Endocrine Abstracts

We present a rare case of bullous diabeticorum that resulted in bony deformity in the lower limb. A 48-year-old female with a background of complicated type 1 diabetes, presented with a 3-year history of a skin disorder associated with recurrent spontaneous bullae and ulceration on her right anterior shin and foot. Skin biopsies showed focal epidermal infarction, subcorneal vesiculation, papillary dermal fibrosis and minimal dermal inflammation, direct immunofluorescence was negative, the overall features were reported as not specific but in keeping with bullous diabeticorum. Typical features of bullous pemphigoid and epidermolysis bullosa were not present. Despite wound care and antibiotic therapy for intermittent secondary infection, there was ongoing degeneration of the skin which progressed to severe scarring and deformity of the bony structure of the right foot. The result was a dystrophic, foreshortened foot, with contractures of several digits. Imaging including plain x-ray, ultrasound of foot, MRI and CT scans showed extensive skin thickening with resorption of underlying bone, marrow oedema and deformity of bones of the forefoot and mid-foot. The impression was that the bone deformities were secondary to skin inflammation similar to that seen in epidermolysis bullosa. There were no features of neuro-arthropathy (Charcot foot) or of osteomyelitis as the cause of the foot deformities. In summary we report a case of a severe bullous diabeticorum leading to bony abnormalities secondary to contractures due to skin inflammation.