Case 157: Diabetic Foot: Osteomyelitis, Peripheral Neuropathy, Peripheral Arteriosclerosis Obliterans, Sepsis and Still Both Legs after 15 Years

At age 49 on the 25th of October 1985, this male diabetic presented in the office for another opinion. A culture was taken, vascular tests performed and a sample treatment with the Mini-boot administered along with an injection of gentamicin into the bed of his ulcer. Hospital admission was recommended and deferred for four days. On October 29th, he was admitted to the Bryn Mawr Hospital for the first time. He presented with a large plantar foot ulcer that had begun with a cut he had incurred on the beach the summer of 1984. He sought care from his family doctor and then a general surgeon. Their antibiotics and outpatient therapies were not effective. He was then hospitalized for intravenous antibiotics and bedrest and discharged again on oral antibiotics. The foot did not heal. His physicians attended his ulcer over the next year as an outpatient. In August of 1985, he developed a "massive cellulitis" of the foot again leading to hospitalization, debridements and bone biopsy. He was given intravenous Tobramycin for a month and again discharged with an open ulcer and a prescription for Duracef. Unhappy with his fate, he sought opinions from various clinics and institutions around Philadelphia. One podiatry Professor urged immediate hospitalization, vascular evaluation, long term antibiotic therapy and a two-stage reconstruction of his dislocated big toe with the thought that the dislocation caused the persistent trophic ulceration on the bottom of his foot. It was in his search for another opinion that he had come to our Boot Clinic.


October 25, 1985: His Doppler waveforms were biphasic and sharp in the anterior tibial at the ankle. The waveforms for the posterior tibial and peroneal were reduced and monophasic. The pulse volume at the ankle was normal. He had no apparent need for surgical revascularization


October 30, 1985: second day of hospitalization and treatment. Note the prominence of the "ball of his foot" and his hammer toes.


November 2nd, 1985: The ulcer is cleaner and the granulations redder.

He had weighed 108 lbs at age 10, 165 lbs at age 18 and 185 lbs at age 25. He had reached 310 lbs at age 44. He presented now at 217 lbs well above his ideal calculated weight of 160 lbs. He did not know how long he had had diabetes. His usual medications included Benamid 500 mg twice daily, Minipress 1 mg daily, and two injections of NPH insulin. He admitted to drinking 8 ounces of beer a day. Clinical symptoms of neuropathy included his lack of foot pain and impotence. His blood pressure was 170/95 supine and 148/86 standing. He had upper and lower dental plates. His ocular lenses were slightly cloudy and he had moderately advanced diabetic retinopathy (red spots and hemorrhages in both eyes and proliferative changes near the discs). Both popliteal pulses and the right dorsalis pedis pulse were 1+. The left pedal pulses were questionable-to-absent. On October 25th his toe ulcer was odoriferous and "juicy" . Bubbles in the expressed drainage suggested "gas". The culturette was easily introduced 1.75 cm through the ulcer bed into the foot. Abundant Enterobacter cloacae was obtained. Position and deep pain sensation were diminished and light touch sensation was absent bilaterally. He had no foot pain.


His foot x-rays showed obvious disintegration and osteomyelitis of his first MP joint. His 4th MP joint also was abnormal.

He was treated with intravenous Tobramycin the first few hospital days along with local gentamicin injections into and around his first metatarsal-phalangeal joint. He received Mini-Boot therapy with his foot immersed in Sea Soaks and gentamicin. He was pleased to find that his foot swelling decreased more in the first few days of boot therapy than it had in his previous month of hospital care. An orthopedic consultant cut the extensor tendon of his first toe to successfully reduce the dorsal displacement of his toe. He was given a more aggressive insulin program and directions to test his sugar four times daily. Unfortunately, he began to feel good and insisted on leaving the hospital to return to work on November 8th.

He was erratic in coming for his outpatient treatments claiming to have important business pressures that kept him on his feet. In late December, he developed fever, headache and myalgias that he interpreted as "flu' and skipped his treatments altogether. On January 4th, 1986 he developed an ecchymosis around his right eye and a sensation as if he had been dealt a blow to the eye. On the 6th of January, he came to clinic feeling especially sick and was admitted for sepsis.


His foot was again swollen. He had a new dark purple spot on the dorsum of his first MP joint. He had multiple red spots on his foot and leg.

Blood cultures grew out Staphylococcus aureus. Our orthopedic consultant placed a Penrose drain through the plantar ulcer, between the first and second metatarsal heads and out the purple spot on the dorsum of the foot. He was given steroids, intravenous vancomycin and higher dosages of insulin. His usual Boot treatments were resumed and he improved. The physicians on the boot service went on a ski vacation and in their absence a general internist and an infectious disease consultant followed his case. They recommended radical surgical debridement and at least four weeks of inhospital intravenous antibiotic treatment. He refused their recommendations. He continued to improve and signed out against physician's advice so that he could be near his desk at work.

Indeed, he became a good outpatient and his foot did well. He stopped his treatment, however, before his final pictures were taken. He sought care of his diabetes and routine podiatry closer to home. In May of 1991 he developed another foot ulcer. He was given oral antibiotics with no success. He was again hospitalized for intravenous antibiotics again with no success in healing his ulcer. His surgeon provided him with Cipro for the next ten months. Finally on May 13th, 1992 he developed "flu" symptoms reminding him of his previous episode of sepsis. He came to Bryn Mawr and was hospitalized on May 16th, 1992.


He now had an ulcer under his 2nd metatarsal head.


His second toe and the dorsum of his foot were discolored.

His pedal pulses were again absent. A culture probe was admitted into the base of his ulcer and easily advanced perhaps two inches in the direction of the big toe. His Doppler waveforms were again abnormal but present... and modest PPG tracings could be made from his big toe. A vascular surgery consultation was deemed inappropriate.


The Doppler waveforms in the tibial vessels at the ankle level had all lost amplitude... but were present and potentially capable of augmentation with boot therapy.

His glycohemoglobin level of 13.6% on admission pointed to poor recent glycemic control. Serial cultures grew abundant Alpha streptococci, few Enterococci, few Staphylococcus aureus and some Candida albicans. His foot x-ray showed possible osteomyelitis of the proximal phalanx of the 2nd toe. He was treated with intravenous Vancomycin and later Ancef. One or both vancomycin and Ancef were injected into his ulcer bed before his daily boot therapy. In addition, his foot was pumped in the Mini-Boot while immersed in Sea Soaks containing gentamicin and amphotericin-B. He was discharged to office care on June 27, 1992.


His foot was well healed through the summer, but his big toe was again displaced dorsally. His extensor tendons were again cut to allow the toe to fall into a normal straight out position.


On February 19, 1994 he presented with a loose big toenail, a subungual abscess and a red toe. The nail was removed. He responded nicely to a few outpatient boot treatments and oral Cipro.


In October 1996, he noted swelling of both legs, scraped his shin and developed some redness. He was started on furosemide and given some Long-Boot therapy with Sea-Soaks gentamicin wet-to-dry dressings over the lesions.


His legs did well. As of February 1998, his legs had remained intact. However, he had not been a well-controlled diabetic and was walking with a broader stance than in the past.

He retired and began paying more attention to his diabetes with good results. Laboratory tests included an EKG November 1999 showing atrial fibrillation and an old inferior myocardial infarction; BUN 25 and creatinine 1.2 mg/dl in July 2000; and a glycohemoglobin A1C of 5.8% in September, 2000. His eyes and body, however, witnessed his many years of less well-controlled diabetes.

On November 28th, 2000, he presented again with infected foot ulcers. His Insurance company was advised standard care would require immediate hospitalization and intravenous antibiotics, which, in view of his past history, we did not expect to be successful. Instead, we offered outpatient Boot therapy and local antibiotics. They agreed to cover his treatments. A heavy growth of Enterococcus species (sensitive only to penicillin and vancomycin) and lesser growths of Stenotrophomonas maltophilia (sensitive to ceftazidime, trimeth-sulfa, and ticarcillin) and Coagulase-negative staphylococci (sensitive to gentamicin, Cipro, clindamycin, trimeth-sulfa, and vancomycin) were grown from the blister drainage. He was begun on local injections of gentamicin and Vancomycin along with oral Augmentin. In view of his leg swelling, he was treated with bilateral Long Circulator Boots. Before each boot session, he was given a dilute hydrogen peroxide Sea Soaks foot wash and his local antibiotic injections.


November 28th, 2000.


November 28th: the lateral aspects 4th and 5th toes especially appeared to be devitalized.


December 7th, 2000: The infection and swelling have largely been controlled.


The devitalized superficial skin is drying. The deeper tissues remain vital.

 


December 28th, 2000: The black areas have sloughed off and, except for a few raw spots, the skin was intact.


Likewise the dark areas sloughed off beneath the toes. Worried that his insurance had expired, he subsequently skipped his treatments. As he was now 98% healed, he has a good chance of healing now on his own. We hope so.

Comments: A man given to excesses: weight, work and beer. A man probably not compliant with his other doctors, who were, however, able to keep him in the hospital longer then we could. When we improved his status, he chose to leave the hospital for outpatient treatment. Unfortunately, he was not reliable in attending to his outpatient therapy. When he did, he did well. He broke every "rule" preached by those advocating bypass surgery, surgical debridements and long term intravenous antibiotic therapy. Are these "rules" founded in good controlled clinical research or do they merely relate to a style of practice that has worked for some physicians. It is obvious that these "rules" do not apply if therapy with the Circulator Boots and local antibiotics are employed. In recent years, he has become a well-controlled and compliant diabetic. He remains a diabetic still with a significant tissue burden of disease. Boot therapy helps him overcome these burdens. It may be noted that his insurance company profited in allowing his last outpatient treatments: a successful outcome gained at far less expense than the usual hospitalization.

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