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Complications of Diabetes Mellitus: Foot Ulcer

Complications of Diabetes Mellitus: Foot Ulcer

A 67-year-old woman with insulin-dependent diabetes mellitus and uncontrolled hyperglycemia complained of fatigue and malaise. For 2 years, a draining ulcer had been present on the bottom of her left foot. The patient had septicemia; blood cultures were positive for Staphylococcus aureus. White blood cell count was 16,000/μL; erythrocyte sedimentation rate, 130 mm/h; and glucose level, 310 mg/dL. The patient was hospitalized; empiric therapy with cefazolin and gentamicin was started. The foot wound was irrigated and debrided. The ulcer extended deeply through the first web space, dorsally to the skin surface, and into the entire great toe. Extensive necrotic tissue was found. The patient's circulatory status was very poor; she had severe peripheral vascular compromise. Drainage portals were established. Cultures were obtained. Despite the extensive irrigation and debridement and the continued antibiotic therapy, the ulcer did not improve. A transmetatarsal amputation was performed. Initially, the patient's condition improved; however, necrotic tissue at the surgical site was extensive. Cultures grew Proteus organisms, methicillin-resistant staphylococci, enterococcus group D streptococci, Klebsiella organisms, and Morganella organisms. Ciprofloxacin and vancomycin replaced the initial antibiotic regimen; however, the patient's elevated blood urea nitrogen and creatinine levels precluded long-term therapy. Because the transmetatarsal amputation site began to break down and the bacterial necrosis persisted despite continued antibiotic therapy, below-knee amputation was scheduled. During surgery, swollen tissue, very pale and extremely poor vascularity, and the absence of muscle contractility were noted; above-knee amputation was performed. Dramatically compromised circulation and diminished bleeding and muscle contractility were evident even at this level and at this distance from the ulcer. Within 2 days of the operation, the patient was talkative and lively. The surgical site healed uneventfully. The patient was fitted for a prosthetic limb, and her glucose level was brought under control. She was very pleased with the outcome.

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