Beyond the Expected: Early-onset Charcot Neuroarthropathy in a Young Diabetic Female

Charcot neuroarthropathy (CN) is a progressive destructive joint disease where both nerve and joint damage occurs. It results from various causes, including trauma, exposure to toxic substances, rheumatoid arthritis, and metabolic disorders such as diabetes.[1] Recently, its incidence among diabetic cases has increased significantly from 7% to 37%. The CN may present in acute or chronic phases and may sometimes be mixed, as in the current case.[2] Patient classification is essential, and it relies on clinical and radiological presentation, including: The prodromal phase (Stage 0) is the acute stage where only clinical signs are seen on the local examination, such as edema, redness, and worm area, while the radiology shows no signs except for magnetic resonance imaging (MRI) Fragmentation phase: This phase is characterized by bony lysis and inflammation; patients show inflammation signs and erythema Coalescence phase: A reparative phase of the affected bone and joints; signs of inflammation are less prominent Consolidation phase, i.e., chronic CN, when bone healing starts, the inflammation subsides; however, bone deformity is seen.[3] Timely diagnosis is crucial to prevent irreversible joint and bone description. CN is considered a medical emergency; when missed, it can lead to catastrophic complications, including limb loss. CASE PRESENTATION A 23-year-old female single presented with left foot and ankle edema for the last 3 days; it was progressive in onset, painless, and prevented her from walking correctly. The patient had a known case of juvenile diabetes on insulin for the last 13 years, and she was poorly controlled. She denies previous attacks. Her local examination revealed a mild swollen left ankle associated with mild redness. No tenderness was reported. Her neurological examination shows signs of neuropathy. The differential diagnosis includes gout, cellulitis, and deep venous thrombosis [Figure 1]. X-ray showed a classical Charcot joint with calcification, callus formation, and deformity. On MRI, there were signs of inflammation of the bone, where joint effusion, muscle, and subcutaneous tissue edema were seen [Figure 2]. Her investigation revealed elevated renal indices, so contrast MRI was not possible.Figure 1: X-ray of the left foot (a) lateral projection. There is soft-tissue edema involving the dorsal aspect of the foot (blue line). Increased heel pad thickness (white line). (b) Frontal projection there is lateral subluxation of the tarsometatarsal joint (red dots); multiple fractures with callus formation involving the 3rd and 5th metatarsal shafts (green dots)Figure 2: (a) Magnetic resonance imaging; Sagittal T2-weighted short-tau inversion recovery – sequence images; showing bone marrow edema of the midfoot (white arrow) and neck of the talus (yellow circle) with ankle joint effusion (red arrow), there is associated soft tissue and muscle edema of the dorsal, plantar aspect of the foot compartment (blue arrow) as well as the posterior ankle joint region. (b) T2 coronal image through the foot showing hyperintense signal intensity (SI) (bone marrow edema) involving the first metatarsal bone (circle) and tarsometatarsal subluxation (blue arrow)The current case is unusual for a young age, usually seen in older patients with long-standing diabetes mellitus. Thus, it underscores the importance of tight glycemic control and patient education regarding such complications.[3] Moreover, it should alert the physician to consider CN as a differential diagnosis in joint swelling, even among younger ages, especially if they already had neuropathy. Early diagnosis by integrating medical and imaging techniques, particularly MRI, is vital for early diagnosis to preserve joint function and prevent further progression and deformity.[2] A multidisciplinary approach by an endocrinologist and orthopedics is needed for strict glycemic control, with complete offloading to prevent deformity and reduce inflammation. QUIZbased on the imaging provided here; can you differentiate the case from bone osteomyelitis? Do we need additional imaging? Answer: The radiology examination shows a diagnostic dilemma that could be resolved by an IV contrast MRI examination to exclude bone inflammation, i.e., osteomyelitis. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.