Case 184: Treatment of Osteomyelitis (1991), Leg Ulcers (1995) and Heart Failure and Chronic Renal Failure (1998)

Treatment of Chronic Osteomyelitis: This lady presented at age 74 for boot therapy on July 29, 1991 because of a persistent infected ulcer in her right foot. She had had bypass surgery in her right leg in 1986. Worsening angina led to sextuple coronary bypass surgery with the use of her mammary artery on January 5th, 1990; a postoperative sternal infection had required muscle-flap closure. Ultrasound showed normal left ventricular function on July 9th, 1990 accompanied, however, by aortic sclerosis, mild aortic insufficiency, moderate mitral insufficiency and concentric LVH. The development of the ulcer in her right foot led to study of her legs on the 30th of July 1990; an ABI of 0.61 in left leg and 0.95 in right leg along with diminished pulse volumes in left leg with especially low readings in the left midfoot were reported. Foot x-rays on August 28th, 1990 showed advanced degenerative joint disease of right 1st MP and 5th MP joints. Her rubor and drainage were thought to be associated with osteomyelitis which was treated under the guidance of her endocrinologist, vascular surgeon (various debridements), orthopedic surgeon and infectious disease specialist over the next year. Her hyperkalemia (K+ 5.1-6.0 mEq/L), anemia (Hgb 10.1), mild azotemia (BUN 26-32 mg/dl) and creatinine retention (2.1 on May 13th, 1991) were attributed to chronic renal insufficiency by her physicians. A repeat bone scan on May 6th, 1991 showed increased uptake over the right first MP joint. On June 4th, the orthopedic specialist was able to probe the ulcer showing extension into the joint space. An elevation of her sedimentation rate to 103 mm/hr on the 17th of July 1991 was attributed to the osteomyelitis in her right foot, then present for a year. In the meantime, her ophthalmologist had found 20/400 vision in both eyes associated with with macular degeneration, cataracts and minimal background retinopathy. Her vascular surgeon recommended amputating her first toe and removing the joint. The orthopod recommended a resection of her first ray. She refused and was referred by another patient to our boot clinic on July 29th, 1991. She was then taking insulin 15 units, atenolol, furosemide, Volataren, Ascriptin, Augmentin, vitamins and iron. Her HgbA1c of 8.4% (N< 6.1%) pointed to a lack of ideal control of her diabetes. Her walking capacity was limited to 1-2 blocks. She was treated on 13 occasions as an outpatient with local injections of gentamicin into the joint space followed by Mini-Boot treatments. Her ulcer healed and she was dismissed on September 3rd. X-rays at Bryn Mawr were thought to be as suggestive of gouty arthritis as osteomyelitis. Her uric acid level was found to be only mildly elevated at 7.23 mg/dl, a value in keeping with her renal dysfunction.

Her first metatarsal head had destructive changes compatible with the diagnosis of osteomyelitis... but gout was also suggested.

!992-1994: As the endocrinologist at her hospital died, she began coming to our office for diabetes management in January, 1992. Her hemoglobin A1c 8.8 (N<6.2) was still elevated . Her thyroid function was normal (TSH 1.53). In May 1992, her cardiologist noted bilateral leg edema (right leg more than left) and started Pravachol 20 mg per day for her modest hypercholesterolema. In August 1992, her creatinine was noted to be holding at 2.0 mg/dl. Her ophthalmologist reiterated that her visual loss was more due to macular degeneration than to her diabetes. In January 1993, her cardiologist attributed her dypsnea to left ventricular hypertrophy and possible diastolic noncompliance of her left ventricle. On February 2nd, 1993 her serum creatinine was again 2.0 mg/dl and a thallium persantine test was negative for ischemia. During the rest of the year, she was noted to have two-block claudication, her cardiologist added Procardia for her hypertension, her ophthalmologist began Pilocar and Betoptic for glaucoma and she ate excessively enough to maintain her weight at the 180 pound level.

November 14th: An edematous ulcerated leg not responding to the diuretics of her cardiologist.

November 27th: Less swelling and the ulcer drying up and healing.

December 12th: Dismissed from the Boot Room.

1996: Her cardiologist noted on January 19th that her ECHOcardiogram showed mild pulmonary insufficiency, mitral annular calcification, severe mitral regurgitation, aortic stenosis (mild with valve area 1.4 cm2), mild aortic insufficiency and tricuspid insufficiency with normal function and size of her left ventricle. On January 22nd, her hemoglobin was noted to have fallen (7.2 gm/dl). Her renal function (creatinine 2.4mg/dl) was not abnormal enough to explain her anemia. Her cholesterol had dropped to 152mg/dl. A barium enema showed a sessile polyp in her proximal ascending colon. Her chest showed cardiomegaly with mild congestive heart failure. On January 29th, her surgeon removed a 1.3x1x1 cm villanous adenoma with moderate atypia. She was discharged with prescriptions for Lanoxin 0.25 mg qd, Isordil 10 mgTID, Aldactone 25 mg qd, Lasix 40 mg qd, Apresoline 25 mg BID, Losartin 50 mg qd, Zocor 20 mg qd, Tenormin 25 mg qd, Aminophylline 100 mg TID, and Ferrous sulfate 300 mg BID. On February 7th, her hemoglobin was 11.5 gm/dl and her digoxin level was in a toxic range (2.8 mg/dl). On March 19th, her hemoglobin was 10.8 gm/dl and her renal function unchanged (BUN 36 and creatinine 2.4 mg/dl). In July, her cardiologist found her ankles swelling to have increased and increased her diuretics to include Zaroxolyn 2.5 mg 3 days a week. On July 22nd, her BUN was noted to have increased to 81 mg/dl and her creatinine to 3.4 mg/dl. She was advised to avoid phosphorus in her diet. Oral calcium carbonate was prescribed to bind phosphorus in her intestines and Rocaltrol (Dihydroxy-vitamin D) was given 0.25 mg daily.

August 21st: Basal congestion and cardiomegaly pointed to congestive heart failure.

The boot service, on the other hand, noted the warm weather, the confusion of the patient, the unlikely possibility that she had been drinking an adequate amount of fluid, her known cardiac dysfunction and the possibility that she had a combination of dehydration and congestive heart failure. If the latter were true, further fluid restriction would worsen her renal failure and indeed possibly kill her in the absence of dialysis. A fluid challenge accompanied by heart support with the Circulator Long-Boots was accomplished.

Our IQ electrical impedance apparatus was used to document we could indeed improve her cardiac output. Here are shown her dZ/dt waveforms representing changes in her cardiac output on a beat-by-beat basis during booting on alternate heartbeats. The top line is her EKG. On the bottom line, the red arrows show her assisted beats and the black arrows the unassisted beats.

She was first given 5% glucose in half normal saline at 40 ml per hour for two days. Her urine output increased and the infusion was increased to 80 ml per hour. On the 27th of August, her BUN had dropped to 69 mg/dl and her creatinine had dropped to 4.9 mg/dl. She continued on the Cytomel. Her TSH was less than 0.05 and her thyroxine serum level was less than 1.0 ug/ml suggesting that her thyroid cancer no longer made thyroxine and might not now take up radioactive iodine. On August 28th, she was transferred to our Transient Care Unit to continue her stroke rehabilitation, to await a new thyroglobulin level and to continue her booting. There she achieved her lowest values for BUN (49 mg/dl) and creatinine (4.2 mg/dl).

September 4th: Her dypsnea had improved and her lungs cleared with her boot therapy.

Over the Labor Day weekend, she again received no booting for four days; on the 4th day she again appeared to have a new stroke and her creatinine were found to have risen to 4.6 mg/dl. With reinstitution of booting, her cerebral function improved and she was discharged home to receive her boot treatment as an outpatient. A rising thyroglobulin level (3775 ng/ml) appeared to necessitate more I131 therapy. Her Cytomel was discontinued and TSH allowed to rise. Subsequently, an I131 scan revealed multiple foci of tumor and another 31 mCi of I131 was administered as an outpatient. She is to continue booting as an outpatient to support her heart and kidneys... until the effort is no longer in her interest because of the spread of her tumor.

Comments: This lady is included for many reasons. Her initial osteomyelitis had resisted the best care her hospital had to offer for over a year. A short course of local antibiotics and boot therapy had a long-lasting benefit and the foot remains intact today. Her leg ulcers developed in spite of the vain attempts of her cardiologists to prevent peripheral edema. The cardiac-assist action of our Long-Boots helped her control her edema and heal her legs. Suffering from potentially terminal congestive heart failure and uremia, she was benefited again by the cardiac-assist action of booting. Her multiple medical problems and lack of any remaining peripheral veins made her no candidate for any form of surgery. Could her problems have been treated by any other method? Her mitral valve disease contributed likely to her heart failure but does not prevent immediate benefit from booting. Her aortic valve, fortunately, did not have significant insufficiency; if it did, Long-Booting would have had no cardiac benefit. These patients do not need to be booted everyday. Booting Monday, Wednesday and Fridays seems to keep them free of problems. As with this patient, however, a four or five day lapse in therapy is commonly associated with a return of heart failure and a worsening of renal function. In this patient, cerebral function seems also to fail.