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Early detection of Charcot neuroarthropathy is critical for preventing the bone and joint destruction associated with later stages, but symptoms that mimic other conditions can make a differential diagnosis difficult.
Newer theories have emerged that more accurately describe the pathogenesis of this condition. CN will be seen primarily in the diabetic population; however, keep in mind that any disorder that causes neuropathy can predispose an individual to the development of CN. Individuals with CN in the acute phase will typically present with a red, hot, swollen foot.4 Edema and erythema are usually present, and unilateral presentation is more common than bilateral presentation. Temperature changes will be noted in the affected limb, which has been verified by limited thermographic study.23 Recording the skin temperature differential between limbs on the initial presentation and all follow up visits may help the practitioner determine staging and progression of CN, but to our knowledge, a study has not been performed to confirm this.
Chronic phases of CN will present with a temperature that is more similar to the unaffected contralateral limb. A number of differential diagnoses may preclude the practitioner from immediately diagnosing CN. Infection such as cellulitis, septic arthritis, or osteomyelitis can usually be rejected as a differential diagnosis if an open ulceration is not present and traumatic inoculation did not occur.25 Laboratory studies including complete blood count (CBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) should be completed. Deep venous thrombosis (DVT) will present with an enlarged limb and will be seen in a patient experiencing a hypercoagulable state as a result of genetics, surgery, age, immobilization, medications, or metastatic disease.
Well’s criteria can be utilized to determine those most at risk for DVT.28, 29 In this system, +1 point is given to those most at risk, such as those with cancer, paralysis or immobilization of more than three days, tenderness along course of deep veins, leg swelling, pitting edema, prior DVT, and collateral superficial veins.
Gout is the result of deposition of monosodium urate crystals within a joint; it typically occurs in the first metatarsophalangeal joint but can present in any joint of the foot. Ankle sprains are one of the most common injuries presenting to the emergency department, second only to knee injuries.
Septic arthritis is potentially one of the most dangerous differential diagnoses on this list to miss. Diagnosis should be made quickly through an accurate and thorough clinical exam, and definitive treatment should not be delayed while waiting for laboratory results to be completed. The Eichenholtz classification system is the one most frequently utilized when evaluating neuroarthropathy. Early changes, such as those associated with stage 0 Charcot, can reliably be observed with triphasic bone scan. It can still be difficult to differentiate infection from arthropathy based on MRI evaluation alone, as bone edema and osteomyelitis can have a similar appearance.38 It is, therefore, important to carefully evaluate MRI studies for subtle differences that can lead to a correct diagnosis.
It is important to remember that infection will be caused by contiguous spread from ulceration or surrounding cellulitis; osteomyelitis in the absence of these entities is extremely rare.
Cellulitis will be seen as a low signal in the soft tissues surrounding the bone on T1-weighted images and hyperintensity seen on T2-weighted images. FDG-PET (2-fluoro-2deoxy-glucose positron emission tomography) scanning offers some very distinct advantages over MRI in relation to Charcot neuroarthropathy. PET scans have another distinct advantage in that patients with metal implants can be reliably evaluated with this technique without complicating artifacts to obscure views, which can occur with MRI.
FDG PET is rarely utilized clinically in the diagnostic workup of Charcot neuroarthropathy today.  Limitations of this imaging modality include its significant expense, which can range from $2,000 to $8,000 depending on the institution.
Although many confounding differential diagnoses exist, Charcot arthropathy can be relatively simple to diagnose if the practitioner has an understanding of the condition and a high index of suspicion.
Although treatment of CN is beyond the scope of this article, it is worth noting that if a practitioner comes across an individual with suspected CN, implementing non-weight bearing status is of utmost importance.
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However, if your child has developed a rash and seems unwell, or if you're worried, you should see your GP to find out the cause and for any necessary treatment. Eczema is a long-term condition that causes the skin to become itchy, red, dry and cracked. Impetigo is a highly contagious bacterial infection of the surface layers of the skin that causes sores and blisters.
If you think your child has impetigo, see your GP for a prescription of antibiotic cream, which should clear the infection within seven to 10 days. A heat rash (prickly heat) may flare up if your child starts to sweat, for example because they are dressed in too many clothes or the environment is hot and humid. Keratosis pilaris is a common and harmless condition where the skin becomes rough and bumpy, as if covered in permanent goose pimples.
It commonly affects young children aged one to five years, who tend to catch it after close physical contact with another infected child.
Children tend to catch it after close physical contact with another infected adult or child – for example, during play fighting or hugging.
Hives (also known as urticaria) is a raised, red, itchy rash that appears on the skin.
Most children won't need treatment as slapped cheek syndrome is usually a mild condition that passes in a few days. Psoriasis is a skin condition that causes red, flaky, crusty patches of skin covered with silvery scales. There is no cure for psoriasis, but a range of treatments can improve symptoms and the appearance of the affected skin patches. Cellulitis is a bacterial infection of the deeper layers of the skin and the underlying tissue. It causes a red-brown spotty rash, which tends to start behind the ears and spread to the head, neck, legs and rest of the body. Most childhood rashes are not measles, but you should see your GP if you notice the above signs. The information on this page has been adapted by NHS Wales from original content supplied by NHS Choices. Poor hygiene can cause armpit boils because of the dirt that is trapped within the hair follicle.
Armpit boils in women may occur as a result of excessive underarm shaving, which can lead to an ingrown hair under the arm.

Staph bacteria are present on the skin's surface and can be found in the nose, armpits or other warm creases of the skin. Clinical photograph of Charcot foot demonstrating foot and leg edema after removal of an Ace bandage. A neurovascular, or French, theory8,14 suggests that autonomic neuropathy leads to increased blood flow, resulting in a “washing out” of the bone with subsequent osteopenia, resorption, and fracture. A triggering traumatic event in the face of neuropathy results in inflammation.  Pro-inflammatory cytokines such as interleukin IL-1b and tumor necrosis factor alpha (TNF-a) are released.
Clinical photograph of bilateral lower limbs demonstrating increased foot and leg edema on the left side, consistent with Charcot neuroarthropathy. Although CN can occur within any joint of the foot, the midfoot is the most common location.19 A study by Herbst 20 found that 50% of Charcot cases occurred in the midfoot, 28% in the hindfoot, 19% in the ankle and 3% in the forefoot. Temperature differences between limbs will return to zero when the acute phase of CN is complete.
Testing is simple and involves the application of the monofilament wire to various locations on the plantar and dorsal aspects of the foot.
Infection, or osteomyelitis, is one of the main alternative diagnoses and is one of the most difficult to differentiate. This patient will experience pain in the posterior leg when pressure is applied to medial and lateral aspects of the calf.
Those suffering from hypertension are three times more likely to develop gout.  Thiazide diuretics, stress, surgery, infection, pneumonia, stroke and myocardial infarction have all been implicated as potential triggers. Weightbearing lateral radiograph demonstrating Charcot dislocation of the Lisfranc joint with dorsal subluxation and increased soft tissue edema. A patient with an ankle sprain will present with a history of trauma, which can potentially be the inciting event for the development of Charcot neuropathy. Eichenholtz developed a series of three radiographic stages to describe the progression of change within the neuroarthropathic foot .33 Stage 1, termed the “stage of development”, is characterized radiographically by fragmentation of articular cartilage and subchondral bone. An individual in stage 0 will present with an acute, red, hot, swollen foot and bounding pulses. Some studies even indicate that abnormalities could be seen with a technetium-99 bone scan months before clinical or radiographic abnormality becomes apparent.34 Uptake will be noted in all three phases.
The benefits of MRI over plain radiographs include a more rapid determination of bone stress injury, which typically precedes fracture in these individuals and can lead to diagnosis at the stage 0 phase.
Infection is favored as the diagnosis if sinus tracts, subchondral cysts, bone marrow abnormalities that are diffuse in nature, or erosions of the bone are noted.
Lateral subluxation of metatarsal bases 2-5 with fracture at 2nd metatarsal base and slight medial dislocation of medial Lisfranc joint; obliteration of Lisfranc joint space. Osteomyelitis will more commonly be seen in areas that are typically prone to ulceration such as the digits, metatarsal heads, calcaneus, and malleolus. PET scans can differentiate infection from CN on the basis of glucose metabolism; infection will result in a higher uptake of glucose, which can be measured. Ring PET has been found to be more reliable than hybrid (dual head gamma camera) PET in at least one study,39 since the resolution of ring PET scans is higher than hybrid PET scans.
Ionizing radiation exposure and limited availability of this technology outside of a tertiary care setting are also limitations that can preclude its routine use. When a diabetic, insensate individual presents without an open ulceration and has a red, hot, swollen foot (especially the midfoot) with bounding pulses, Charcot arthropathy should be at the top of the practitioner’s list of differential diagnoses. The patient should be placed in a posterior splint or total contact cast and given crutches or a wheelchair to ensure that no additional pressure is applied to the foot. If you continue without changing your settings, we'll assume that you are happy to receive all cookies on the NHS Direct Wales website. The most common form is atopic eczema, which mainly affects children but can continue into adulthood. The rash can appear almost anywhere on the body, with the scalp, feet and groin being common areas. It causes a non-itchy rash on the palms of the hands and soles of the feet, and can sometimes cause mouth ulcers and a general feeling of being unwell.
However, most adults are resistant to the virus, meaning they are unlikely to develop the condition if they come into contact with it. They leave small red blotches and silver lines on the skin, which may be found on the palms of the hands or soles of the feet. It happens when a trigger (see below) causes a protein called histamine to be released in the skin. The infection creates large lesions that form under the armpit and are usually filled with a clear fluid called pus. Failure to bathe regularly can cause excess dirt, sweat and bacteria to collect under the armpit, causing a painful boil to appear.
Virchow and Volkmann challenged the French idea and proposed a neurotraumatic, or German, theory suggesting that individuals with neuropathic changes undergo a traumatic event, which progresses to an inflammatory response.14,15 The insensate foot fails to respond or feel pain as a “normal” individual’s foot would. These factors are known to stimulate RANK-L (receptor activator of nuclear factor kappa-B ligand) which induces maturation of osteoclasts.
This diagnostic tool may allow the clinician to assess whether to transition the affected foot from acute therapy, such as total contact casting, into more conservative, chronic therapies, such as CROW walkers or protective diabetic footwear with custom bracing or custom molded inserts.
Radiographs will show evidence of bony consolidation and sclerosis will be resolving.  Significant deformities may be present, depending on the effectiveness of treatment (if any) prior to evaluation. Fracture, cellulitis, deep venous thrombosis (DVT), gout, ankle sprain, and septic joint are also differential diagnoses that can usually be ruled out with an adequate history and physical examination.
Points are tallied and a high probability of DVT is associated with a score of more than 3, moderate probability if the score is 1 or 2, and low probability if a 0 score is obtained. Sprains will present with tenderness to the medial or lateral ligamentous areas that house the ankle joint.
Infected joints are usually monoarticular and severely painful, and will present similar to gout.
Joint aspiration with synovial fluid analysis for gram stain and culture are performed in order to tailor antibiotic coverage.

If osteomyelitis is suspected, osteomyelitis indium 111 labeled or HmPAO scan can be obtained. Diagnosis is determined by low signal intensity on T1 weighted images within the bone itself.
In the presence of infection, a more localized involvement and cortical breaks are visualized.27,36,37 Localized abscess formation can also be seen as a contiguous source in osteomyelitis.
Ring FDG PET offers a higher sensitivity and specificity in differentiating Charcot foot from infection when compared to MRI results. Time will tell if this diagnostic modality’s usage will increase but certainly it may be, pending future improvements in cost effectiveness, accessibility, and increasing awareness and education of practitioners.
Multiple diagnostic tools are now available to help differentiate CN from osteomyelitis, including MRI and FDG- PET. Protecting the limb will prevent further breakdown of the neuroarthropathic joint and allow the healing process to begin. Sur quelques arthropathies qui paraissent dependre d’une lesion du cerveau ou de la moelle epiniere.
High rate of Charcot foot attacks early after simultaneous pancreas-kidney transplantation.
Evaluation and treatment of stage 0 Charcot’s neuroarthropathy of the foot and ankle. Difference in presentation of charcot osteoarthropathy in type 1 compared with type 2 diabetes. Pattern of diabetic neuropathic arthropathy associated with the peripheral bone mineral density.
The use of thermography in the early diagnosis of neuropathic arthropathy in the feet of diabetics. The Semmes Weinstein monofilament examination is a significant predictor of the risk of foot ulceration and amputation in patients with diabetes mellitus.
Infection and neuroarthropathy: the utility of C-reactive protein as a screening tool in the Charcot foot. Correlations between clinical probability and Doppler ultrasound results in the assessment of deep venous thrombosis.
The diabetic charcot foot: MRI discloses bone stress injury as trigger mechanism of neuroarthropathy.
Neuropathic arthropathy of the foot with and without superimposed osteomyelitis: MR imaging characteristics. Potential role of FDG PET in the setting of diabetic neuro-osteoarthropathy: can it differentiate uncomplicated Charcot’s neuroarthropathy from osteomyelitis and soft-tissue infection? Preoperative imaging of Charcot neuroarthropathy in diabetic patients: comparison of ring PET, hybrid PET, and magnetic resonance imaging.
The infected area may become red and inflamed; it may also easily become irritated when clothes rub across the surface. According to New York University Langone Medical Center, the boil will soften with time, which can cause a large pus-filled head to form at the top of the boil. According to Hope College Health Center, boils may occur as a result of a Staph infection developing around the armpit and usually heal on their own.
As a result, continued pressure and repetitive trauma cause destructive changes within the bones and joints of the foot.
Inflammatory cycles typically result in pain, which in a sensate individual would lead to splinting to protect the limb and induce healing. Patients may not sense the wire when it touches them, which would confirm a diagnosis of neuropathy.
However, individuals with septic arthritis will present clinically with fever and additional constitutional symptoms (by comparison, systemic responses are only occasionally seen in cases of gout).
Stage 2, termed the “stage of coalescence”, is characterized radiographically by absorption of debris, fusion of larger fragments, and sclerosis of bone ends. Radiographic presentation may include a simple or comminuted fracture but may also be normal in some. A referral to a foot and ankle specialist equipped to deal with this population should be made as quickly as possible.
According to the Better Health Channel, armpit boils may occur due to buildup of dead skin cells and bacteria on the skin under the arm.
Staph infections are most common in areas that are covered with body hair, which makes the armpit an ideal place for the bacteria to dwell.
Patients will describe pain that develops very acutely over a period of six to 12 hours.  Untreated, these attacks will usually resolve in three to 14 days.
Diffuse pain may be noted if significant swelling is present.  Radiographic evaluation can rule out underlying ankle fracture. Inoculation, via direct or more commonly hematogenous extension, is necessary for infection to occur.
Because CN is primarily an articular disorder, subchondral distribution will typically be seen as well. If an opening such as a cut is present on the surface of the skin, bacteria may enter and form boils. Yu stated that once fragmentation or osteopenia was noted on clinical radiographs, the condition had progressed from stage 0 to stage 1. Patients with normal sensation will relate that this condition is so painful they cannot even let the bed sheets touch their foot at night. Yu also emphasized the need to identify the individual with stage 0 in order to prevent the sequelae of undiagnosed Charcot.

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