A 68-year-old male, resident of Crete island, with history of type 2 DM (diagnosed 2 years before, with satisfactory glycaemic control, HbA1c = 6.5%) and intermittent claudication (Fontaine class IIb) was referred to our diabetic foot clinic due to a 1-month history of erythema, swelling, tenderness and local warmth of the left lower limb along with paronychia and the presence of a diabetic foot ulcer (DFU) in distal phalanx of 1st toe of the left foot probed to bone. The patient had been hospitalized for 10 days in a peripheral hospital, where he underwent surgical nail removal and surgical debridement, and was treated with double antibiotic therapy. He was prescribed antibiotics for 1 week after discharge. Upon admission to our hospital, he had typical “sausage toe” (1st toe of the left foot), Fig. 1a. Inflammation markers were significantly elevated (erythrocyte sedimentation rate (ESR) = 101 mm/h, C-reactive protein (CRP) = 16.3 mg/L (normal values: < 3.3 mg/L) and white blood cell count (WBC) = 13.310/μL. The rest of biochemical analysis was normal. X-ray of the left foot revealed destruction of proximal and distal phalanx of the 1st toe (image compatible to osteomyelitis), Fig. 2a. He was initially treated with intravenous daptomycin, aztreonam, plus low-molecular weight heparin and pentoxifylline. Swab culture after debridement showed methicillin-resistant Staphylococcus aureus (MRSA) and Stenotrophomonas maltophilia, both sensitive to ciprofloxacin, so antibiotic therapy was switched to ciprofloxacin and clindamycin. Nasal swab culture was also positive for MRSA, and nasal mupirocin was given.
Additionally, he underwent colour Doppler ultrasound and CT angiography of the lower extremity arteries. The patient presented 95% stenosis of the left popliteal artery and total occlusion of the posterior tibial artery of the right lower limb. Two weeks after admission, patient was discharged and continued his antibiotic treatment with ciprofloxacin and clindamycin per os as outpatient.
After discharge, the patient was seen on weekly basis. A gradual clinical improvement and a significant reduction of the inflammation marker levels were observed. Five weeks after discharge, the patient underwent a successful angioplasty, in order to perform revascularization and restore an adequate blood flow to his left lower limb. Blood tests at this time point were almost within normal ranges (ESR = 17 mm/h, CRP = 4.01 mg/L and WBC = 8.160/μL. He continued antibiotic treatment for 5 more weeks (a total of 3 months). After the end of treatment, inflammation markers had returned to normal (ESR = 19 mm/h, CRP < 3,3 mg/L and WBC = 7.800/μL). Plain X-ray showed focal osteogenesis at the damaged proximal and distal phalanx of the 1st toe. Clinically, the patient presented minimal edema of his toe without erythema and his DFU was almost healed (Fig. 2b, c).
Eventually 4 months after the end of the treatment, the patient presented with complete healing of his DFU, reconstruction of his osteomyelitis defects and complete restoration of his toe nail and his foot functionality. He was able to walk 3 km without claudication. One and a half year after his initial visit, the patient remains in good shape, and plain X-ray is almost normal (Figs. 1b, d).