Phlegmon

A 62-year-old male diabetic patient with type 2 diabetes diagnosed at the age of 42 years and treated with sulfonylurea, biguanide and acarbose and whose diabetes control was acceptable, visited the outpatient diabetic foot clinic due to infection of the sole of his right foot. He had hypertension and coronary heart disease treated with metoprolol and aspirin. He had no previous history of foot problems.

On examination, the patient had fever, severe diabetic neuropathy, and bounding pedal pulses. He had hallux valgus, claw toes, prominent metatarsal heads, ony-chodystrophy and dry skin. Callus formation superimposed on a neuropathic ulcer over his third metatarsal head was present; a callus was also noted over his fifth metatarsal head. A superficial, painless, infected ulcer with purulent discharge was present under Lisfranc's joint (Figure 8.21). This infection progressed to a phlegmon 2 days after a minor shear trauma.

The patient was admitted, and intravenous amoxicillin-clavulanate was initiated. A plain radiograph excluded osteomyelitis or gas collection within the soft tissues. Computerized tomography revealed a phlegmonous subcutaneous mass under the base of the metatarsals (Figure 8.22). A sterile probe was used to detect any sinuses or abscesses, but none was found. The patient remained bedridden for 1 week and the infection subsided. He continued antibiotics for one more week with limited mobilization and he was released from hospital in excellent condition. Oral antibiotics were continued for two more weeks. Preventive footwear was prescribed and the

Figure 8.21 Superficial infected ulcer with purulent discharge under Lisfranc's joint. Callus formation is superimposed on neuropathic ulcer over the third meta-tarsal head with callus formation over the fifth metatarsal head. Hallux valgus, claw toes, prominent metatarsal heads, ony-chodystrophy and dry skin can be seen

Figure 8.21 Superficial infected ulcer with purulent discharge under Lisfranc's joint. Callus formation is superimposed on neuropathic ulcer over the third meta-tarsal head with callus formation over the fifth metatarsal head. Hallux valgus, claw toes, prominent metatarsal heads, ony-chodystrophy and dry skin can be seen

Callus Formation
Figure 8.22 Computerized tomography of the feet of the patient whose right foot is shown in Figure 8.21. A phlegmonous subcutaneous mass is present under the base of the metatarsals (arrow)

patient continued to visit the outpatient diabetic foot clinic on a regular basis.

Computerized tomography is useful in identifying areas of phlegmon within the soft tissues. It may provide information about the exact anatomic location and extent, so that aspiration or surgical drainage can be undertaken. Magnetic resonance imaging and ultrasound studies are also helpful in this respect.

Keywords: Neuropathic ulcer; computerized tomography; phlegmon

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