A 42-year-old man with hypertension, type 2 diabetes diagnosed at age 25 years, and gastroparesis presented to the emergency department with right lower extremity blisters that had developed spontaneously over the prior 36 hours. He reported a tingling sensation in the affected area but no pruritus or pain. He had no history of leg trauma and no chemical or extreme temperature exposure. Medications included insulin lispro (sliding scale 3 times daily) and insulin glargine (20 units nightly). On physical examination, he was afebrile and had normal vital signs. His extremities were warm with palpable distal pulses. Hyperpigmented macules were present on the anterior lower legs below the knees, and tense bullae were present on the anterior aspect of the right lower extremity, dorsal foot surface, and toes (Figure). There was no surrounding erythema or edema, and findings on the remainder of the skin and mucocutaneous examination were unremarkable. Laboratory testing revealed a blood glucose level of 375 mg/dL (20.81 mmol/L) and hemoglobin A1c level of 9.8%. Results of a basic metabolic panel and complete blood cell count were within reference range except for mild anemia (hemoglobin level, 10.9 g/dL).
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Daniela Kroshinsky, MD, MPH, Department of Dermatology, Massachusetts General Hospital, 50 Staniford St, Second Floor, Boston, MA 02114 (email@example.com).
Published Online: March 24, 2023. doi:10.1001/jama.2023.3101
Conflict of Interest Disclosures: Dr DeWane reported having a patent pending for Microneedle patch for immunostimulatory drug delivery. No other disclosures were reported.
Additional Contributions: We thank the patient for providing permission to share his information.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
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