A 55-year-old man with insulin-treated type 2 diabetes of 15 years' duration, peripheral neuropathy and impaired liver function due to previous hepatitis B infection presented late with acute Charcot's osteoarthropathy of
the right foot. Two years subsequently he developed neuropathic ulceration of the left 2nd toe. The ulcer became infected and he was admitted to hospital for intravenous antibiotics and underwent a ray amputation. He was discharged after 3 weeks. His left foot became red, swollen and warm, and Charcot's osteoarthropathy was diagnosed. He declined a total-contact cast but said that he would rest the foot as much as possible. (Two nights later one of the authors saw him in Central London at a Promenade Concert hiding behind a pillar so as not to be seen and reprimanded for not resting!) He developed a rockerbottom deformity with a neuropathic ulcer over the bony prominence, and re-presented with severe infection and spreading cellulitis. He was admitted for intravenous antibiotics and surgical debridement of the foot, with removal of infected soft tissue (Fig. 5.13). Three months later, he complained of severe pain in the region of his lumbar spine. An MRI scan revealed infection of the disc between the 4th and 5th lumbar vertebrae, which was treated with long-term antibiotics and resolved.
• Metastatic infection can develop from a primary infection in the foot
• Presentation of metastatic infection may be delayed.
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