Case 90: Yeast Cellulitis Claims Leg of Man with Diabetes and HMO Insurance

This 54 year old man presented December 4th, 1994 in our office with a 10-year history of poorly controlled diabetes complicated by retinopathy and months of foot blisters. His family doctor had referred him to a vascular surgeon who obtained an arteriogram. The latter showed diffuse arteriosclerotic disease with mild left iliac stenosis, mild popliteal stenosis, single vessel runoff from the knee down the anterior tibial to the ankle, no continuous flow into the foot and diffuse disease of the left dorsalis pedis. The Bryn Mawr Hospital Vascular Laboratory found pressures in the midfoot of 70 in the right and 40 mm Hg in the left foot His vascular surgeon referred him for boot therapy. He arrived December 6th with a 3 by 6mm spot of focal skin necrosis over his left 5th toe bunion, a 7 by 1 mm black split in the skin on the outside of the distal left big toe and rubor of all five toes. Hammer toes and loss of his extensor digiti quinti muscles pointed to the presence of peripheral neuropathy but his light touch and vibration senses were normal and he could feel that standard 5.07 fiber in both feet. We found his hemoglobin A1C to be 13.8%. He was begun on an insulin program and outpatient Circulator Boot therapy. He was advised that he should receive daily therapy in view of his extreme ischemia, the presence of tissue necrosis and the threat of additional necrosis in the big toe.

The toes of his left foot were ruborous compared to the proximal foot and the toes of the right foot. He had some focal necrosis over his 5th toe bunion. A black split on the big toe was not photographed..

Treatment of the left leg was emphasized but both legs were treated three to four times a week through the rest of December and through January, once or twice a week through the first 20 days of February, four to five times a week through the end of February and through March and finally two to three times a week in April. Unfortunately, his perceived need to continue his job as an athletic trainer kept him on his feet.

These pictures were a little underexposed. Still it is obvious that the color of the toes has become that of the rest of the foot. The black toe fissure enlarged early in his treatment.

The necrosis over the 5th toe bunion had also extended. Again an overall uniform foot color is seen. March 10th, 1995.

The capitation arrangement of his medical insurance did not allow our personal examination of the blood flow in his leg. Such tests were to be done only at their capitated vascular laboratory where essentially segmental pulse volumes were done. Serial reports were sent to his primary care physician who had to authorize his boot therapy. In January he was notified of the extent of the problems and needs of the patient; an improvement in the color of the feet was noted while the black spots had enlarged somewhat. In February, he was notified that the patient was then "ambulating with some freedom. However, it should be noted that the black eschars remain on his big toe and fifth toe bunion. With proper care I would expect these black areas to peel off much like a scab....At the margin between the good and dead tissues is a potential portal of entry for bacteria, which in a partially vascularized foot could, of course, raise havoc. It is not uncommon for patients with such partially-treated feet to attempt to go their way only to find an infection entering through these portals and causing a necrotizing cellulitis. Not uncommonly, then, the limb is lost or the patient requires an extensive treatment program to regain the lost ground and heal the foot. Hence, we must go on record as stating that the patient's best interest is served by continuing with his therapy. "

The patient returned April 13th after a week lapse in treatment. Local and oral antibiotics had no effect. He was admitted to the hospital where again antibiotics did not appear to be helping. An incision was made under the big toe to reach pink tissue within the foot and obtain a culture.

While the participating vascular surgeon had referred the patient for boot therapy and the primary care physician signed the appropriate referrals for the therapy, the HMO manage care group had to approve the therapy and referred the treatment program to their medical director. Circulator Boot therapy is listed by Medicare as a physical therapy modality and the HMO had capitated physical therapy sites, none of which performed vascular studies or vascular treatments. The medical director thus approved our treatments and suggested that they be charged as office visits. The latter were submitted and not paid at the time... nor since. While Medicare pays for treatment with the Circulator Boot systems, it had not paid for any soak solutions or antibiotics used during the treatment. Such ancillary costs are properly charged to the patient. The patients commonly attempt to get Medicare to pay the bills anyhow. This patient likewise wanted his HMO to pay for his antibiotics and soaks. The HMO responded and refused payment and further requested we provide the soaks and antibiotics without charge to the patient. Our patient was aware of these coverage issues and feared that he might someday be responsible for the costs of his treatment. Leg amputation was clearly covered but leg salvage was not.

The death of his brother interrupted his therapy and was a major personal loss. He consulted his vascular surgeon again for a possible transmetatarsal amputation. Preoperative vascular testing, however, showed that while his pulse volume was improved at the ankle, anoxia of the distal foot either due to infection or ischemia was present and the amputation was likely to fail. He was admitted to Bryn Mawr Hospital on the 24th of April, 1995 for cellulitis of the foot, organism undetermined. A time limit for insurance coverage was understood by the patient and his surgeon suggested a deadline of 4-5 day therapy before leg amputation. The first two days intravenous Vancomycin had no benefit on his cellulitis. He met with his psychiatrist and his priest; he accepted the leg amputation as his likely fate. To get a good tissue culture, an incision was made at the margin of the eschar and normal skin at the base of his big toe medially and a deep tissue culture was obtained. Fungi were seen on smear and eventually grown out. Fluconazole was started and his pain and rubor appeared to be diminishing.

May 1st, 1995. His cellulitis appeared to be receding and the big toe was well demarcated.

On the dorsum of the foot a little reddening persisted over the second metatarsal head. Had the foot been saved?

The deadline for amputation had arrived! Rather than await the results of his anti-yeast therapy, his leg was removed May 2nd. pathological sections of his foot revealed yeast and hyphae compatible with our clinical diagnosis of a resolving tissue yeast infection. He had arteriosclerosis as expected. .

Comments: The HMO was a problem throughout this case. We were negotiating with people inexperienced in vascular medicine. An initial vascular laboratory assessment was not allowed. We like to do our own testing before prescribing boot treatment. We want to include at least six inches of well vascularized leg within the compression bags. If the transcutaneous PO2 level is very low, we like to utilize topical oxygen to prevent tissue breakdown early in the course of our treatments. We have to get blood to the ankle before the midfoot and the midfoot before the toes etc. With topical O2 we may prevent tissue loss while this revascularization process proceeds. The arteriogram showed us where contrast was able to go but gave no data on its speed , pressure or benefit. The anxiety of the patient was magnified daily with the realization that the cost of his treatment was of more concern to his HMO than his outcome. Doctors frequently are not paid for their efforts by HMO's. Cerebral work costs the doctor time. Boot treatment may cost the doctor time in supervising the care but it also costs money for technicians, compression bags, electrodes, treatment tables, compressors etc. As HMO's reduce the reimbursement they pay for such services and minimize the profit margin of such services, free care to those in need becomes impossible. This man might have lost his leg eventually someday anyhow. He lost it at the time he did because of a deadline of mankind and not an act of God. And those enforcing the decisions of the HMO still have not authorized the payment of the funds they agreed to pay. If the doctor reads his contract with the HMO, he /she finds there is an official appeal process. The HMO hopes the doctor will not appeal. Again, troublesome doctors may be dropped from HMO's. We are appealing.