An unusual cause of a foot ulcer in a patient with type 1 diabetes

Abstract

A44-year-old man with type 1 diabetes of 23 years duration attended the diabetes clinic for annual review. His HbA1C was 8.3% controlled on a basal-bolus regime of Novorapid and Insulatard. He had a four-year history of hypertension, controlled (132/88 mmHg) on lisinopril 20 mg, and hypercholesterolaemia, controlled (see table 1) on ezetimibe 10 mg and fenofibrate 160 mg (statin intolerant), all once-daily. Background diabetic retinopathy was the only known microvascular complication. He was also taking thyroxine 150 μg once-daily for hypothyroidism. There was no history of ischaemic heart disease, however, he took prophylactic aspirin 75 mg once-daily, as per the Diabetes UK guidelines. The patient worked as a tree surgeon and was an ex-smoker of twenty-one pack years, with an alcohol consumption of two units per week. His other details are shown in table 1. This ‘Alphabet strategy’ template is the basis of our annual review and the core of our letter to general practitioners. On examination he looked well. The dorsalis pedis and posterior tibial pulses were present and equal bilaterally. Monofilament (10 g) testing revealed no peripheral neuropathy. The most striking features were of two small but distinct foot ulcers, together with an ulcer on his left hand (see figures 1 and 2). Astonishingly, these ulcers had originally appeared in a matter of seconds, unlike those of a typical diabetic foot ulcer.