ESA-SRB-AOTA 2019

Bilateral acute Charcot neuroarthropathy in a young woman with type 1 diabetes, with concomitant osteoporosis and vitamin D deficiency (#599)

Kate Hawke 1 , Anna McLean 1 , Ashim Sinha 1
  1. Cairns Hospital, Cairns City, QLD, Australia

Charcot neuroarthropathy (CN) is a potentially devastating condition requiring early identification to reduce progression to long-term disability. The mean age in diabetes cohorts is 60 years, with male predominance (McEwen 2013). We describe a case of a young woman with acute CN with rapid sequential involvement of both feet.

A 32-year-old woman with type 1 diabetes mellitus presented with 24 hours of atraumatic left foot pain, swelling and bruising. Her background included a low-trauma radial head fracture.

The left foot had loss of longitudinal arch and diffuse swelling. Monofilament sensation was absent at the plantar 5th metatarsophalangeal joint and the lateral midfoot. The left foot was warmer at medial midfoot and lateral forefoot by 2.4 and 2.1 degrees Celsius, respectively.

Left foot Xray and MRI demonstrated past fracture of calcaneus and 1st and 2nd metatarsals.

We diagnosed acute CN, Brodsky 3b Eichenholtz 1 changes. Management was immediate left foot offloading. After four days, the contralateral foot developed bruising and pain. Right foot Xray showed old fractures of the 1st to 4th metatarsals.

Bone mineral density (BMD) was reduced for age. 25-hydroxy-vitamin D was 24nmol/L (reference 50-150nmol/L). This was treated with intramuscular vitamin D. Faecal pancreatic elastase was in the severe exocrine insufficiency range at 52ug/g (reference > 200ug/g). Bone markers were consistent with healing fractures, with elevated P1NP.

We report a case of bilateral acute CN with an underlying fracture pattern, in a patient with diabetes and osteoporosis. The relationship between BMD and CN is unclear (Rogers 2011, Zhao 2017). Reduced femoral neck BMD has been demonstrated in patients presenting with CN (Young 1995), but others have found no difference in baseline BMD between CN and matched non-CN patients (Jansen 2018). Fracture pattern CN (but not dislocation pattern) has been associated with a peripheral deficiency of BMD (Herbst 2004).

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