Case Presentation: 88-year-old insulin dependent diabetic male with complaint of swelling and redness to the right second toe Presented by Richard H. Mann, DPM

		Richard H. Mann, DPM Diabetic Foot Care Center Delray Beach, FL

HPI:  Patient is an 88-year-old white male who presented to the office with a complaint of swelling and redness to the right second toe, extending to his midfoot.  He claimed that he had been having swelling and redness to the foot for the past week that it had been getting worse.  His wife had been treating the foot unsuccessfully with topical antibiotics and cortisone.  This was the first episode of this problem that he has had.  There is no history of trauma to the area.

PMH:  IDDM, peripheral neuropathy, anxiety, hypertension, atrial fibrillation, CAD, dementia, dyslipidemia, urinary frequency, colon cancer and osteopenia. 

PSH:  pacemaker implantation, transurethral resection of the prostate, partial resection of the colon on two separate occasions, bilateral cataract extractions

Medications:  Ritalin® 20 mg b.i.d, Lantus® 38 units every morning, Humalog® 5 units before dinner, atenolol 50mg q.d., Imdur® 60 mg q.d., Aricept® 10 mg q.d., Coumadin® 3 mg every third day and 1.5 mg on other days, Prandin® 4 mg with breakfast, 2 mg with lunch, and 4 mg with dinner; aspirin 81 mg q.d., Aricept® 4 mg q.d., enalapril 20 mg b.i.d., Pravachol® 40 mg q.d., and Demadex® 20 mg q.d., Calcitrol® 0.25 mg, vitamin D 600 mg b.i.d., Antivert® 25 mg q.d. prn dizziness.

Allergies:  NKDA

SH:  negative for the use of alcohol or tobacco products, lives with his wife, an attentive and concerned caregiver.

Physical Exam: He was unable to sense a 5.07/10g Semmes-Weinstein monofilament to any of ten sites to his feet.  He was significantly insensitive to light touch from the mid-calves down.  There were absent deep tendon reflexes at both the ankles and knees.  He was unable to feel a 256 Hz tuning fork to his lateral malleoli bilaterally.  There was 3 x 3 mm ulceration on the distal aspect of the right second toe that probed to bone and slightly undermined in all directions.  The wound had some nonviable and crusted elements in it.  There was cream-colored exudate in the wound that was expressed with compression to the distal toe. Culture and sensitivity sample was taken. There was erythema extending to the proximal interphalangeal joint.  There was no streaking noted on the foot.  There were no palpable inguinal or popliteal lymph nodes.  +1 edema was noted to the feet bilaterally.  There were absent dorsalis pedis and posterior tibial pulses noted bilaterally.  Capillary perfusion to the halluces was slightly delayed.

Vascular Exam: In-office vascular analysis was performed with a Koven Smartdop®45:  The brachial artery had an opening pressure of 128 mm Hg on the right and 126 mm Hg on the left.  The posterior tibial artery was noted to have an opening pressure of at 120 mm Hg on the right and 90 mm Hg on the left.  The dorsal dorsalis pedis artery was noted to have an opening pressure of 148 mm Hg on the right and 158 mm Hg on the left.  Waveform morphology showed evidence of mild to moderate obstructive arterial disease.  PPG analysis demonstrated an opening pressure of 98 mm Hg to the right hallux and 110 mm Hg to the left.   ABI on the right was WNL, 148/128=1.15. 

Imaging:  X-rays of the right foot show no rarefaction of the bone to the distal aspect of the right second toe.  There was no evidence of calcification of the vessels to the foot noted on x-ray.   Tch 99 triphasic bone scan was consistent with osteomyelitis to the distal aspect of the right second toe. CT of the right foot was positive for osteomyelitis of the second distal phalanx.

Lab:  Wound exudate grew out vancomycin susceptible Staph Aureus

Diagnosis:  Ulceration of the distal aspect of the right second toe with osteomyelitis of the distal phalanx.

Treatment:  The patient was admitted to the hospital and an ID consultant was called in to manage antibiosis.  The patient was started on Cubicin IV and rifampin.  Within 3 days, he developed a significant skin rash and the antibiotics were changed to Rocephin®.  The patient subsequently developed a rash that necessitated the Rocephin be discontinued as well.  At that time, he was put on oral doxycycline.  The patient underwent an amputation of the distal aspect of the right second toe approximately 2 weeks after the initial diagnosis of osteomyelitis.  Healing was uneventful. The doxycycline was discontinued by the ID consultant four weeks post amputation.

Discussion:  This case serves to demonstrate the importance of prompt diagnosis and intervention in cases of osteomyelitis.  It illustrates that rapid in-office vascular analysis is an important tool in predicting clinical outcomes and the selection of appropriate treatment regimens to maximize satisfactory clinical outcomes.

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