• Tom Alsaigh, Gurpreet Dhaliwal, Eri Fukaya, Nicholas J Leeper, and Nazish Sayed.
• From the Division of General Internal Medicine, Department of Medicine, and the Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla (T.A.), the Department of Medicine, University of California San Francisco School of Medicine, and Medical Service, San Francisco VA Medical Center, San Francisco (G.D.), and the Division of Vascular Surgery, Department of Surgery (E.F., N.J.L., N.S.), and the Division of Cardiovascular Medicine, Department of Medicine (N.J.L.), Stanford University School of Medicine, and the Stanford Cardiovascular Institute, Stanford University (N.J.L., N.S.), Stanford - all in California.
• N. Engl. J. Med. 2023 Apr 6; 388 (14): 131813241318-1324.

AbstractA 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.

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