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Case 121: Necrotizing Cellulitis of Toes in Older Lady with Few Current Risk Factors

This 73 year old osteoporotic women suffered a fracture of her left 5th metatarsal head about June 29th, 1997 while in Detroit. She returned to Philadelphia where her orthopedic surgeon examined her and applied a cast. He removed the cast on July 28th, 1997, because of swelling and discoloration of her toes. An oral antibiotic (Keflex) was prescribed for two weeks with some improvement. However, she abruptly became worse and visited her family doctor who noted a blue-black discoloration of her third toe, purple discoloration of her fourth toe, blisters on the proximal dorsal aspects of her third and fourth toes, a fissure between the fourth and fifth toes, reddening of her whole distal foot and pain sensation only with "direct pressure". While she had not smoked in recent years, she had a previous 132 pack-years of smoking. It was his impression that she had gangrene of her third toe, cellulitis of her fourth toe and a recent fracture of her fifth metatarsal. Anxious because of the deterioration of her foot in spite of standard therapeutic measures, he referred her to our boot clinic.

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We found that her family doctor had described her toes accurately. While her 3rd toe could not be said to be actually gangrenous and dead, it clearly was threatened.

The plantar surface of the foot was likewise discolored and infected fissures were found under 3rd, 4th and 5th toes.

On presentation, we found her pedal pulses to be present and limited our vascular testing to PPG testing of her toes to document that pulsatile flow was present (it was). We cultured the dark blisters on the dorsum of her 3rd toe and recovered a moderate growth of coagulase-negative staphylococci, which were sensitive to all antibiotics. Why, one might ask, had her toes gotten worse if the administered antibiotic was appropriate? Occasionally, the presence of fungus, yeast or even tuberculosis can present in such a fashion....or work synergisticly with other bacteria. Our smear for tuberculosis and our yeast cultures eventually were reported as negative. Still, the doctor cannot wait the days needed for these studies to be accomplished and reported when feet are rapidly deteriorating. We changed her oral antibiotics to Doxycycline and Fluconazole to intercept the wide spectrum of potential septic emboli that might be produced in pumping on her feet. We injected gentamicin locally into her blisters and their tissue bases. We then pumped her feet in a solution of Sea Soaks containing gentamicin and Fungazone. The treatment was continued on a daily basis as an outpatient until the feet were out of danger. Thereafter, she was pumped three times a week until he pain was gone and healing almost certain. She did well.

Her foot totally recovered and she resumed an unfettered ambulatory status.

Comments: Lots of questions. Why did this lady suffer this illness? She was not diabetic and had given up smoking. Why did we not hospitalize her to get her off her feet and administer intravenous antibiotics? Why did we not do a bone scan, an MRI of her foot, or some imaging procedure to help us judge the extent of her infection in the soft tissue and the bone? Why had we not "covered our tail" and obtained consultations with infectious disease, general surgery and vascular surgery lest this lady continued to deteriorate in spite of our best efforts? This is a litigious world. Was her insurance company pleased that we were able to save her toes/?leg without incurring these various expenses? We do not know why infection rapidly progesses in some people. We did not need any additional studies; they would not alter our therapy. Consultations may oblige one to alter one's treatment plan. We did not want to do incisions and drainage procedures. We did not want to go to the operating room. We were confident in our approach and knew we would likely have success in our outpatient treatments. No, the insurance company was not grateful.