Case 103: Leg Successfully Treated for Necrotizing Cellulitis and Subsequent Gangrenous Toes Holds Up Well After Stroke While Control Leg Deteriorates.

This 76 year old diabetic ex-marine drill sergeant was admitted to the Bryn Mawr Hospital on the 16th of June, 1985 on the vascular surgical service with a foot ulcer of several days duration. His foot was described as edematous and erythematous. Proteus and a few Enterococci were cultured. He was given parenteral Cefoxitin. Pulse volume measurements in the hospital vascular laboratory showed pseudohypertension at the ankle level with pulse volume categories of "3" and "4" at the ankle , foot and thigh. In spite of his antibiotic therapy, the black and necrotizing areas on his foot enlarged and on June 24th a boot consultation was requested. Mini-Boot therapy preceded by local injections of gentamicin and ampicillin was started and his foot was quickly sterilized. No film proved to be in our camera at this time.

After 4 weeks of therapy, the reddening of his foot had largely faded and the ulcer at the base of the 5th toe was closing.

The areas of necrosis on the plantar surface became well-demarcated..

He was transferred to our nursing home facility for further Mini-Boot therapy and local treatments. Unfortunately, he suffered a small medullary stroke (Mini-Boot therapy offers no protection against stroke or coronary heart disease) and was again admitted to Bryn Mawr on July 31st. Once stabilized, he was again transferred to the nursing home for a few more weeks of therapy. Thereafter, his treatments were continued in our office outpatient clinic. He traveled to Florida during Christmas to visit family and continued his treatments until healed on his return.

He returned from Florida with a residual ulcer.

By May 21st 1986, his foot was well healed.

He had transportation difficulties and had little follow-up until the November 20th, 1987 when he presented with ischemia of his first and third right toes.

Whether infection or infarction, portions of both the 1st and 3rd toes were dead.

With outpatient treatment, the 3rd toe autoamputated and the 1st toe stabilized.

He was again stable until he presented with a major stroke after which he provided with expectant care and no booting. His right leg remained intact during his failing days, while his "control" left leg deteriorated.

Comments: This man was spared a leg amputation and kept ambulatory for two years. He had few if any other therapeutic options. The prognosis of ischemic legs is worsened by strokes. The latter may decrease exercise, promote stasis and decubiti and increase trauma. The stroke victim may be dependent on others for personal hygiene, nutrition and transportation. The patient commonly becomes despondent. He/she may indeed become a major burden on their family. .