Pain as the sole early warning of infection

An 82-year-old woman with type 2 diabetes of 38 years' duration, profound peripheral neuropathy and a previous history of neuropathic ulceration, complained of pain in her hallux at a routine foot clinic appointment. There was no history of trauma. On visual examination and palpation, nothing abnormal was detected, X-ray was unremarkable, and she was apyrexial. She was Afro-Caribbean with heavy pigmentation. She was advised to keep a close eye on the toe and return immediately if it deteriorated and to return in 48 h for review. When she came back 2 days later she had an infected ulcer on the apex of the toe, severe unilateral oedema and cellulitis spreading up the leg (Fig. 5.2). She was admitted to hospital and given intravenous amoxicillin 500 mg tds, flucloxacillin 500 mg qds, metronidazole 500 mg tds and ceftazidime 1 g tds. The toe healed in 2 weeks.

Key points

• Pain may have been the first symptom of infection in this neuropathic foot

• Elderly neuropathic patients complaining of new pain of unknown aetiology with no other clinical signs or symptoms should be rechecked within 48 h

• It is difficult to detect cellulitis in pigmented skin.

Fig. 5.2 Ulceration at the apex of the hallux with cellulitis.

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

Early warning signs of infection and signs of deterioration should be searched for with great assiduity in all diabetic foot patients (Fig. 5.3), especially those with breaks in the skin. Some infected breaks in the skin will be obvious; others will only make their presence known by:

• Discharge or exudates which collect under callus or skin and present as a blister

• Colour changes under callus or nail plate

• Pain or discomfort

We believe that if the practitioner waits for florid signs of infection to develop then valuable time is lost. We act upon the early signs of infection.

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