Necrotizing fasciitis in a previously neuropathic foot that had become neuroischaemic

A 67-year-old man with type 2 diabetes of 22 years' duration and a previous history of frequent neuropathic ulceration, developed fever, rigors, fatigue and malaise, and asked his general practitioner to visit him. Influenza was diagnosed and paracetamol was prescribed. The general practitioner called again, 2 days later, when the patient had not improved, and told him to continue taking paracetamol. Two days later the patient's wife became aware of an unusual odour, checked her husband's feet, and found that his hallux was purple and a large ulcer had developed on the side of his foot. Same day admission was arranged. The patient had extensive wet gangrene and necrotizing fasciitis of the plantar aspect of the foot (Fig. 6.22a,b). It was noted that the foot pulses were not palpable and

Fig. 6.22 (a) The hallux is red and purple at its tip. There is a large area of wet necrosis and sloughing of tissue on the lateral border of his foot, (b) It is possible to pass a probe from the medial to the lateral border of the foot, (c) The large tissue defect has been surgically debrided and received a split-skin graft which has taken: the hallux has been amputated, (d) The 2nd toe has also developed necrosis and autoamputated. The foot has healed.

Fig. 6.22 (a) The hallux is red and purple at its tip. There is a large area of wet necrosis and sloughing of tissue on the lateral border of his foot, (b) It is possible to pass a probe from the medial to the lateral border of the foot, (c) The large tissue defect has been surgically debrided and received a split-skin graft which has taken: the hallux has been amputated, (d) The 2nd toe has also developed necrosis and autoamputated. The foot has healed.

Doppler studies disclosed that the patient, previously neuropathic, had become neuroischaemic.

Extensive debridement of infected soft tissue and amputation of the hallux was performed as an emergency procedure leaving him with a large tissue deficit. Staphylo coccus aureus and Pseudomonas was grown from the tissue. He was treated with ceftazidime 1 g tds and fluclo-xacillin 500 mg qds. He underwent a distal arterial bypass. His postoperative progress was slow and the tissue defect was covered with a split-skin graft (Fig. 6.22c,d). After discharge he attended the diabetic foot clinic at monthly intervals for sharp debridement of callus from the skin graft.

Key points

' Diabetic foot infections may masquerade as influenza

• Patients who cancel their appointments because of 'flu-like symptoms' should have their feet checked

• Our education programme specifically warns patients that symptoms of flu may be caused by foot infections

• Soft tissue destruction in the neuroischaemic foot is usually due to infection

• Always be on the outlook for neuropathic feet that have become neuroischaemic

• Extensive tissue loss in the neuroischaemic foot should be managed ideally with an arterial bypass.

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Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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