Case 144: Extensive Necrotizing Cellulitis, Distal Arteriosclerosis Obliterans and Osteomyelitis Cured by Local and Systemic Antibiotics and Mini-Boot over Two years.

At age 61, this man was admitted to the Bryn Mawr Hospital on the 28th of August 1992 and discharged a month later with diagnoses of (1) necrotizing cellulitis of his left foot, (2)diabetes mellitus, (3) peripheral arteriosclerosis obliterans, (4) peripheral neuropathy and (5) arteriosclerotic heart disease. He presented with a 30 year history of diabetes that had been discovered by his dentist. He was treated with insulin the last 14 years. He had reached a weight of 260 lbs in 1959, well above his ideal weight of 177 lbs; he presented now at 194 lbs. He had had a penile prosthesis inserted in 1985, a cholecystectomy in 1986 and a quintuple heart bypass in the Bryn Mawr Hospital in 1991.

His foot problems began in March 1991 when he developed lesions on the tops of his first and fifth right toes; these healed with conservative measures. In late June 1992, he experienced pain under his fourth toe and subsequently an ulcer was noted that led to two hospitalizations at his community hospital in July and August. He was discharged from his second hospitalization August 21st with persistent foot pain and a prescription for Cipro. He came to our boot clinic on August 25th as his foot was getting progressively worse in spite of his hospital and outpatient treatments. Appropriate phonecalls revealed he had a Staphylococcus aureus resistant to Cipro but sensitive to gentamicin, amoxicilliin, clindamycin, cefroxadine and sulfa.

The distal aspect of the dorsum of his foot was reddened especially over the lateral three toes and metatarsal heads.

The left 4th toe was bluish and ulcerated on his plantar aspect. It was considered to be possibly lost. He agreed to local gentamicin injections into the toe.

On the plantar surface, the cellulitic process extended from the three lateral toes distally, along the arch and up to the internal malleolus. He was advised that our local antibiotic injection technique was not standard therapy but, in view of the intense reddening of his arch and the threat of breakdown, we would recommend local injections in the reddened area also. As noted on the heel tape, the arch was not so protected as the idea did not seem necessary to him at the time.

He was started on outpatient Mini-Boot therapy and given Bactrim. His fourth toe recovered its color and did well. His pain in the arch persisted. He was hospitalized for more frequent boot therapies and intravenous antibiotics on August 28th. Positive physical findings included bruits in both carotids, complete dental plates, a mid-line thoracotomy scar, an apical systolic murmur, cholecystectomy and appendectomy scars, a penile prosthesis, a long scar down the right leg from his saphenous vein removal, 2+ popliteal pulses bilaterally, absent dorsalis pedis and posterior tibial pulses, edema of the left ankle, reddening of the left arch and a loss of tissue turgor under the plantar area under the 4th metatarsal where the tissue was soft. He was unable to feel the 6.10 fiber in his distal feet. His white count was 14.4 with a shift to left. His sodium was 132 mEq/L, bilirubin 1.1 mg/dl, BUN 28mg/dl and creatinine 1.2 mg/dl on admission. X-ray studies during his hospitalization included a film of the left shoulder showing his IV catheter to be curled up in his upper arm, the left knee showing extensive vascular calcifications but no arthritis, left foot showing extensive vascular calcifications but no definite osteomyelitis and on September 24th, an arteriogram showing patent superficial femoral and popliteal arteries with runoff bilaterally through the anterior tibials which became diseased in their distal third and had no reconstitution of a significant length of the dorsalis pedis and poor inflow into an incomplete plantar arch. Non-invasive vascular testing on August 25th had shown markedly widened low Doppler waveforms in the distal foot, a widened anterior tibial in the instep, and very low and wide (collaterals?) waveforms in the area of the posterior tibial and peroneal arteries at the ankle. A very wide and low but distinct PPG waveform was recorded off his big toe while the PPG's from the other toes were flat. Vascular surgery was consulted but saw no opportunity for intervention.

He continued to have considerable foot pain through much of his hospitalization. He was begun on intravenous Vancomycin . Intravenous Clindamycin was soon added. In view of his continued pain and the necrotic changes developing in his arch, local gentamicin into the arch was added. The usage of local Vancomycin and gentamicin was associated with some pain relief supporting the belief his pain was due to his infection. His great redness had also raised the question of gout but his uric acid level of 5.4mg/dl, questionable benefit from a trial of therapy with Naprosyn and Cytotec along with the developing necrosis in his arch were evidence against pain and inflammation due to gout. Indeed, the necrosis began at the time the therapeutic trial with Naprosyn began raising the possibility that the drug might have an adverse effect on white cell function perhaps impeding phagocytosis of bacteria. The Naprosyn was stopped.

September 30th. Returning to Clinic OPD treatment. Fever and pain gone. Normal 4th toe color. Treatment: Bactrim-DS orally and local gentamicin injections and Mini-Boot with Vancomycin and Urecholine in the bath.

October 5th. Skin color better but plantar lesion wider perhaps due to his ambulation. Same treatments.

November 11th. Skin color normal. Lesion improving.

May 4th, 1993. Callus developing along the length of his lesion was periodically trimmed. His local gentamicin and Vancomycin injections were continued along with his Mini-Boot treatments in a Sea Soak antibiotic bath.

August 24th, 1993. Been ambulatory and going to work now for almost a year. Lesion still not healed.

August 4th, 1994. His treatments were tapered in frequency as he healed. His local injections varied according to his cultures: gentamicin, Vancomycin, Fortaz and Tobramycin were all used for periods.

April 14th, 1995. He came to Clinic with this large blister. The possibility of an allergy to the Neosporin he was using at home was considered. He was given a foot soak in Sea Soaks with a little hydrogen peroxide. His lesion was cultured (no growth eventually reported) and he was given a dry Mini-Boot treatment.

June 1st, 1995. Routine booster treatment and callus removal. He had become a good diabetic with normal glycohemoglobin levels.

February 11th, 1999. He has not required boot treatment for over three years. His foot remains healed but he continues to require debridement of callus over the previous ulcer site.

Comments: This man had had two unsuccessful hospitalizations for the same foot problem in the month before coming to Bryn Mawr. He had had discussions with his previous physicians that did not include local injections and Mini-Boot therapy. As his 4th toe appeared lost, he agreed to an initial injection in that toe which appeared to be quite successful. His foot pain made him quite leery to receive injections in the arch. When the injections in the arch were begun, his pain there decreased. He was of necessity advised of alternativie therapies throughout his hospitalization. His vascular testing was compatible with the eventual findings of his arteriogram: distal small artery disease with marginal flow in his feet. Neither our surgeons or those in his previous hospital considered him a good surgical candidate. When his cellulitic area began to break down, the possibility of a wide surgical debridement from his 4th toe to his medial malleolus was also considered. The idea of a new larger surgical lesion to heal was unappealing. A follow-up x-ray in 1995, showed changes in his 4th and 5th metatarsal heads of old osteomyelitis. His foot continued to do well but his 4th metatarsal-phalangeal joint is ankylosed. He is fortunate he did not have and does not now have HMO insurance. The HMO's require periodic review by their physicians who have little experience in patient care by our methods and have a mandate by their organization to limit or deny "unnecessary care". It is quite likely that this man's care and costs would have been greatly reduced had he started our program earlier. Again, once he had his disease, his long term costs are reduced in avoiding leg amputation (see our Epidemiology library). This man had an extensive necrotizing cellulitis. The Joslin group lists cellulitis over 2cm, extensive tissue or bone damage, systemic toxicity and threatened limb loss as elements of their Group III patients in whom they did multiple operations in 36%, forefoot amputations in 67% and leg amputations in over a third (Joslin's Diabetes Mellitus, 12th edition, pps 717-18). For more on cellulitis, see our cellulitis library.