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
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.