Case Report
報告者：Clerk6 黃郁晴
指導者：翁日升 醫師
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Patient Profile
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Name：吳○淳
ID：003060417C
36 y/o, Male
Underlying diseases：
▸ Type 2 DM for 18 years, under medication
▸ CKD stage 3a
▸ Chronic hepatitis
▸ Chronic pancreatitis
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Chef Complaint
▹ Swelling and red on right 2nd toe region 2 weeks ago.
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Present illness
▹ A 2*1cm2 wound on the base of right 2nd toe region, and
some pus was drained from the wound. Red and swollen
2nd toe was noted. The patient didn’t feel pain after took
antibiotic treatment as Curam two weeks ago.
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History
▹ Occupational history：倉儲業
▹ Family history：
▸ Mom-Hypertension
▸ Dad-Maybe DM
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Timeline
Fasciectomy:
Necrotizing
suppurative
inflammation
Cellulitis on
right 4th and 5th
toe region
2nd Sequestrectomy:
4th metatarsal
Osteomyelitis
2021/09/21 2021/09/22
Antibiotic therapy
1st Sequestrectomy: 4th
and 5th metatarsalphalangeal joint
5th toe amputation
2021/10/06 2021/10/13 2021/11/24
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Antibiotic therapy
2021/09/22-2021/12/02 Curam
------------------------------------------------------------------2021/12/09-2021/12/23 Taigexyn+Invanz
2021/12/23-2022/01/06 Taigexyn
2022/01/06-2022/01/20 Taigexyn+Bacide
2022/01/20-2022/02/04 Taigexyn
Followed the
2022/02/04-2022/02/10 Cinolone +Bacide
CRP and ESR
2022/02/10-2022/03/24 Invanz
2022/03/24-2022/04/07 Mero
2022/04/07-2022/04/21 Teicod
2022/04/21-2022/05/12 Invanz+Bacide
2022/05/12-2022/06/06 Mero+Bacide
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Culture
2022/08/05 (pus)
▹ Enterococcus faecalis
▹ CRAB (Acinetobacter baumannii)
▹ Proteus hauseri
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Image
1st Sequestrectomy
5th toe amputation
2021/09/21
2021/10/07
2021/11/18
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Perfusion
▹ Reripheral artery disease
is NOT favored
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Image: Three-phase skeletal scintigraphy
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Image
2022/08/10
2023/01/06
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Operation
▹ Sequestrectomy
▹ 2nd metatarsal bone
Discussion
Osteomyelitis in diabetic foot
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Classification
hematogenous
nonhematogenous
Microorganisms that seed
the bone in the setting of
bacteremia
• Contiguous spread of
infection to bone (old)
• Direct inoculation of
infection (young)
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Classification
Acute
Chronic
• Few days or weeks
• Sequestra are absent
• Over months or years
• Sequestra are usually
present
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Risk factors
hematogenous
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•
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Endocarditis
Intravascular devices
Orthopedic hardware
Injection drug use
Hemodialysis
Sickle cell disease
nonhematogenous
• Poorly healing soft tissue
wounds (decubitus ulcers)
• Orthopedic hardware
• Diabetes
• Peripheral vascular disease
• Peripheral neuropathy
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Microbiology
▹ Rarely mono-microbial
▹ Staphylococcus aureus (including methicillin-resistant S.
aureus)
▹ Coagulase-negative staphylococci
▹ Aerobic gram-negative
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Osteomyelitis in diabetes
▹ a "sausage" toe, erythema
▹ nonpitting edema that obliterates the normal contour of
the digit
Better prognosis
Place
Frequency
(%)
ankle amputation
risk (%)
Forefoot
90%
50%
Midfoot
5%
18.5%
Hindfoot
5%
0.33%
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Osteomyelitis in diabetes
▹ ≥ 2 signs of inflammation (swelling, erythema, blood
serum secretion or simply blood with or without bone
fragments)
▹ Can occur without any local sign of inflammation
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Diagnosis
▹ Grossly visible bone or ability to probe to bone (Depth > 3mm)
▹ Ulcer size > 2 cm2
▹ Ulcer duration > 1-2 weeks
▹ Erythrocyte sedimentation rate (ESR) >70 mm/hour
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Diagnosis
Probe to bone
Probing to bone with a sterile
blunt metal tool should be
included in the initial
Radiography
assessment of diabetic patients
with infected pedal ulcers.
Other image tool
(e.g. MRI, PET/CT)
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Diagnosis
At least two weeks behind clinical
infection:
 Osteopenia and bone resorption
 Cortical loss
 Bony destruction
 Periosteal reaction
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Diagnosis
MRI is generally considered the study
of choice for further assessment
 Demonstrate abnormal marrow
edema as early as one to five days
 Intravenous contrast does not
improve the detection of
osteomyelitis
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Diagnosis
▹ The gold standard for the diagnosis of osteomyelitis is the
bone biopsy which provides histological and microbiological
findings.
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Treatment
▹ Medical or Surgery? The guidelines broadly recommend
the specific conditions for surgical or medical approach
combined with conservative surgery.
Antibiotics
Reduce the length of
hospitalization
Advantages
Disadvantage
Surgery
Drug resistance
Higher recurrence
Longer treatment time
Impair the foot balance
(re-ulceration)
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Treatment
▹ 119 diabetic patients who underwent resection of the
metatarsal heads due to osteomyelitis.
Toes
Re-ulceration risk
1st
69%
2nd
44%
3rd
52%
4th
25%
5th
19%
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Treatment: IDSA guidelines
Antibiotic therapy without surgery should be considered:
▹ High risk of foot function loss in case of radical resection of infected bone
▹ Severe deficiency in foot perfusion without chance of revascularization
▹ Infection confined to the forefoot with only a minimal loss of soft tissue
▹ Excessive surgical risk according to patients general conditions.
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< 6 weeks
https://doi.org/10.2147/DMSO.S181198
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https://doi.org/10.2147/DMSO.S181198
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Thanks for your listening