Hi I am asking for advice on a patient I saw today with blisters on his left foot. Case details are:
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42yo caucasian male owns his own panel beating business, works aprox 14hrs/day, 6 days/week.
PHx: CVA; hypertension; diagnosed T2DM 3 weeks ago.
Meds: coversyl; aspirin; insulin
Allergies: Nil
Footwear: at work rotates between 3 pair of slip on work boots, wears cotton socks; outside work usually sports shoe & thongs
Hx: 6 month Hx of sudden onset of blisters on plantar, medial & lateral aspect of L) midfoot. Multiple blisters at any one time in varoius stages of development & resolution. Often has to break blisters due to large size causing pain when working. Denies havig blisters anywhere else on body. Denies itching; redness and states that whenever he breaks the blisters the fluid is always clear and has no unusual odour
Has seen his GP multiple times over 6 months where he has been prescribed topical & oral antifungals; oral AB's and topical corticosteroids at different times none of which has made any difference. GP has taken samples of blister fluid & skin for pathology testing which was apparently NAD. Three weeks ago GP decided to test for diabetes and fasting glucose was 30; admitted to hospital commenced on IV insulin now on daily insulin. Reports that over past 2 weeks average BGL reading have been between 9 - 11mmol/L. GP has referred to me for opinion.
Pt denies any change in footwear (socks or shoes) preceeding onset of blisters.
O/E: No neuropathy on monofilament testing; vibration 8octales bi-laterally. Pedal pulses strong & regular bi-laterally; CR 2 secs; colour & temp normal. No bony deformity; no nail dystrophy. R) foot skin in good condition with no xerosis or HK.
L) foot has multiple blisters on plantar, medial & lateral aspect in various stages of development and resolution. Some mild redness around some of the larger blisters but skin otherwise normal. Skin on non affected areas of L) foot is normal.
Pt & his wife claim that he doesn't sweat excessively and as indicated above he is very rigorous with his foot hygiene. Denies palmar or armpit sweating (wife says he hardly ever seems to sweat under armpits).
Any suggestions as to a diagnosis would be welcomed. I would especially like to know if anybody has seen this presentation associated with hyperglycaemia (and would that be likely to only affect one foot). I personally don't think this is a fungal infection.
Regards,
David Kelly
Australia
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