A. Kim 1 , Y. Braver 1 , A. Jaffer 1 ; 1 The Clevelend Clinic Foundation, Cleveland, OH LEARNING OBJECTIVES: 1) Recognize the clinical presentation of diabetic neuropathic arthropathy. 2) Review the management of acute-onset Charcot arthropathy. CASE INFORMATION: A 51-year old African American female insulin-dependent diabetic of 12 years presented with a 2 month history of right lower extremity (RLE) swelling. This was associated with erythema, warmth, and minimal pain. She also reported a 3-day history of lowgrade fever and generalized weakness. She had previously been treated with oral antibiotics for presumed cellulitis with no improvement. Diagnostic studies at that time revealed a normal WBC of 10 K/cmm with an elevated sedimentation rate (WSR) of 31 mm/hr. X-ray of the right foot/ankle showed soft tissue swelling without evidence of bony destruction. Lower extremity duplex revealed no deep vein thrombosis. CT scan of the extremity revealed only subcutaneous edema. A subsequent right ankle joint aspiration was performed which was negative for crystals and infection. The physical exam on admission was notable for an afebrile, obese female with 2+ pitting edema extending from the dorsal aspect of the right foot to the knee associated with warmth, erythema, and tenderness. There were no areas of skin breakdown or ulcers. Decreased sensation to pain, temperature, and proprioception was noted. The patient was admitted for cellulitis and started on IV antibiotics. Laboratory studies showed WBC of 8 K/cmm with an elevated WSR of 64 mm/hr and a CRP of 3.8 mg/dl. Blood cultures were negative. The patient remained afebrile with mild improvement of her symptoms. A MRI of the extremity revealed changes in the midfoot and forefoot consistent with an acute neuropathic arthropathy. Orthopedic consultation fitted the patient with a total-contact cast, instructed her on no weight bearing in the RLE with follow-up in 4 weeks. DISCUSSION: Diabetes mellitus is now the most common cause of neuropathic (Charcot) arthropathy. The foot and ankle are the most commonly affected joints. Unilateral swelling, warmth, and erythema are typical clinical findings and it is usually painless. The pathogenesis of this disease is unclear but may be related to a combination of peripheral neuropathy and neurovascular insufficiency allowing repetitive microtrauma. This can result in chronic destruction of bones and joints ultimately resulting in deformities and disabilities. In early disease, it may be difficult to differentiate from cellulitis, osteomyelitis, septic arthritis, crystalline arthritis, and osteoarthritis. Therefore, having a high clinical suspicion and obtaining studies such as MRI or In-111 labeled leukocyte scan can help make a prompt and accurate diagnosis so that aggressive immobilization can be initiated.