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M Horsey, P Hogan, and T Oliver

-year-old Caucasian female was seen in our Emergency Department with a chief complaint of progressive right leg pain, edema and erythema over the course of 1week ( Fig. 1 ). Her past medical history was significant for hypothyroidism, a DVT in the right

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Jingjing Jiang, Mei Zhang, Ronghua He, Meiping Shen, and Wei Liu

palpable in the left anterior neck, elastic and smooth was identified. She had erythema on her face and both hands. Velcro rales were heard at both lower lobes of the lungs. There was slight edema on both legs. Investigation Initial laboratory tests

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Daphne Yau, Maria Salomon-Estebanez, Amish Chinoy, John Grainger, Ross J Craigie, Raja Padidela, Mars Skae, Mark J Dunne, Philip G Murray, and Indraneel Banerjee

episodes of sepsis secondary to central line infections, necrolytic migratory erythema from glucagon infusion and raised transaminases from octreotide. Pancreatectomy was performed at 3 months of age due to refractoriness to medical therapy but

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Arshiya Tabasum, Ishrat Khan, Peter Taylor, Gautam Das, and Onyebuchi E Okosieme

goiter. Her visual acuity was 5/6 in both the eyes. She had fullness of her eyelids on the right side with erythema below the right inferior orbital rim. She had right eye proptosis and diplopia on vertical gaze but with no lid lag or retraction. Her

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Anna Luiza Galeazzi Rech, Yvon Stüve, Andreas Toepfer, and Katrin E Schimke

to the MTP fifth joint on the right did not show adequate progress. However, the patient was not disturbed by this at all. He was complaining about severe pain in his left foot, strongly affecting his mobility. Other than mild erythema, moderate

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Aishah Ekhzaimy, Afshan Masood, Seham Alzahrani, Waleed Al-Ghamdi, Daad Alotaibi, and Muhammad Mujammami

physical examination revealed the presence of an extensive facial rash not sparing the nasal folds. He also had periorbital erythema with edema (heliotrope rash), erythematous papular lesions on the knuckles (Gottron papules), and decreased muscle tone in

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Yael Lefkovits and Amanda Adler

Summary

Necrobiosis lipoidica diabeticorum (NLD) is a chronic granulomatous dermatitis generally involving the anterior aspect of the shin, that arises in 0.3–1.2% of patients with diabetes mellitus (). The lesions are often yellow or brown with telangiectatic plaque, a central area of atrophy and raised violaceous borders (). Similar to other conditions with a high risk of scarring including burns, stasis ulcers and lupus vulgaris, NLD provides a favourable environment for squamous cell carcinoma (SCC) formation (). A number of cases of SCC from NLD have been recorded (, , ); however, our search of the literature failed to identify any cases of either metastatic or fatal SCC which developed within an area of NLD. This article describes a patient with established type 1 diabetes mellitus who died from SCC which developed from an area of NLD present for over 10 years. Currently, there are a paucity of recommendations in the medical literature for screening people with NLD for the early diagnosis of SCC. We believe that clinicians should regard non-healing ulcers in the setting of NLD with a high index of clinical suspicion for SCC, and an early biopsy of such lesions should be recommended.

Learning points:

  • Non-healing, recalcitrant ulcers arising from necrobiosis lipoidica diabeticorum, which fail to heal by conservative measures, should be regarded with a high index of clinical suspicion for malignancy.
  • If squamous cell carcinoma is suspected, a biopsy should be performed as soon as possible to prevent metastatic spread, amputation or even death.
  • Our literature search failed to reveal specific recommendations for screening and follow-up of non-healing recalcitrant ulcers in the setting of necrobiosis lipoidica diabeticorum.
  • Further research is required in this field.
Open access

Alessandro Mantovani, Maddalena Trombetta, Chiara Imbriaco, Riccardo Rigolon, Lucia Mingolla, Federica Zamboni, Francesca Dal Molin, Dario Cioccoloni, Viola Sanga, Massimiliano Bruti, Enrico Brocco, Michela Conti, Giorgio Ravenna, Fabrizia Perrone, Vincenzo Stoico, and Enzo Bonora

Summary

Vertebral osteomyelitis (or spondylodiscitis) is steadily increasing in Western countries and often results from hematogenous seeding, direct inoculation during spinal surgery, or contiguous spread from an infection in the adjacent soft tissue. We present the case of a 67-year-old white patient with type 2 diabetes who went to Hospital for high fever, back pain, and worsening of known infected ulcers in the left foot. Despite intravenous antibiotic treatment and surgical debridement of the foot infection, high fever and lower back pain continued. Bone biopsy and two consecutive blood cultures were positive for Staphylococcus aureus. A spinal magnetic resonance imaging (MRI) was performed, revealing serious osteomyelitis in L4 and L5 complicated by an epidural abscess. Contiguous or other distant focuses of infection were not identified. In this case, diabetic foot could be considered as a primary distant focus for vertebral osteomyelitis. Clinicians should consider vertebral osteomyelitis as a ‘possible’ diagnosis in patients with type 2 diabetes complicated by foot infection that is associated with fever and lower back pain.

Learning points

  • Vertebral osteomyelitis is increasing in Western countries, especially in patients with type 2 diabetes.
  • The primary focus of infection is the genitourinary tract followed by skin, soft tissue, endocarditis, bursitis, septic arthritis, and intravascular access.
  • Diabetic foot could be a rare primary focus of infection for vertebral osteomyelitis, and, however, vertebral osteomyelitis could be a serious, albeit rare, complication of diabetic foot.
  • Clinicians should keep in mind the many potential complications of diabetic foot ulcerations and consider vertebral osteomyelitis as a “possible” diagnosis in patients with type 2 diabetes and foot ulcers associated with nonspecific symptoms such as lower back pain.
  • Early diagnosis and correct management of vertebral osteomyelitis are crucial to improve clinical outcomes.

Open access

Benjamin G Challis, Nicolai J Wewer Albrechtsen, Vishakha Bansiya, Keith Burling, Peter Barker, Bolette Hartmann, Fiona Gribble, Stephen O'Rahilly, Jens J Holst, and Helen L Simpson

Background Pancreatic neuroendocrine tumours (pNETs) that secrete glucagon are associated with well-recognised clinical features of the glucagonoma syndrome including necrolytic migratory erythema (NME), weight loss, diarrhoea, anaemia

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Michal Barabas, Isabel Huang-Doran, Debbie Pitfield, Hazel Philips, Manoj Goonewardene, Ruth T Casey, and Benjamin G Challis

particularly affected the legs, perineum and lower back ( Fig. 1A ). The appearances were in keeping with necrolytic migratory erythema, prompting referral to endocrinology. Figure 1 Clinical and radiological features at diagnosis. (A) Representative