Case 89: Poorly Controlled Diabetic with Peripheral Neuropathy and Arteriosclerosis Obliterans Complicated by Cellulitis, Abscesses, Osteomyelitis and Ulcers

At age 56, this black male with a history of poorly controlled diabetes for 18 years was referred November 7, 1991 on his 9th hospital day with an abscessed foot and osteomyelitis of his first metatarsal-phalangeal joint. With an ideal weight of 151 pounds, he had been enjoying a 255 pound weight and blood glucose levels in the 200-275mg/dl range for years. His family doctor had been treating him with oral agents and diet. A construction worker with numb neuropathic feet, he had walked on recently-poured asphalt paving burning the sole of his foot in June of 1991. He was followed by his podiatrist who referred him to his family doctor when the osteomyelitis proved unresponsive to oral antibiotics. The latter hospitalized him and began intravenous antibiotics. He had no palpable pedal pulses and no leg reflexes. He had a red streak from his foot to the upper 3rd of his calf. Background retinopathy and EKG changes of inferior wall myocardial ischemia were noted. Enterococci and Beta-hemolytic streptococci were cultured from his feet. His fever and foot drainage persisted. His family doctor became worried and called for a boot consultation. .

The culturette probe entered perhaps 3-4 cm into the foot and returned soaked with pus. A roll of tape holds the toe apart for the picture. November 7th, 1991.

Obvious osteomyelitis of 1st MP joint before admission October 29th, 1991.

Eleven days into therapy with boot and local antibiotics, November 18th, 1991.

Outline of bones generally sharp while joint cartilage hazy, January 31st, 1992.

Follow-up April 2nd, 1993. Bones healed and joint fused.

Boot therapy was commenced and he was transferred from the hospital to our nursing home boot facility for our standard therapy: (a) systemic protection against septic emboli with an appropriate oral antibiotic (Augmentin in his case), (b)injection of appropriate antibiotics into the infected areas of his foot by the boot nurse (gentamicin and Vancomycin), (c) Mini-Boot therapy with his foot immersed in Sea Soaks containing Methacholine (a cholinergic agonist is added if neuropathy is prominent) and appropriate antibiotics (here again gentamicin and Vancomycin). He was discharged from the nursing home with a walking air cast December 15, 1991 and his therapy was continued in our outpatient boot room. He returned to work wearing his air cast. On December 30th a culture showed Acinetobacter anitratus. His oral antibacterial therapy was changed to Bactrim-DS and his local injections to ticarcillin. He had been changed to insulin and his glucose levels were much improved. With his booting, the numbness in his left foot receded while that in the right persisted. On February 27th, 1992, he complained of pain in the right leg where he had known arteriosclerosis obliterans also (no palpable pulses, monophasic Doppler sounds at the ankle with pseudohypertension). Subsequently, his right leg was booted and the numbness receded there also.

Here on March 3rd, 1992, our technician holds his toes apart. He appeared to be close to healed. On May 7th, he did appear healed and his booting and Bactrim-Ds were discontinued.

In August, he returned with a small draining sore at his previous abscess site. Staphylococcus aureus was cultured. Boot therapy and local antibiotics were again begun.

His foot responded nicely and the sore healed. X-rays showed no new changes. He was again discharged November 9th, 1992.

He went to work throughout his treatments. The ambulation and his construction shoewear, which may be required on the job, posed obvious hazards. He returned November 28th, 1992 with a new lesion between his left 4th and 5th toes. E-Coli and Staphylococcus aureus were cultured. This responded quickly to therapy and again he was discharged.

He returned on August 31, 1993 with a new lesion, this time on his right foot. He had come early but not early enough. The lesion penetrated his interphalangeal joint which was filled with pus. Abundant Staphylococcus aureus, moderate Beta-hemolytic streptococcus and some Klebsiella pneumoniae were recovered. The infection was contained but by few millimeters of skin around the circumference of the toe. As seen below, the infection transected the toe and an autoamputation eventually occurred. During this episode, he wore his air cast on his right foot and reported to work for light duty. As the toe lesion granulated in, abundant Pseudomonas aeruginosa invaded the lesion. The latter was treated by adding ceftazidime to the Mini-Boot bath.

Penetrating ulcer right 5th toe, August 31st, 1993.

His autoamputation had been assisted; a portion of healthy red tissue was cut across in the clinic, September 23rd, 1993.

Here the lesion had dried up. It was eventually shaved smooth.

By June of 1994, he was working again full time. A brief hospitalization for a small myocardial infarction during the summer and a fractured shoulder after a fall in December were major setbacks. His feet, however, did well until October, 1995 when he developed an infected blister under his left first metatarsal head. The blister broke leaving an infected ulcer. The latter responded to our routine therapy as shown below. He continues to develop callus at the site and require debridements and appropriate local therapy if it appears infected. He has continued to work when he can and is counting the weeks until he can retire.

The culturette probe entered the blister and a small cavity. November 11th, 1995.

Without the overlying skin, a modest sized ulcer was seen. November 30th, 1995.

Grease from his topical antibiotic is on his lesion and some secretions are crusted under his big toe. The ulcer healed but callus repeatedly formed and required debridements. February 6th, 1996.

Comments: This man requires repeated care and will require it as long as he is active on his feet. Continuity of care in his case was allowed mostly by his workingman compensation insurance. With his continued coverage, he has salvaged both feet over six plus years. He claims to have but a few months left before he can retire and hopefully wear proper shoewear all the time. Such cases, of course, bother the insurance reviewer who is bound to wonder if the patient would not profit from seeking another doctor. The interested reader would do well to check our medical library section in this regard. Helequist points out that their patients who healed ulcers commonly develop new ulcers. Griffith points out that meticulous foot care may help avoid foot ulcers but is not a sure preventive. Waugh points out that many physicians may appear to have cost-effective records in regard to these patients because the patients, failing to improve, merely change doctors and have multiple admissions to different specialties and institutions. Jonsson points out that foot problems are the most costly complication of diabetes as measured by hospital days used. Humphrey et al point out that modern day surgical techniques have not avoided leg amputations in diabetics. And Greant points out that amputation of one leg is followed in one third of cases by amputation of the other leg. Our man and his insurance company did well: except for the initial hospitalization by his family doctor he was not hospitalized for his foot problems; he eventually healed all of his ulcers and lost but one small toe; and he has both legs. Obviously, he would have done better if he did not develop any foot lesions in the first place. To accomplish primary prevention, the insurance company will have to promote specialty care of diabetes.