Recurrent multifocal active Charcot neuro-osteoarthropathy in a young woman with childhood-onset type 1 diabetes: a case report

Background: Active Charcot neuro-osteoarthropathy (CNO) is an inflammatory and destructive complication of diabetes-related neuropathy that usually affects the foot and ankle. Recurrent multifocal disease, particularly with extra-foot involvement, is uncommon. We report the case of a young woman with childhood-onset type 1 diabetes who developed three anatomically distinct episodes of active CNO over seven years. Case presentation: The patient had type 1 diabetes diagnosed at 5 years of age and longstanding unstable glycaemic control. In 2017, at the age of 25 years and during pregnancy, her HbA1c decreased from 12.0% to 7.2% over 6 weeks. At 24 weeks' gestation, after a reported right ankle/foot injury, she developed persistent swelling of the right foot and ankle. Radiographs, followed later by postpartum magnetic resonance imaging (MRI), were consistent with active right midfoot CNO. Offloading was prescribed, but adherence was suboptimal and the deformity progressed, ultimately requiring transtibial amputation 2 years later. Two weeks postpartum, while the first episode was still active, she presented with a painless, warm, swollen left knee. Computed tomography demonstrated severe tibial plateau destruction consistent with active Charcot arthropathy of the knee, and total knee arthroplasty was performed 2 months later. In 2024, after end-stage kidney disease, 2 years of haemodialysis, kidney transplantation, and treatment with belatacept plus prednisone, she developed a third episode involving the left foot/ankle. MRI again supported active CNO, and treatment with a non-removable cast was initiated. Conclusions: This case highlights that active CNO may occur at a young age in people with childhood-onset type 1 diabetes and may recur at multiple sites, including the knee. Trauma, abrupt improvement in glycaemia, and post-transplant immunosuppressive and glucocorticoid exposure were plausible contributors in this patient, but a single case cannot establish causality. The main clinical message is the need for early recognition, prompt offloading, and lifelong surveillance in high-risk patients.