An Alternate Explanation.
An Alternate Explanation.
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DOI：
10.1056/nejmcps2210419
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发表时间：
2023-04-06
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一位48岁的男性，长期患有2型糖尿病(最近的糖化血红蛋白水平，6.5%)和慢性肾脏疾病(基线肌酐水平，每分升3.3毫克[292μ摩尔每升]；肾小球滤过率，每1.73m2的身体表面积每分钟24毫升)，向他的初级保健医生提出3个月的麻木、刺痛和多个手指和脚趾尖端微弱的紫罗兰色变色的病史。他的身体检查显示，手套和袜子分布中的光触觉减少；可以触摸到放射状和踏板脉冲。维生素B12水平为每毫升260微克(每升192微克分子；正常范围为每毫升190至950微克[每升140至701微克分子])。他没有吸烟，没有喝酒，也没有使用非法药物。一个月后，左脚出现了一个非创伤性伤口。踝臂指数(ABI)为1.2(正常范围为0.91~1.3)。伤口护理是针对一种假定的神经性溃疡而开始的。
A 48-year-old man with long-standing type 2 diabetes mellitus (recent glycated hemoglobin level, 6.5%) and chronic kidney disease (baseline creatinine level, 3.3 mg per deciliter [292 μmol per liter]; glomerular filtration rate, 24 ml per minute per 1.73 m2 of body-surface area) presented to his primary care physician with a 3-month history of numbness, tingling, and faint violaceous discoloration of the tips of multiple fingers and toes. His physical examination showed reduced light-touch sensation in a glove-and-stocking distribution; the radial and pedal pulses were palpable. The vitamin B12 level was 260 pg per milliliter (192 pmol per liter; normal range, 190 to 950 pg per milliliter [140 to 701 pmol per liter]). He did not smoke tobacco, drink alcohol, or use illicit drugs. One month later, a nontraumatic wound developed on the left foot. The ankle–brachial index (ABI) was 1.2 on both sides (normal range, 0.91 to 1.3). Wound care was initiated for a presumed neuropathic ulcer.