Right Leg Pain, Swelling, and Erythema for Two Days

Abstract

A 40-year-old male with diabetes mellitus and hepatitis C-related cirrhosis presents to the emergency department with a 2-day history of right leg pain, redness, and swelling. He states that he thinks he may have been bitten in the leg by a bug while sleeping. On physical examination, his temperature is 37.8 °C, heart rate is 110/min, blood pressure is 90/60 mmHg, and respiratory rate is 18/min. His right leg is markedly swollen as compared to the left. The skin overlying the calf region is erythematous, with one 3 cm bullae, and an area of violaceous skin. There is no palpable crepitus. Plain X-ray of the leg demonstrates gas bubbles within the soft tissue in the calf. The foot itself is pink and warm, with normal pulses. Laboratory values are significant for a BUN of 40 mg/dL (normal 7–20 mg/dL), serum glucose of 200 mg/dL (70–100 mg/dL), creatinine of 1.6 mg/dL (0.8–1.4 mg/dL), white blood cell (WBC) count of 24 × 10³/μL (4.1–10.9 × 10³/μL), hemoglobin of 9.5 g/dL (13.8–17.2 g/dL), and a serum sodium of 128 mEq/L (136–144 mEq/L).