Infected Plantar Ulcer With Osteomyelitis

A 50-year-old female diabetic patient with type 2 diabetes diagnosed at the age of 44 years and treated with sulfonylurea, was referred to the outpatient diabetic foot clinic because of a chronic infected ulcer on her left foot. The patient lived alone and she was being treated for depression; she had good diabetes control. A minor trauma under her left foot was reported to have occurred 2 years previously. She had treated the injury with different types of gauzes and creams, but it failed to heal. She presented to the clinic with a large, painless, infected ulcer under her left foot (Figure 8.23).

On examination, an irregular, soaked, foul-smelling ulcer with sloughy bed, and surrounding cellulitis of 3 cm in diameter was found; body temperature was normal. Diabetic neuropathy was diagnosed, while peripheral pulses were normal. Signs of osteomyelitis (osteolysis of the first metatarsal head, and the base of proximal phalanx of the hallux, with periosteal reaction) were noted on the radiograph (Figure 8.24). A post-debridement swab culture from the base of the ulcer revealed methicillin-resistant Staphylococcus aureus and Escherichia coli. The patient was admitted to the hospital. The white blood cell count was 14,700/mm3, anemia (Hb: 9.8 g/dl) characteristic of chronic disease was found, the erythrocyte sedimentation rate was 90 mm/h and the level of C-reactive protein was 70 mg/dl. She was treated with 600 mg teicoplanin

Minor Infected Toe
Figure 8.23 A large, irregular, soaked and infected neuropathic ulcer with sloughy bed and surrounding cellulitis of 3 cm in diameter is shown here. A minor trauma reported to have occurred 2 years earlier was the cause of this ulcer

intravenously once daily and the ulcer was debrided and dressed. The cellulitis progressively subsided, the ulcer became clear and healthy granulating tissue began to cover the ulcerated area (Figure 8.25). The patient was discharged from the hospital in good clinical condition. She continued treatment with intramuscular teicoplanin for three more months and attended the outpatient diabetic foot clinic on a weekly basis. Complete offloading of pressure from the ulcerated area was achieved by the use of a wheelchair for most of her activities. Platelet-derived growth factor-^ (becaplermin) was

Stress Reaction Phalanx
Figure 8.24 Osteolysis of the first metatarsal head and the base of proximal phalanx of the hallux with periosteal reaction due to osteomyelitis are shown on this plain radiograph of the foot illustrated in Figure 8.23

applied once daily. The ulcer diminished progressively (Figure 8.26) and healed in 4 months; no relapse occurred.

All patients with deep or long-standing ulcers should be evaluated for osteomyelitis. The possibility of an ulcer being complicated by osteomyelitis increases when the diameter of the ulcer exceeds 2 cm and the depth is greater than 3 mm; the possibility of complications becomes even higher when the white blood cell count, the erythrocyte sedimentation rate and the C-reactive protein levels are high.

Treatment of acute osteomyelitis includes parenteral administration of antibiotics for 2 weeks initially, and the continuation of oral treatment for a prolonged period (at least 6 weeks).

Acute Osteomyelitis Patient Photo
Figure 8.25 Clear ulcer with healthy granulating tissue after 1 month of appropriate treatment in the patient whose foot is shown in Figures 8.23 and 8.24

Keywords: Neuropathic ulcer; acute osteomyelitis; platelet-derived growth factor-^ (PDGF-y6, becaplermin)

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Responses

  • franziska
    What are the symptoms of a infected toe?
    7 years ago

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