A 55 year old diabetic presenting with a rash and polyneuropathy.

Presentation of CaseA 55-year old man from Hazara was admitted to the Aga Khan University Hospital because of fever, generalized weakness and pain and swelling in his legs.The patient had been well until 14 months ago when he was diagnosed to have diabetes meHitus.He was treated with Gliclazide but his blood sugars remained high and he later went to a Hakeem.The Hakeem gave him some powder.which he took every day in a glass of water.Six months prior to presentation he developed progressive weakness and pain in his legs.At the same time he noticed swelling in his feet, which gradually extended to involve his legs and later his hands and arms as well.Eventually his face became puffy.He had difficulty in getting up from a squatting position and as his weakness worsened he became bed bound.The pain in his legs was described as a sharp burning sensation particularly in the soles, with tenderness in both legs.He had fever intermittent but 15 days prior to presentation this had become constant at 102°F.The patient's past medical history was unremarkable.He had a left hemiorrhaph in the remote past.Review of systems was also non-contributory: there was no history of chronic cough, weight loss, bowel or bladder dysfunction.He came from Haripur Hazara, and was married with children.He did not smoke nor drink (alcohol) and reported no other addictions.He had never travelled outside Pakistan.Medication history was significant for having taken various forms of herbal medicines from Hakeems.He had no known allergies.On examination; he was a middle aged man, in mild distress due to pain and generalized edema.The temperature was 37.5°C, pulse 100/min respiratory rate 24/mm and blood pressure 150/90.There was a diffuse maculo -papular, erthematous rash over entire body; worse on the face and trunk.There were some dry shiny scales on legs.No lymphadenopathy.cyanosis or clubbing was noted.Periphend arterial pulsations were present.There was mild tenderness in muscles, particularly calves, to palpation.Cardiovascular, respiratory and abdominal examination was unremarkable.On neurological examination, the patient was alert and oriented with intact speech and intellectual function.Cranial nerves showed no deficits.