Perspectives in Circulation Today
Follow-up of Osteomyelitis Treated by Local Antibiotics and the Circulator Boot
The Sed rate and C-Reactive Protein
Success in Treating 42 Consecutive Episodes
Dillon reported the success of local antibiotic injections along with Circulator Miniboot treatments in healing 42 consecutive episodes in 35 patients(Vasc Surg 24(9):683-696,1990 and Errata page 249 volume 25). The combination of diabetes, vascular impairment and osteomyelitis had made previous treatments unsuccessful for most patients. One had amputation of two mummified toes and healed his amputation sites and other lesions. Another healed initially but developed a Charcot foot in time that resulted in a BK amputation. The other patients were healed without sequelae. Three patients were illustrated in detail and the controversy among attending physicians over management described. The infectious disease specialist and the orthopedic surgeons favored amputations because of progressive changes in foot x-rays while Dillon favored declaring cures because of normalizaton of the sedimentation rates and healing of the associated soft tissue lesions. Time showed that the lesions were indeed healed as the bone remodeling restored the lesions in question. Amputation proved to be rarely necessary. The outward appearance of the foot and the normalization of the sed rate proved to be important in the decisions to avoid amputation. The abstract of this article and a link to the entire manuscript is found in our website "Pneumatic Boot" library.The Erythrocyte Sedimentation rate (ESR)
and C-Reactive Protein (CRP)
In outlining the significance of the ESR to patients and students, a simplified explanation is helpful. Leukocytes, it may be observed, do not swim; they crawl over surfaces where they can phagocytize bacteria trapping them against the wall of the surface. Bacteria often can swim and avoid the leukocytes. Like a spider, the leukocyte can "spin a web". Cytokines result in the production of paraproteins (immunoglobulins) and fibrinogen which may coat the surfaces of cells, bone and foreign bodies. The coated surface has receptors that may attach to the bacteria and hold it in place for the leukocyte to engulf. Erythrocytes are likewise coated and may stick together in clumps settling rapidly in the test tube. As inflammation subsides and the production of the paraproteins and fibrinogen subsides, the red cells cease clumping and the ESR returns to normal. The ESR, hence, has been a good non-specific guide as to the activity of inflammatory and infective processes.
CRP was some advantages over the ESR and will be discussed further in another Newsletter. The ESR is affected by the concentrations of fibrinogen, monoclonal antibodies and red cell morphological abnormalities unlike the CRP. On the other hand, the ESR may detect paraproteins that may or not be part of an acute phase reaction and escape a rise in the CRP. Progressive systemic sclerosis and SLE are examples where a significant discrepancy between the CRP and ESR may be found; minor increases in CRP may be found while the ESR is very high.Warning: Both beauty and danger are in the eyes of the beholder. To the rheumatologist, an elevated ESR may indicate the presence of collagen disease or an arteritis. We have seen them prescribe a course of steroids to a patient with an elevated ESR and osteomyelitis...not a good idea.
A plea: If you cannot match our results, maybe you should join us! Others have. See Niezgoda in our abstracts.