Ulcer with diffuse spreading erythema in neuropathic foot

A 44-year-old man with type 1 diabetes of 29 years' duration and severe peripheral neuropathy who was not previously known to the diabetic foot clinic was admitted to hospital with an infected left 3rd toe and extensive oedema and diffuse cellulitis extending up the leg. His pedal pulses were bounding. He had peripheral neuropathy. He had a mild fever 37.5°C. The 3rd toe was sloughy with two ulcers which probed to bone (Fig. 5.17a). X-ray was normal. Day 1 C-reactive protein (CRP) was 106 mg/L. Initially he was given amoxicillin 500 mg tds, flucloxacillin 500 mg qds, metronidazole 400 mg tds and ceftazidime 1 g tds intravenously. By day 3 toe discolouration was marked (Fig. 5.17b). On day 3 the CRP was still raised at 105 mg/L. A swab grew Streptococcus group B and mixed anaerobes. His antibiotic therapy was changed to gentamicin 5 mg/kg daily with amoxicillin 1 g tds and metronidazole 500 mg tds intravenously. By day 5 he showed improvement and his CRP had fallen to 60 mg/L. By day 7 there was further improvement with resolution of bluish discolouration and the CRP was 36 mg/L (Fig. 5.17c). X-ray showed that there was destruction of the proximal interphalangeal joint of the 3rd toe and of the periarticular phalanges (Fig. 5.17d). However, clinically he continued to improve and eventually healed after 16 weeks (Fig. 5.17e). After the toe healed, he failed to attend regular follow-up appointments, but did attend as an emergency when he spilled boiling water on his feet. The resulting burns were superficial and healed quickly, after which he was lost to follow-up again.

Key points

• Serial CRP measurements are usually a useful indicator of progress of diabetic foot infections

• Serious infections often involve more than one organism

• The initial microbiological sample which is either cur-ettings or a deep wound swab is extremely important in the management of diabetic foot infections

Diabetic Foot Management

Fig. 5.17 (a) On day 1 the patient's CRP was 106 mg/L. The toe was infected and there was severe cellulitis, (b) On day 3 the CRP was still raised at 105 mg/L and the discolouration of the toe was present. The cellulitis had not resolved, (c) Cellulitis is resolving, bluish discolouration is fading, CRP is 36 mg/L. We noted scaling and desquamation of the previously intensely cellulitic area, (d) Destruction of proximal interphalangeal joint of 3rd toe. (e) The foot healed in 16 weeks.

Fig. 5.17 (a) On day 1 the patient's CRP was 106 mg/L. The toe was infected and there was severe cellulitis, (b) On day 3 the CRP was still raised at 105 mg/L and the discolouration of the toe was present. The cellulitis had not resolved, (c) Cellulitis is resolving, bluish discolouration is fading, CRP is 36 mg/L. We noted scaling and desquamation of the previously intensely cellulitic area, (d) Destruction of proximal interphalangeal joint of 3rd toe. (e) The foot healed in 16 weeks.

• Streptococcus group B is an important pathogen of the diabetic foot

• Antibiotic therapy needs to be focused towards the organisms isolated on initial culture

• Bone and joint destruction may be treated conservatively with antibiotics as long as soft tissue infection is resolving.

Peripheral Neuropathy Natural Treatment Options

Peripheral Neuropathy Natural Treatment Options

This guide will help millions of people understand this condition so that they can take control of their lives and make informed decisions. The ebook covers information on a vast number of different types of neuropathy. In addition, it will be a useful resource for their families, caregivers, and health care providers.

Get My Free Ebook


Post a comment