Case 70: Distal Small Vessel Disease and Infection Treated with Local Antibiotics and Mini-Boot
A diabetic since age 11, this man was referred at age 45 on April 9th, 1986 with an infected gangrenous right foot. His difficulty had begun on February 29th, 1986 with a blister of his right fourth toe. His doctors initially prescribed Betadine foot soaks, local debridements, ten days of intravenous Mefoxin in the hospital and subsequent outpatient whirlpool treatments. His foot suddenly became worse leading to another hospitalization on March 27th for an open amputation of his 4th toe. Pseudomonas aeruginosa and Enterococci were cultured and intravenous antibiotics and whirlpool treatments were continued. Adjacent areas of the third and fifth toes along with the amputation site became blackened. Reddening of the dorsum and the sole of the foot suggested that the infection was uncontrolled and spreading and that a transmetatarsal amputation was lost as an option. A beneath-the-knee amputation was mentioned. The patient requested transfer to the Bryn Mawr Hospital for boot therapy.
Foot on Arrival March 9, 1986. The blackened area suggests necrosis associated with Pseudomonas infection. The sallow blue color of the 5th toe suggested it was lost. The necrotic process eroded into one third the thickness of the third toe at its base. A little hair was seen on the proximal foot.
After transfer to Bryn Mawr, Doppler testing showed proximal pulses in the foot but poor flow in the distal foot. He received Mini-Boot treatments with his foot immersed in Sea Soaks and antibiotics three to four times a day in the hospital for three weeks. Prior to the first morning treatment, the obviously infected areas of the foot were also infiltrated with antibiotics. The 3rd and 5th toes mummified and were clipped off in the office. He retained his leg and foot.
The cellulitis is gone. Hair is growing freely on the dorsum of the foot. The 3rd toe still has to be trimmed back. He is fully ambulatory and working, October 31, 1986.
The foot is well healed with a small area of callus-like tissue persisting over the 3rd toe amputation site, November 9, 1987.
Comments: The damage to his foot resulted most likely from infection to which his foot was predisposed by small vessel disease. Some argue about the nature of "small vessel disease" in diabetes. Here was a man with fading Doppler signals distal to the ankle. Call it what you will. We have had various patients referred from the local hospital of this patient. All had had whirlpool and Pseudomonas infections. We hypothesized that the whirlpool was the villain. First, hot water is a hazard for ischemic and/or neuropathic feet. Second, either sterile tap water or saline is used in the whirlpool and both are hard on ischemic tissue (we prefer Sea Soaks). Next, whirlpools and their motors are not easily and cheaply sterilized. Finally, whirlpool treatments do nothing to restore the circulation. Indeed, the weight of the water on the skin impedes blood flow through the small vessels. Healthy people survive whirlpool nicely... people with ischemic disease or neuropathy may not.
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