Case 62: Sepsis, 15-Year Ulcer, Osteomyelitis, Arteriosclerotic Heart Disease and Rest Pain in Opposite Leg

At age 72 this man presented December 13th, 1991 at the Bryn Mawr Hospital with suspected generalized sepsis, a 25-year history of diabetes, a 25-year history of having a tender spot beneath his right first metatarsal head, a 15-year history of having ulcers in this area (the area "rarely healed") and a history of having tried many physicians and podiatrists in attempts to cure his foot. Contact casting, for example had failed and resulted in a "swollen leg". He had coronary angioplasty in 1989. His cardiologist was giving him Cardizem, Isordil and Lopressor for his heart and elevated blood pressure. His right leg limited his walking to one half a block. His relative weight was 1.42. He had found his way to a vascular surgeon near his home at the New Jersey shore. The latter obtained a bone scan showing possible osteomyelitis in his first right metatarsal-phalangeal joint and in his sesamoid bone. He was admitted to the nearby New Jersey hospital for possible debridement. Vascular testing showed an ankle/arm index of 0.61 in the right leg and 1.59 in the left. Faced with surgery, he requested transfer to Bryn Mawr to be closer to home and was hospitalized there December 13th.

On presentation, the dorsum of his foot was ruborous and there were red streaks up his calf and thigh.

On the plantar surface he had a large ulcer with visible bone.

His temperature was 100.2 F. His ankle blood pressure in the right foot varied from 40 to 70 mm Hg. Light touch sensation was absent and he could not feel the wooden sticks used to measure 2-point discrimination. Pseudomonas maltophilia and Staphylococcus aureus were cultured from the plantar ulcer. Laboratory finding included a serum sodium of 134 mEq/L, a white count of 11.6 (85% polys and 1 band), an erythrocyte sedimentation rate of 115 mm/hr and multiple premature ventricular beats on his EKG. He was treated with intravenous Timentin and Vancomycin and local foot injections of gentamicin. He received both Long-Boot treatments from his groin to mid-foot and Mini-Boot treatments with his foot immersed in multi-electrolyte solution (Sea Soaks) containing gentamicin, Vancomycin and methacholine. He did well and, when he was stable and afebrile, he was discharged on Bactrim-DS, Fluconazole, an outpatient Circulator Boot program and a walking Air-Cast.

His sesamoid was protruding from his ulcer 3/11/92 and was plucked out of the ulcer bed.

While his initial ulcer was essentially healed, a large devitalized area under the lateral three metatarsal heads developed with excess activity.

Over the next 18 months, he received 225 boot treatments to his right leg and 91 to his left leg. Periodic cultures guided the use of both oral antibiotics (usually Bactrim-DS and occasionally Fluconazole) and locally injected antibiotics (generally gentamicin). His ambulatory treatments had the advantage of limiting his hospital time but the disadvantage of prolonging his overall treatment time. Daily activities like hours of leaf raking, for example, clearly slowed healing. The treatments to his left leg began in May 1992 when he complained of rest pain. Both legs have done well.

His ulcer healed but he develops callus at the site which commonly has to be cut back.

Comments: As of December, 1996, the legs of this man continue to do well. He seems to be more limited his heart at present. His bradycardia (40-55) range could likely benefit from a pacemaker. He is another example of a patient with many difficulties that were not readily handled elsewhere. .