Case 82: Foreign Bodies and Infection in Ischemic Neuropathic Foot

This man became familiar with the boot service when his wife was referred by the dialysis unit for gangrene of her feet. He was taking oral agents for his diabetes under the care of his family practitioner. He is a former smoker. He developed a dark spot under his first toe on July 11th, 1995 and found it to progressively enlarge. He referred himself for evaluation on July 19th.

Presentation July 19th, 1995

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It appeared that he had a significant neuropathy in his foot secondary to his diabetes: two-point discrimination was increased to five to seven inches and both light touch and vibration sense were absent. Further, he was unable to feel a fiber with a 5.07 stiffness. A glycohemoglobin of 10.3% and a random blood glucose of 230mg/dl pointed to poorly controlled diabetes. Doppler studies showed monophasic sounds in both the anterior tibial and posterior tibial arteries, pointing to the presence of arteriosclerosis obliterans in his tibial arteries. Photoelectricplethysmographic (PPG) tracings showed diminished blood flow in the toes, especially the right 2nd, 3rd and 4th toes. Pulse volume tracings showed diminished pulsations in both ankles, the left more diminished than the right. His ankle/arm index was 0.65 on the right and 0.81 on the left. Examination of his shoe showed a small bulge of a screw in the area of the big toe possibly explaining his lesion. A culture of pus expressed from his toe grew out a moderate growth of Beta-hemolytic streptococcus, some Streptococcus viridans, Citrobacter diversus, Staphylococcus aureus, Enterococcus and a heavy growth of Pseudomonas aeruginosa. He was started on an insulin program along with injections of antibiotics into his toe and therapy with the Circulator Mini-Boot. His toe appeared to be doing well merely having treatments on the 20th, 21st and 31st of July and the 1st of August. He returned on the 7th of August with a major cellulitis under the arch of his foot. A black head was visible in the middle of the arch, which, when probed, proved to be a wire of approximately an inch (2.5cm) in length. The wire was removed; it was thought to be the explanation of his new infection.

August 11th, 1995. Small red spots are seen at the sites of local antibiotic injections. The cellulitis is beginning to recede. The big toe is doing well. He was not hospitalized.

He was begun on our usual program for such patients: (1) an initial culture; (2) a broad spectrum antibiotic to intercept septic emboli from the feet; (3) a daily foot soak (dilute hydrogen peroxide in Sea Soaks) prior to his boot therapy to remove pus and debris; (4) local injections of antibiotics (commonly gentamicin) and (5) Mini-Boot therapy with his foot immersed in Sea Soaks and appropriate antibiotics. He initially was treated daily and, when it was obvious that his infection had been sterilized and the foot was progressing, the frequency of treatments was tapered. His foot did well.

November 10th, 1995. Dismissed from the boot room.

Comments: Diabetic infections are commonly polymicrobial. The toe of this man contained an extraordinary number of pathogens in a remarkably innocuous looking lesion. Like many diabetics with neuropathy, he was the victim of foreign bodies. Again, he was remarkable in having two separate problems in the same foot within a short period of time: a screw in his shoe and a wire embedded in his arch. The infection in his arch was the most dangerous. If the infection is not stopped immediately, tissue necrosis like that shown in "case 1" is common and the foot, if not lost, will require many months to heal. Here our treatment with local antibiotic injections guaranteed that an effective level of antibiotics would be present in his lesion. Finally, it may be noted that he was not hospitalized. These patients are commonly hospitalized for intravenous antibiotics. The latter are not as effective as locally injected antibiotics. Hospitalization does have two major advantages, however: patient compliance and bed rest.