Local signs of infection not noted by patient

A 53-year-old lady with type 1 diabetes of 25 years' duration, proliferative retinopathy with reduced vision, peripheral neuropathy and hallux rigidus developed a neuropathic ulcer under callus on the plantar surface of her right hallux. She was warned of the usual danger signs of deterioration (redness, warmth, swelling, pain, purulent discharge) but did not return to clinic until her routine appointment. Callus had grown over the ulcer preventing drainage and the toe had become cellulitic (Fig. 5.1a,b). Callus was debrided and pus drained (Fig. 5.1c). A deep wound swab was taken and oral amoxicillin 500 mg tds and flucloxacillin 500 mg qds were prescribed. She was reviewed the next day. The toe had not improved and she was admitted for bed rest and intravenous antibiotics according to our protocol, namely amoxicillin, 500 mg tds, flucloxacillin 500 mg qds, metronidazole 400 mg tds and ceftazidime 1 g tds. The swab taken at her outpatient clinic visit grew Staphylococcus aureus and Streptococcus group B. The metronidazole and ceftazidime were stopped when this result became available. She was discharged after 4 days and the ulcer healed in 6 weeks.

Key points

• Patients with impaired vision and neuropathy cannot be relied upon to detect signs of infection such as cellulitis

Dangers Infected Diabetic Toe

Staphylococcus aureus and Streptococcus group B in combination can act synergistically to produce a rapidly spreading infection.

Infected Callus Under Foot
Fig. 5.1 (a) Cellulitis of the right hallux, (b) Cellulitis of the right hallux and a collection of pus under callus, (c) Callus debrided and pus drained.

Lack of discharge does not necessarily mean that an ulcer is healed: it can indicate that callus has sealed it off, preventing drainage. If this happens the foot can deteriorate rapidly

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