
ALT 28 U/L, BUN 62 mg/dL, Serum Creatinine 1,0 mg/dL, Natrium 134 mmol/L,
Kalium 3,7 mmol/L, Serum Albumin 1,3 g/dL, Clotting and bleeding time within
normal limits. HbA1c level was 6,2%, peripheral blood smear showed Anemia
due to chronic disease.

The patient underwent several radiograph examinations including chest and left
foot X-Ray. Chest X-Ray showed normal lung and heart (Figure 4), while evidence
of PIP joint digit III, IV, V destruction with bone debris and subchondral sclerosis
at Proximal phalanges IV, V, metatarsal bones II, IV, V of the left foot were visible
from AP and Oblique projection (Figure 5 and 6). Pencil point deformity on 4th
and 5th left digits alongside with destruction of distal Tibia and Fibula, all the
evidence leading to Osteomyelitis radiographic appearance and Charcot Joint
deformity of the left foot.

Surgical consultation was done and surgical debridement was planned.


Intravenous Cefoperazone 1 gram q12h was given since day one, two Packed
Red Cells were transfused, patient received 4 Units of subcutaneous Rapid Acting
Insulin q12h initially, but stopped on the 4th day of admission due to
hypoglycemia, for correction of hypoalbuminemia, a total of 9 flasks of 20%
human albumin were given before and after surgical debridement.

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