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Looking beyond the canvas of the diabetic foot
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A 55-year-old man presented to the clinic with complaint of right foot pain. The patient related that the pain was of new onset within the past week along with his ulcer getting bigger. His pain was unrelieved with over-the-counter pain relievers, and he also related loss of appetite within the past three days.
The patient’s past medical history was significant for diabetes, hypertension, peripheral arterial disease, neuropathy, anemia, cardiac disease, chronic renal failure and liver failure. The only medications which he reported taking at home were insulin aspart (Novolin; Novo Nordisk) and esomeprazole.
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Regarding his feet, he had a history of multiple foot ulcerations. Upon first clinical encounter, the patient presented with ulceration to the distal tip of his right second toe without drainage, erythema or edema. The toe was darkened in coloration but was not focally gangrenous. The ulceration was confined and overall stable in appearance. Secondary clinical encounter revealed the patient to be in great distress with apparent weight loss and visible agony from pain. The presentation of the foot was markedly changed with ischemic soft tissue changes and destruction with extension of the ulceration to involve the third and fourth toes and associated forefoot about the fourth ray. Greatest soft tissue loss was noted along the fourth ray with more proximal extension as well as serous drainage and fetid malodor noted. The foot was also edematous and erythematous with pain produced with palpation (see figures A-D). Posterior tibial and dorsalis pedis pedal pulses were absent. No radiographs were present for the clinical encounter.
What’s your diagnosis?
A) Wet gangrene.
B) Burn.
C) Dry gangrene.
D) Neuropathic ulcer.
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Figures A - D: Ulceration about the second to fourth toes with marked gangrenous and ischemic changes along with soft tissue destruction about the fourth ray dorsally. Serous drainage (A - yellow arrow). Note damage to plantar (C) and distal (D) toes. |
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CASE DISCUSSION
The patient was previously diagnosed with ischemic ulceration to the second toe and promptly sent for arterial doppler with waveforms and vascular consultation. He presented back to the clinic one day after his vascular tests but had not seen the vascular surgeon.
At this time, the patient’s condition deteriorated. He was emaciated and weak along with visible wet gangrene with suspected gas. The patient was transported to the ER from the office via ambulance with n.p.o. status. Radiographs were taken during surgical preparation with free air noted within the soft tissues along with vessel calcification (see figure E).
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Figure E: Preoperative radiograph demonstrating free air within the soft tissues (red circle) seen as dark bubbles. Note also the vessel calcification affecting the foot with visible presence in the first intermetatarsal space (blue arrows). |
Initial surgery consisted of open distal transmetatarsal amputation of the foot with removal of all nonviable tissue and purulence (see figures F and G). Lower extremity arterial doppler demonstrated hemodynamically significant arterial occlusive disease located in the superficial femoral arteries and the distal distributions of the affected right side with vessel calcification and unobtainable toe pressures. Ankle brachial indices were unreliable secondary vessel calcification. Inpatient vascular service was consulted.
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Figures F and G:
Intraoperative presentation upon initial open transmetatarsal amputation.
Minimal bleeding encountered. Wound packed open after removal of all nonviable
tissue and all purulence evacuated. |
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Following the initial surgery, the patient’s appetite and strength returned. However, during the hospitalization the patient suffered from gastrointestinal bleeding, which later resolved. Due to his renal condition, revascularization was postponed for a few weeks until optimal renal performance. Delayed primary closure was performed prior to discharge with outpatient treatment of the remnant soft tissue defect via collagen dressings (see figure H). Unfortunately, the patient was readmitted to the hospital four weeks after discharge with penile vancomycin-resistant enterococci and sepsis and died secondary to multisystem organ failure.
Patris Toney, DPM, MPH, is an Attending Staff Physician at Mount Sinai Hospital in Chicago, and Past Fellow at the Center for Lower Extremity Ambulatory Research/National Center for Limb Preservation.