Clinical introduction

An 81-year-old man with a 10-year history of insulin-treated type 2 diabetes presented with sudden-onset pain, redness and swelling that began in his right hand the day before admission and extended to the whole arm over the next hours. He was fishing but was not aware of any injury, and symptoms had not given early significant discomfort. On examination the right arm was diffusely tender, purplish and swollen. Diffuse crepitation, reddish-blue bullae with serohemorrhagic discharge were also found (figure 1). Vital signs revealed hypotension, tachycardia and low-grade fever. Laboratory tests showed leucopenia (white blood cells, 3.5/nL), increase of erythrocyte sedimentation rate (103 mm/h), C reactive protein (15 mg/L), procalcitonin (17.93 ng/mL) and elevated myoglobin and creatine kinase (5126 and 2000 U/L, respectively).