A 72-year-old man with type 2 diabetes of 11 years' duration and peripheral neuropathy developed a neuropathic plantar ulcer over his 4th metatarsal head. After 3 weeks the foot became swollen with purulent discharge and he was systemically unwell. He was admitted to hospital and given amoxicillin 500 mg tds, flucloxacillin 500 mg qds and metronidazole 500 mg tds intravenously. An ulcer swab grew Staphylococcus aureus and Streptococcus group B and mixed anaerobes.
The plantar ulcer was the only break in the skin. Within 24 h it was observed that the 4th toe was turning blue (Fig. 6.4a). The patient underwent a double ray amputation. The amputation specimen was taken for histological examination which revealed septic arteritis of both digital arteries (Fig. 6.4b). The lumen of each artery was almost totally occluded by septic thrombus. The foot healed in 8 weeks (Fig. 6.4c).
• When necrosis develops in the neuropathic foot, it is usually due to infection and presents as wet necrosis
• Forefoot plantar ulceration can lead to webspace infection with septic arteritis of the digital circulation
• Septic arteritis leads to gangrene even in the well-perfused neuropathic foot
• Early treatment of septic arteritis may salvage the affected toe.
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