Asymptomatic foot infection under a totalcontact cast

A 45-year-old man with type 1 diabetes of 35 years' duration who had previously undergone amputation of all the toes of his left foot, had a deep plantar neuropathic ulcer and was fitted with a total-contact cast. He was given oral amoxicillin 500 mg tds, flucloxacillin 500 mg qds, metronidazole 400 mg tds and ciprofloxacin 500 mg bd but did not take them. When he returned after 1 week for a routine cast check, the cast was removed to expose a cellulitic foot and ankle. There was an area of oedema and crepitus behind the lateral malleolus and X-ray revealed gas in the soft tissues. He was apyrexial and normogly-caemic. He was admitted, underwent operative debridement of the ankle region and given amoxicillin 500 mg tds, flucloxacillin 500 mg qds, metronidazole 500 mg tds and ceftazidime 1 g tds intravenously. Tissue debridings were sent from theatre for culture and grew anaerobic Streptococcus which was sensitive to metronidazole. The ankle healed in 5 weeks. During the period of bed rest in hospital the plantar ulcer also healed.

Key points

• Infection in the diabetic foot can present without pain, fever or hyperglycaemia

• Infection can develop within a total-contact cast without warning signs or symptoms

Fig. 5.3 The first sign of infection: 4th toe becomes slightly pink.

• Infections that occur within a total-contact cast should be treated promptly and aggressively to prevent serious sequelae

• Gas in the soft tissues is not necessarily caused by Clostridium perfringens but by other anaerobes and Gram-negative bacteria.

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