Iatrogenic necrosis in a renal foot

A 64-year-old man with type 2 diabetes of 16 years' duration, retinopathy, peripheral neuropathy, peripheral vascular disease and end-stage renal disease treated by renal transplantation. He had bilateral peripheral vascular disease and necrosis of the apices of the toes of his right foot, but his left foot was intact. The necrosis had started spontaneously but was slow to resolve and he was admitted for an angiogram. During the procedure he was thought to be hypoglycaemic, and a capillary blood sample was obtained by pricking his left second toe. Within 24 h the toe turned blue and subsequently developed full-thickness necrosis which gradually spread up the foot until it affected the entire forefoot. He refused partial amputation or major amputation, and the foot was regularly debrided (Fig. 6.12). Antibiotics were administered to treat episodes of infection and the necrotic areas remained dry and eventually separated after 2 years. The foot remained healed until he died of a myocardial infarction 6 months later.

Key points

• Blood samples should never be taken from the toes of a diabetic neuroischaemic foot

• Patients in renal failure are particularly prone to develop necrosis following an apparently trivial injury

• Once established in the toe, necrosis may spread rapidly in the forefoot.

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