Diabetic Foot Ulcer (DFU) with lower extremity cellulitis, aggressive infection and abscess: Gangrenous 5th toe - Incision and debridement (I & D) with partial 5th ray amputation - A Case Study

Clinical Problem / Management: A 70-year-old diabetic female with peripheral neuropathy and a twenty year history of well-controlled diabetes was referred to our rural wound center from a walk-in clinic. Patient presented with a lower extremity cellulitis and a DFU. The plantar 5^thmetatarsal ulcer presented as follows: 1.0cm x 1.0cm .04cm depth, moderate amount of malodorous drainage, slough with peri-wound callous. The foot was mildly edematous and warm to touch. Patient was afebrile, and denied pain.

 The patient was started on doxycycline, and changed to oral clindamycin after the culture grew strep B. The ulcerated area was cleansed and a 0.9% cadexomer iodine pad was applied to the wound bed and covered with an absorptive dressing. Patient was fitted with an offloading shoe.

 In the course of two days she developed a secondary ulcer at the base of her 5^thtoe forming a gangrenous abscess. The patient continued to be afebrile and denied pain. A podiatrist consultation was arranged and the patient was admitted for surgery. IV clindamycin and vancomycin were started.

 Patient labs on hospital admission: A1C 6.9, TP 7.0, ALB 3.8, AST 18, ALT 86, BUN, 21, CREAT, 1.0. Thus her nutritional status, liver and renal functions appeared adequate. X-ray left foot– definite evidence of osteomyelitis.

 Outcomes: I &D left foot with partial 5^thray amputation – no complications. Anaerobic culture - Prevotella/Porphyromonas SP 4+. Patient was discharged home after one week on oral clindamycin and was started on Negative Pressure Wound Therapy (NPWT) at the outpatient wound center. After five weeks the wound bed was healed.

 Conclusions:  The patient’s awareness of and response to infection was impaired, probably secondary to her diabetes and peripheral neuropathy. The infection spread rapidly but was controlled with IV antibiotics and surgery. Close monitoring and use of NPWT produced a favorable outcome.