Case 36: Vasodilatation with Cholinergic Agonists in Patient with Recurrent Neuropathic Ulcers and Osteomyelitis

This type 1 diabetic male was referred at age 32 in 1986 for cellulitis and ulcerations of the right foot. He had already had three hospitalizations in 1985 at his hometown hospital. He was given five outpatient treatments and healed his lesions. In the next seven years, he relapsed five times, having various lesions in different toes and feet. Each time he was healed with the use of oral antibiotics, locally injected antibiotics and Mini-Boot therapy

Here he had presented in 1989 and agreed to participate in our studies with cholinergic agents. Atropine (a cholinergic blocker) and methacholine ( a cholinergic agonist) were injected into the sole of his left foot. Photoelectricplethysmographic (PPG) tracings before and after the injections are shown. Both substances increased the amplitude of the PPG tracings, but the methacholine had a significantly greater effect.

Left Foot: Baseline PPG Tracings

PPG Tracings after Atropine (upper) and Metacholine Injections (lower).

The callus around his plantar ulcer on the right foot (which had brought him to the office) was debrided and methacholine was applied; a reddening of the ulcer base is seen. He again was treated with the usual antibiotic-Mini-Boot regimen but with home multielectrolyte soaks containing methacholine added to his program. He healed again.

Plantar Ulcer after Methacholine Application

He resurfaced again July 21, 1990. He had developed another ulcer, cellulitis of his foot and an osteomyelitis of his first metatarso-phalangeal joint. Fever, uncontrolled diabetes and his great distance from home were factors leading to a ten day hospitalization. He was given intravenous antibiotics, locally injected antibiotics and Mini-Boot therapy. His foot again healed.

Recurrent Plantar Ulcer Penetrating to Bone

Osteomyelitis of First Metatarsal Head

Healed Again

Comments: This man illustrates the course of many patients whose diabetes historically was poorly controlled. He had multiple episodes of foot ulcers in spite of a good blood supply. The visible dorsiflexion of his big toe (or hammer toe deformity) is related to his neuropathy. The dryness of his skin is seen in his original photographs and is again related to his neuropathy and lack of sweating. He was instructed in the importance of lubrication and in his later pictures the skin does look healthier. Normal skin will respond to the insertion of a needle with a reflex vasodilatation. The injection of the atropine did not abolish the reflex (here assuming the atropine permeated the tissue well) while the injection of methacholine greatly enhanced the vasodilatation. We commonly will add Urecholine or Methacholine to Sea Soaks and use them alone in patients with a good blood supply and neuropathic lesions that are clean and free from infection.

He also suffered a second consequence of his neuropathy: osteomyelitis of a prominent metatarsal head. (The first consequence was recurrence of his ulcers.) He healed the osteomyelitis nicely and relatively quickly with the combination of intravenous and local antibiotics and boot therapy. Unlike past practices, he did not get many weeks or months of intravenous antibiotics in the hospital or under the care of a visiting nurse. His program was quicker, cheaper and effective..