Pain as the sole manifestation of infection in a neuroischaemic foot

A 77-year-old blind Afro-Caribbean man with type 2 diabetes of 22 years' duration, and peripheral vascular disease complained of pain in his right hallux and was brought to the foot clinic the same day (Fig. 5.7a). There was no swelling or cellulitis but pain was exacerbated by gentle pressure on the nail plate and a small area of nail plate close to the medial sulcus was very gently pared away to expose a small abscess under the nail which was drained (Fig. 5.7b). A deep swab was sent for culture and the abscess cavity was irrigated with normal saline and dressed with Melolin and Tubegauz; amoxicillin 500 mg tds and flucloxacillin 500 mg qds were prescribed. The wound swab grew Staphylococcus aureus and Streptococcus group B. The toe healed in 1 month.

Key points

• Pain may be the sole manifestation of infection in the diabetic neuroischaemic foot and is not always due to ischaemia

• Pain from infection under the nail is exacerbated by gende pressure on the nail plate

• A podiatrist can achieve successful drainage of infection without causing further trauma to the ischaemic toe

Fig. 5.7 (a) This patient complained of pain on the medial side of his toe. There was no swelling or cellulitis. The nail has been gently pared back and a small abscess is draining, (b) Abscess site post drainage.

• Infection in the neuroischaemic foot may not be associated with swelling

• A heavily pigmented skin makes cellulitis difficult to detect.

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