Web Space Infection

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A 72-year-old female patient with type 2 diabetes diagnosed at the age of 61 years, was referred to the outpatient diabetic foot clinic because of an infection in her left foot. The patient had poor diabetes control (HBAic: 8.5%), and was being treated with insulin twice daily. She had background

Figure 8.4 Objects collected from patients' shoes. Loss of protective sensation prevents patients from feeling injurious stimuli

Figure 8.4 Objects collected from patients' shoes. Loss of protective sensation prevents patients from feeling injurious stimuli

Diabetic Foot

diabetic retinopathy and diabetic nephropathy. She reported itching in the fourth interdigital space 6 months previously, probably due to a fungal infection.

On examination, peripheral pulses were weak and she had severe loss of sensation. There was significant ankle edema. A full-thickness painless, infected neuro-ischemic ulcer was present in the fourth web space, with exposure of the subcutaneous tissue (Figure 8.5). No signs of systemic toxic-ity were found. The ankle brachial index was 0.7. The ulcer was debrided and dressed. Swab cultures obtained from the base of the ulcer revealed Staphylococcus aureus and Escherichia coli. A plain radiograph excluded osteomyelitis. She was treated with amoxicillin-clavulanic acid for 2 weeks. Oral furosemide was initiated in order to reduce the ankle edema. The patient had her wound dressed at home daily and attended the outpatient diabetic foot clinic on a weekly basis. A triplex examination of the leg arteries revealed the presence of moderate stenosis in the left superficial femoral and left popliteal arteries. No vascular surgery was undertaken at that time as the ulcer healed progressively.

Fungal infections develop as a result of poor foot hygiene, hyperhidrosis, and accumulation of moist detritus in the webs (Figure 8.6 shows another patient). Interdigital tinea pedis is the most common form of chronic fungal foot infection. Itching, redness, scaling, erosion and soaking of the skin with fluid usually occur, while in the late phase the redness subsides. Trichophyton metagrophytes Trichophyton rubrum or Epidermophyton floccosum may be found.

Topical terbinafine cream cures most infections caused by Dermatophyta, and should be continued for 2 weeks after symptoms subside.

Superficial bacterial infections in the interdigital spaces may cause thrombosis of the adjacent digital arteries and spread to deeper structures through the lumbrical tendons. Furthermore, edema impedes foot circulation, especially in the presence of peripheral vascular disease. Adequate foot hygiene and treatment of the fungal infection could prevent this complication.

Figure 8.5 Full-thickness, infected neuro-ischemic ulcer in the fourth web space with exposure of the subcutaneous tissue. Ankle edema due to diabetic nephropathy, and onychodystrophy can be seen

Lumbrical Atrophy Foot
Figure 8.6 Fungal infection in the interdigital space with claw toe deformity

Keywords: Web space; infection; fungus infection; chronic tinea pedis; Trichophyton metagrophytes Trichophyton rubrum or Epidermophyton floccosum.

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