A 62-Year-Old Male with Long-standing Diabetes Mellitus Who Developed Multiple Complications

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This 62-year-old man currently has a fluid-filled single bulla over the left leg (which is also swollen than the right leg) for the last 3-4 days, which has suddenly appeared. He also had similar multiple bullae in both legs a few years back but didn't recur until recently. He also has left-sided foot ulcers which are worsening and not healing completely (attached images below).  I have attached his recent photos of his foot ulcers. He has been applying Hydroheal AM gel at the site of ulcers with regular dressing. Additionally, from the past 1 month, he has a lesion in the groin which is very itchy and not responding well to topical terbinafine ointment (attached).

He initially used to have intermittent claudication started in 2007 with a mild degree of hyperpigmentation in the legs, followed by the development of great toe ulceration (due to an injury with a sharp throne) in 2010. Then he again got a frictional injury (while walking barefoot on a rough surface) to the plantar surface of the left foot in 2013 with a resultant ulcer in the planter surface (as shown in the images below)

APRIL 2020 (Healed now)

The following images are from the patient's groin region where he has this very itchy lesions sine one month. 

His current list of medications are as follow:

History Till Feb 2020: 
A 62-year-old man with diabetes since 1992 and hypertension since 2010 complained of shortness of breath and pedal edema for three years. He also reports having recurrent fevers since 2011 that last for 12-18 hours.  He also complained of intermittent claudication pain of both lower limbs after walking for around 250 meters since 2007 which subsides even with standing for a few minutes. He also complained of episodes of giddiness after walking and has been noted to have regular day time somnolence along with episodes of nocturnal awakenings due to shortness of breath punctuated by snoring. He also reported having a diminished vision impairment (right more than left) which began earlier in 2006 followed by the diagnosis of bilateral immature cataract and diabetic retinopathy. He had undergone cataract surgery subsequently in 2008 (left eye) and in 2016 (right eye). Meanwhile, he was also provided multiple schedules of retinal photocoagulation and anti-VEGF therapy. He was also given 6 months trial of benzathine penicillin in view of recurrent cellulitis which was found to have reduced fever recurrence. However, as he stopped taking it, his recurrent fever continued. He has a history of diagnosis of coronary artery disease since 2016, hypothyroidism since 2012, hemorrhoids 12 years, diabetic nephropathy and chronic kidney disease since 2012, peripheral neuropathy since 2008, and diabetic foot disease for 2011.


On examination, he has large trunkal obesity and bilateral pedal edema along with hyperpigmentation of the skin and "peau de orange." His fundoscopy revealed a recovering vitreous hemorrhage with proliferative diabetic retinopathy. The retina surgeon had suggested an anti-VEGF for his vitreal hemorrhage followed by retinal photocoagulation which was not amenable this time in view of the current inadequate evidence of benefit and higher cost of the therapy. He was evaluated with RFT, TFT, LFT, Doppler ultrasound of peripheral arteries of both lower limbs, serum iron profile, urine protein to creatinine ratio, echocardiogram, chest x-ray, MRI of the lumbar spine.


On investigations, his pulmonary function test and 2D Echo turned out to be normal. His Hb was 8g % with microcytic hypochromic anemia with reduced serum iron, reduced transferrin saturation, and TIBC with high serum ferritin. His serum creatinine is 1.4 mg % and his urine 24-hour protein excretion is around 2 g%. His blood sugar profile is controlled on insulin glargine at night and plain insulin thrice before meals. His Hba1c is 6.5%. The sleep study showed multiple episodes of sleep apnoea during REM sleep and Doppler examination of lower limbs revealed normal arterial flow. An MRI lumbosacral spine showed mild lumbar canal stenosis.  His first coronary angiogram revealed a 50% stenosis in the left anterior descending artery and 20-25% stenosis in the left main artery and he was then put on dual antiplatelets (aspirin and clopidogrel), atorvastatin beta-blocker). He had again undergone a second coronary angiogram after the local cardiologist diagnoses him 2019 to have non-STEMI, UTI with AKI on CKD, and treated with enoxaparin and broad-spectrum antibiotics. Additionally, he underwent a recent myocardial perfusion scan which showed normal findings.


He was also assessed by the ENT surgeon who performed video laryngoscopy with reverse Valsalva maneuvers which revealed the obstruction during inspiration. He was also assessed by a dermatologist who confirmed skin hyperpigmentation and chronic lymphedema secondary to recurrent cellulitis. The dermatologist advised monthly prophylactic benzathine penicillin for recurrent cellulitis, compressive stockings, emollients application, povidone-iodine dressing of trophic ulcers which has been healing, MCR footwear, and tetanus vaccine. He is also given ferrous fumarate 150 mg once a day in view of his iron deficiency anemia. He is also given pregabalin 75 mg once a day in view of his peripheral neuropathy due to diabetes mellitus.


He is advised to continue non-invasive management in the form of regular exercise for his intermittent claudication which was found more likely secondary to the vascular origin than neurogenic. He has been advised to continue insulin glargine and human insulin with existing doses and frequencies and doubtfully continued empagliflozin 12.5 mg and metformin 500 combinations twice daily which was given by a past endocrinologist. His thyroxine (50 mcg) dose is advised to continue as earlier in view of euthyroid thyroid hormone status. He is asked to add nebivolol 2.5 mg (previously only morning) at night and take prazosin 2.5 thrice daily along with other antihypertensives. For his on and off postural dizziness, he is advised to take promethazine on sos.


In addition, he is advised to reduce his truncal obesity and continue to follow-up over WhatsApp for BP and other clinical problems.