Case 141: Osteomyelitis and Extensive Cellulitis Cured and Foot Salvaged in Young Man

This young man had poorly controlled diabetes since age 9. In February 1987, at age 21, he was found to have retinopathy and osteomyelitis of his big toe. His toe was easily cured with the injection of gentamicin into the toe followed by therapy with the Mini-Boot. The big toe amputation his local physicians had considered was averted. He returned in June 1989 with an infection through the foot between the fourth and fifth metatarsal heads, spreading across the base of the toes to the second toe and spreading into the arch where an abscess pointed. His white count was 31,400. Cultures grew abundant Beta-streptococci, alpha-streptococci, and abundant coagulase-negative staphylococci. His serum sodium was 129 mEq/L and his BUN 56. Serial x-rays showed osteomyelitis of the proximal and middle phalanges of the fourth toe and of the fourth metatarsal head.

June 13th, 1989

June 13th, 1989

He was treated with our usual protocol: initial cleansing foot soaks, local injections of antibiotics into the grossly infected areas of the foot, systemic intravenous antibiotics, placement of his foot into a bag containing Sea Soaks and antibiotics and pumping of the bagged foot within the Mini-Boot. He was treated for 16 days in the hospital. Treatment with oral antibiotics, locally injected antibiotics and Mini-Boot therapy was continued as an outpatient until his foot was out of trouble. He did well.

July 31st, 1989.

July 31st, 1989.

Comments: As a teenager, this young man never learned the essentials of diabetes control. He had no effective supervision except when he was in Bryn Mawr Hospital. In his first episode, his big toe was saved. In the second episode shown here, his foot was salvaged. Notice the macerated cyanotic toe fully recovered. Such toes are commonly prematurely declared lost and amputated. This young man had no insurance other than Medicaid. With the latter now regulated by HMO's, would he have been cured today? These infections move rapidly. The HMO approval process does not.