Case 64: Mottled Foot Saved in Young Women

At 42 years of age, this non-smoking and non-diabetic lady on June 19th, 1994 presented to the Bryn Mawr Hospital with impending gangrene of the right distal foot. Her past history was unusual but did not explain the development of her current lesions. She had had an episode of abdominal pain associated with a mild elevation of her serum amylase (?pancreatitis) in 1988. In September, 1988 she developed a bull-eye shaped rash thought to be erythema multiforme and was treated with steroids (?allergy to topical antibiotics) and was again treated with steroids. In August of 1989 she had another rash and another course of steroids. In November of 1989, she had another bout of abdominal pain associated with an elevation of serum amylase. In December of 1990 she developed prominent ischemic changes in her big toe and lesser changes in her 4th and 5th toes after cold exposure. She had "several" hospitalizations for Dextran infusions and sympathetic blockade with Guanethidine. Her lesions healed. In May of 1991, he had another episode of abdominal pain and in June of 1991, she had an episode of thrombophlebitis. In February of 1991, she experienced weakness on the left side of her body and an arteriogram was thought to show changes in her middle cerebral artery. Finally, she developed pain and discoloration in her right foot leading to hospitalization at a Philadelphia University Teaching Center where she was studied by multiple specialists including those in hematology, vascular medicine, vascular surgery and psychiatry. An intermittent elevation in her platelets and white count was found. An arteriogram showed a blockage in her right popliteal that might have been a source of emboli to her foot. There were other findings, however similar to those found in diabetic legs or in those with a vasculitis: a decreased caliber of the anterior tibial which ended above the ankle, occlusion of the posterior tibial as it entered the arch and occlusion of the peroneal below the mid-calf. Likewise the left leg had multiple stenoses in the posterior and anterior tibial arteries, a completely occluded peroneal and a diffusely diseased planar arch. She was treated with Prazosin, Trental, a morphine drip and Urokinase infusions with no benefit. She was taken to the operating room where the right popliteal proved to be partially blocked by atherosclerotic plaque and a femoral-popliteal bypass, using a vein from the left leg,, was performed. Postoperatively, her foot continued to look ischemic. She was told that she would likely loose some toes and that a transmetatarsal amputation would not likely heal . A BK-amputation was held out as the most likely successful procedure. As an alternative approach boot therapy was offered along with transfer to Bryn Mawr. She elected the latter and was scheduled to arrive at Bryn Mawr around 2PM, June 19th, 1994. .

On presentation for boot therapy, the distal foot was mottled (ink marks roughly denoting the margin between good and bad tissue). The skin over the 1st metatarsal joint to the end of the big toe remained lard white even after prolonged dependency. The tips of the 2nd and 3rd toes were dark and drying out. In left foot (not shown), she had mild cyanosis of the toes.

Her arrival was delayed until the late evening as she wanted to confer with each of her consultants before leaving the hospital. Dr. Dillon returned in his gardening clothes to greet her with no entourage of interns or students. "Am I in the right place?" she asked. Early in the course of her hospitalization, few boot treatments a day were accomplished as she required great explanation before any treatments were done. A routine was slowly established. Her foot was first soaked in the morning with Sea Soaks and gentamicin to keep the skin hydrated and the bacteria count in the skin low. The foot was then wrapped in a single layer of sterile gauze and oxygen catheter placed around her arch. The foot was then placed in a plastic bag to contain the oxygen and the bag was contoured against her foot with loose gauze. Oxygen was run at 1 liter a minute. It was hoped that the topical oxygen would help keep the skin envelope intact until booting restored cutaneous blood flow. The bagged foot was then placed in the Miniboot as many times a day as she would allow. Her pain made her fearful but she found she was actually comfortable during the booting procedure. She was advised that the dead portions of her foot would demarcate and we would anticipate autoamputation of the dead tissue. Her laboratory data included an admission white count of 14.7 that peaked at 18.5 on June 25th. By July 11th the count was normal and remained so. Her glycohemoglobin was elevated to 8.3% on admission (normal <6.1%) but it was noted that she had been maintained on intravenous glucose solutions during the previous weeks, that she was not thought to be diabetic and it was found that her subsequent blood glucose values were all normal. Her blood cultures were negative while her urine grew abundant Enterococci. Her foot lesions only grew out occasional coagulase-negative staphylococci. Later yeast were recovered and she was given oral Fluconazole. The skin slowly improved and the margin of the on the mottling gradually moved distally. Demarcation occurred across the proximal one third of the 1st to 3rd toes and the tip of the 4th toe; the distal portions of the toes mummified and were clipped off.

The dry dead portions of the toes were clipped off leaving a proximal margin of black eschar, Aug 25th, 1994.

Loose dead material was also occasionally trimmed, Oct.14th, 1994.

Once an open lesion was present, an initial dilute peroxide foot soak was added to help debride the lesion and reduce the bacteria count without the use of antibiotics. The latter were injected locally if an area appeared infected and were also used within the Sea Soaks solution in the Mini-Boot therapies. She was discharged from the hospital to the nursing home boot facility and then to the office treatment center.

Bone protruded from the lesion and some necrotic fat persisted on the plantar areas, Dec. 1st, 1994.

Normal skin moved in from the edges toward the bone, Feb. 3, 1995.

On occasion, bony cortex was scraped away and marrow bared to allow skin coverage, June 21, 1995.

The foot was generally solid and she was walking without difficulty. A few small firm areas of bone still protruded. Jan. 10, 1996.

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