Case 180: Diabetic Foot: Ulcer Healed and Osteomyelitis Aborted with Boot Therapy.

This 47 year old grocery clerk had been known to have high blood glucose levels since he had a stroke in 1996. He regularly visited his cardiologist who had seen him safely through a coronary angioplasty procedure. He presented to the boot clinic January 26th, 1998 with a 12 week history of a draining sore lateral to his right 5th metatarsal head. His review of symptoms was unremarkable except for orthostatic hypotension. His hemoglobin A1c was 10.4% and his erythrocyte sedimentation rate 39 mm/hr. Vascular testing done at his HMO capitated site noted ankle/arm indices of 1.47 in the right leg and 1.6 in the left. He had no palpable distal pulses.

A thick odoriferous callus was trimmed away revealing a small ulcer through which the culture probe appeared to reach the 5th metatarsal-phalangeal joint.

He was given a cleansing foot soak in Sea Soaks and dilute hydrogen peroxide. He was then given a 500mg sample of Augmentin orally. Next, his lesion and 5th MP joint were injected with gentamicin. His foot was then immersed in Sea Soaks containing gentamicin and his lower leg pumped in the Mini-Boot. These treatments were repeated daily over the next four days. His foot appeared to be doing well. His culture report then returned: a heavy growth of Enterococci (sensitive to ampicillin and vancomycin), a heavy growth of coagulase-negative Staphylococci (sensitive to Cipro, TMS, tetracycline and vancomycin) and a heavy growth of Streptococcus group D, a non-Enterococcus species, (sensitive to chloramphenicol, erythromycin, tetracycline and vancomycin) were grown out. The gentamicin was replaced with vancomycin both in the injections and in the Sea Soaks. An x-ray of his foot showed no clear-cut evidence of osteomyelitis.

After 12 outpatient treatments, his sedimentation rate was 15mm/hr and his foot appeared to be healed. If he had osteomyelitis, it was aborted. He was dismissed from the boot room to the diabetic clinic to follow-up on his diabetes training.

Comments: This man had had no instruction regarding management of his diabetes. The penetration of his ulcer and the probe hitting bone suggested that he might have had osteomyelitis. We loaded his joint space with antibiotic less he did have osteomyelitis. His x-ray did not show it (but serial x-rays were not done as he healed and his sed rate fell to normal). His HMO allowed the determination of an ABI, which was elevated ABI suggesting medial calcinosis. His lack of palpable peripheral pulses again suggested significant obstructive arterial disease. Further vascular testing would have been helpful and might have altered our boot procedures. Still, he responded nicely to our outpatient treatments and has continued to do well. His prognosis will depend on his future compliance to a good diabetes program.