Case 192: Chronic Transverse Osteomyelitis of the Big Toe Cured and Amputation Averted with Outpatient Treatments.

Born March 25th, 1947, this lady achieved a weight of 170 pounds at age 18 and 195 pounds by age 25. For her 69.5 inches height, we calculated she had an ideal weight of 165.25 pounds for her frame and history (compared to 148 pounds for a women her height with medium frame). She achieved a maximum weight of 259 pounds during a pregnancy. She was to present at 217 pounds in Bryn Mawr on December 21st, 1998. With obesity and a family history for diabetes, she was not surprised to find herself diagnosed as having diabetes in 1991 when she had a yeast infection. Again likely associated with her obesity have been the development of arthritic symptoms in hips, knees and back. In the notes of her family doctor, it appears that her present toe problem began with a skin "burn" she incurred getting out of a pool. Having an ulcer by the 25th of July, she was then given amoxicillin 500 mg three times daily. On August 25th, her doctor found a "crater" on her plantar and outer aspect of her great toe. He found her pedal pulses and ankle/arm blood pressure ratios to be normal. He advised her to continue the Amoxicillin. The infection persisted leading her to consult orthopedic and podiatric specialist at an academic center in North Carolina in October. A bone scan showed osteomyelitis of the proximal phalanx of the distal big toe. Their recommendations to her included a formal vascular work-up, open toe biopsy and culture if the blood flow was good, and possible amputation if the blood flow was poor. A culture of her drainage produced a heavy growth of Enterobacter cloacae (sensitive to ceftazidime, ceftriaxone, ciprofloxacin, gentamicin and ticarcillin) and Beta-hemolytic streptococci. Her sedimentation rate was 60mm/hr. She was hospitalized, the toe debrided, and intravenous antibiotics administered for 8 days. She was discharged to take Trovan 200 mg daily and to continue on her usual medications (metformin, aprazoloxic, acidophilis, Darvocet and Voltaren). At her follow-up visit in December, she was advised she should have her toe amputated. Coming by this website on the Internet, she sought out our office in Bryn Mawr for a second opinion. She gave us a history that began in July of 1997 when she had a fungus-laden nail that she treated herself both poking a hole in her skin and possibly leaving a portion of a toothpick in the skin adjacent to the nail groove. She sought the help of a podiatrist who apparently suspected she had a paronychia and incised the nail groove and the lateral toe but found no pus. He then removed the side of the nail to the nail bed and curetted out the lateral nailbed and the tissue proximal to it toward the distal interphalangeal joint. He prescribed the amoxicillin. The soft tissue in the distal toe healed in a few days but the area over her distal interphalangeal joint became purple and hurt. She thought she was bruised and did not return to the podiatrist because she felt he had been too aggressive. The joint continued to be bluish and tender over the next year. Then on July 25th, 1998, she blistered her toe on the hot cement of a pool in Key West. The blister failed to heal taking her family doctor and her orthopod. She reiterated the story of her hospitalization and the recommendation for amputation.

December 10th, 1998: She brought this film with her showing radiolucency almost across the entire distal proximal phalanx of the big toe and a small radiolucency in the lateral proximal portion of the distal phalanx.

December 21st, 1998: Her toe ulcer on presentation prior to debridement.

December 21st, 1998: Her toe ulcer after debridement of callus and loose crusts. The ulcer clearly penetrated to the bone.

Both her posterior tibial and dorsalis pedis pulses were easily palpable with firm touch (2+). Modest PPG waveforms were demonstrated in all of her toes. Two-point discrimination of 6-10 cm in both feet and decreased vibration sense (Bio-thesiometer readings of 35-39 volts in her big toe) pointed to significant neuropathy. A culture of the drainage expressed from her toe grew a heavy growth of Beta-hemolytic streptococci, a heavy growth of coagulase-negative Staphylococci (sensitive to clindamycin and vancomycin and intermediate to gentamicin) and a moderate growth of Enterococcus species (sensitive to ampicillin and vancomycin), a report not too different from that obtained at the time of her hospitalization. While the culture incubated, we began her therapy with local injections of gentamicin into her ulcer and the joint space before a Mini-Boot treatment. After the second day of treatment, the toe appeared to be smaller and she returned to North Carolina continuing with the Trovan. When the culture returned, we called her to report that her Trovan was likely not effective as our culture showed Cipro (which has a similar antibacterial action) to be ineffective and the Trovan had not prevented her from growing our pretty much the same multiple organisms. She returned for outpatient boot therapy on December 31st. She still had an investment in a supply of Trovan, which we allowed her to finish, but we added local injections of both Vancomycin and Urecholine into her toe. She received treatments daily from January 2nd to January 9th, 1999. We did not renew the Trovan but replaced it with ampicillin 500 mg and clindamycin 300 mg both to be taken three times daily. Lactinex three tablets after each meal was added to hopefully lessen the gastrointestinal effects of her oral antibiotics.

January 9th, 1999: The penetrating ulcer was closing and the drainage was gone.

February 8th, 1999: The ulcer was closed. A small blood blister is seen at a needle site.

February 8th, 1999: The big toe remained slightly swollen.

August 25th, 1999: She returned for an evaluation of an infra-malleolar ulcer which she had developed while fishing in rubber wading boots. Her toe had remained healed.

August 25th, 1999: Her toe swelling was reduced. Her toenail needed trimming.

October 29th, 1999: The radiolucent areas had recalcified. Ink marks were on the film across the distal interphalangeal joint.

Comments: The distal interphalangeal joint of this lady was symptomatic from July 1997 until we saw her in December 1998, a period of one and a half years. Oral and intravenous antibiotics had proved ineffective. Having failed standard care to heal her infection, she was offered the standard remedy: toe amputation. In our Epidemiology library, we find that toe amputation significantly increases the likelihood of new ulcerations in the neuropathic foot. "Standard" care can be expensive. Here, boot therapy and local antibiotics proved to have a rapid therapeutic effect. The vancomycin used locally here may have an irritating effect potentially producing some swelling and redness itself. The patient with neuropathy feels no pain with the injection. Non-diabetic patients may feel pain. The pain, however, disappears within a few minutes once the Mini-Boot begins to massage the foot. This lady had no pain but did have some swelling suggesting some irritation after the injections. The Urecholine was added because of her neuropathy to produce some vasodilation of the capillary beds. With repeated use, it may promote reddening suggestive of cellulitis. It does not promote drainage, however, and cultures hopefully will become sterile as the treatments proceed.