A 65-year-old male patient who had type 2 diabetes since the age of 45 years and was being treated with sulfonylureas, was brought to the emergency clinic suffering from a fever. He had left paraplegia following a stroke 6 months earlier. One month before admission the toes of his left foot became gradually very painful;
Figure 7.6 Dry gangrene of all toes
the patient was usually calm, but occasionally he suffered from bouts of excruciating pain. A general practitioner prescribed cotrimoxazole, pentoxyphyllin and fentanyl patches.
on examination, the patient was febrile and his condition was critical. His second left toe was edematous and painful, with a black ischemic ulcer on the dorsum; the tip of the toe was white (Figure 7.7); a gangrenous pressure ulcer was visible on the left heel (Figure 7.8), due to lengthy confinement to bed. callosity was present under the right fifth metatarsal head, as well as onychodystrophy, due to peripheral vascular disease. No pulses were palpable on his left foot. Both his calves were painful to touch. No other site of infection was found. The patient was classified as Fontaine stage IV. Osteomyelitis was not found on the radiographs. Swab cultures revealed Staphylococcus aureus and Pseudomonas aeruginosa and the patient was treated with ciprofloxacin and clin-damycin. Blood cultures were negative. on the second day the patient felt better and became afebrile by the third day of hospitalization.
A digital subtraction angiography, carried out 10 days after admission, showed 80% stenosis of both iliac arteries, and almost complete obstruction of both superficial femoral arteries (Figure 7.9), while the popliteal arteries were filled from proximal collateral circulation (Figure 7.10). The peripheral arteries had moderate atheroma-tous disease. Aorto-iliac intravascular stents were inserted (Figure 7.11).
carried out and calf supportive devices promoted the healing process.
An infected gangrenous area of the foot and particularly on a toe with bounding feet pulses is a condition that is sometimes seen. This is called 'diabetic gangrene' and it is caused by a thrombosis in the toe arteries which is induced by toxins produced by certain bacteria (mainly staphylococci and streptococci). Plantar abscesses may also result in septic arteritis of the plantar arch and eventually gangrene of the middle toe.
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