Endocrine Abstracts

UNUSUAL PRESENTATION OF DIABETES FOOT ULCER

AM Mousa, G Knight, S Muzulu, J R Rochester. Rotherham General Hospital, Moorgate Road, Rotherham S60 2UD.

Introduction

Phalangeal metastases commonly display inflammatory symptoms that mimic an acute infection. We describe a rare case of bronchogenic carcinoma with metastases to the left 3rd and 4th toes, which presented as presumed diabetic foot ulceration.

Case Report

A 74-year-old diabetic man presented with painful, inflamed and ulcerated left 3rd and 4th toes. A clinical diagnosis of infected diabetic toes was made and X-ray showed destruction of terminal phalanges of the 3rd and 4th toes consistent with osteomyelitis. The toes were amputated. The patient had a haemorraghic left pleural effusion with negative gram stain, culture, acid-fast bacilli and cytology. Histology of the toes showed identical undifferentiated carcinomas. Further investigations confirmed patient had a bronchogenic carcinoma with metastasis to 3rd and 4th toes and he received palliative treatment and died some months later.

Discussion

Foot metastases most frequently involve the tarsal bones and phalanges are involved only in a minority of cases. Most metastatic lesions in the digit initially involve bone and subsequently spread to soft tissue. The terminal phalanx appears swollen, blue-red, tender and fluctuant, which mimics infection. Less commonly red purple, dome shaped, verrucous or ulcerated nodules are observed in the distal nail bed. In our patient two toes were affected simultaneously, which is unique, and led to a clinical diagnosis of infection. At times metastases may be the initial sign of an underlying silent primary malignancy. Metastases to the terminal phalanges from bronchogenic carcinoma account for 43% of cases.

Conclusion

Phalangeal metastases should be considered in the differential diagnosis of inflammatory processes affecting the digits and x-ray and histology should be performed in every doubtful case because it can be the first presentation of occult malignancy. The diagnosis is especially problematical in diabetic patients in which foot ulceration and infection are common.