Care of a neuroischaemic ulcer with diffuse spreading erythema

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A 79-year-old man with type 2 diabetes of 5 years' duration with hypertension and steroid-treated polymyalgia

Fig. 5.18 (a) Ulcer with cellulitis on toe spreading to the foot. tibial artery, (d) Occlusions of anterior tibial artery,

(b) X-ray was initially normal, (c) Stenosis at origin of anterior (e) Angioplasty of anterior tibial artery.

Fig. 5.18 (cont'd) (f) Straight-line flow of anterior tibial artery to the foot, (g) Fracture through proximal phalanx of

greater toe. (h) Ulcer healed after 9 months, (i) Healing of fracture.

rheumatica was referred from his local hospital with neuro-ischaemic ulceration of his right hallux and diffuse spreading cellulitis involving the forefoot (Fig. 5.18a). The ulcer had been present for 3 weeks, had first appeared to be a blood blister and had a moist sloughy base. A

probe inserted into the ulcer touched bone. X-ray was initially normal (Fig. 5.18b). He was treated with amoxicillin 500 mg tds, flucloxacillin 500 mg qds, metronidazole 500 mg tds and ceftazidime 1 g tds. Tissue was sent for culture and grew MRSA and mixed anaerobes. Antibiotic therapy was changed to vancomycin 1 g bd and metronidazole was continued. Pedal pulses were impalpable and transcutaneous oxygen tension was 31 mmHg. He underwent digital subtraction angiography which showed stenosis and occlusions of the anterior tibial artery (Fig. 5.18c,d). He underwent angioplasty, dilating stenoses and occlusions along the anterior tibial artery on to the dor-salis pedis artery (Fig. 5.18e,f) following which his transcutaneous oxygen tension rose from 31 to 47 mmHg. Repeat X-ray showed fracture through the proximal phalanx of the greater toe (Fig. 5.18g). But as the ulcer was continuing to improve and soft tissue infection was resolving he continued on conservative therapy with Hyaff applied to the ulcer and a 'Scotchcast' boot. The ulcer healed after 9 months (Fig. 5.18h) and there was reasonable resolution of the bony changes to the proximal phalanx although there was resorption of bone of the distal phalanx (Fig. 5.18i).

Key points

• Angioplasty can be a valuable adjunct to treatment for infection in the neuroischaemic foot

• Even if the improved blood supply is temporary and the artery restenoses after a few weeks or months, the management of infection will have benefited from the increased perfusion

• Initial culture was crucial in this case indicating MRSA which necessitated a change in antibiotic treatment

• Osteomyelitis can sometimes be treated conservatively.

Ulcer with extensive deep soft tissue infection

Neuropathic feet and neuroischaemic feet. The antibiotic treatment is the same as for extensive cellulitis, except that intramuscular therapy with ceftriaxone is probably not sufficient therapy. Every attempt should be made to give intravenous therapy.

If the patient shows signs of systemic sepsis such as systolic pressure <100 mmHg or tachycardia > 125/min, then it may be advisable to give also a stat. dose of gentam-icin 5 mg/kg/day. It has a wide spectrum of action against Gram-positive and Gram-negative organisms and it has a significant postantibiotic effect for 24 h.

However, patients in this group may well need surgical debridement as well as intravenous antibiotic therapy.

The follow-up plan is the same as described for extensive diffuse erythema or cellulitis.

Clinical and microbiological response rates have been similar in trials of various antibiotics and no single agent or combination of agents has emerged as most effective.

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