Treatment of necrotizing soft tissue in diabetics: The guillotine

By Isabella A. Reichard Manrique, Dean Alessi, Dorothy Juliet Benonaih-Jumbo, Sarah Moore, Mabel Okoampah, Michael Davry

A 60 year-old male with diabetes and HTN presents to the Emergency Department with progressively worsening right foot pain for the past three to four days. The patient is a heavy smoker; one pack of cigarettes per day for 20 years, and has a past medical history of CHF s/p surgical implantation of a cardioverter defibrillator, CAD, and stroke with a past surgical history of a cardiac angiogram with stent placement. Patient’s heart rate and rhythm were normal. Doppler assessment detected posterior tibial and dorsalis pedis pulses. On examination of the right lower extremity, a 2-3cm full-thickness wound located on the plantar surface of the right foot at the midsole area of the 3rd and 4th metatarsals with tenderness to palpation and decreased ROM. A bedside I&D of the right foot was attempted but failed, resulting in a vascular surgery consult. Imaging revealed a puncture wound involving the plantar aspect of the right foot with subjacent pyomyositis involving the plantar intrinsic muscles with multiple localized gas locules along the plantar fascia to the level of the tarsometatarsal joints. These areas are pathognomonic of abscess, edema, and soft tissue swelling extending from the toes to the mid-calf consistent with cellulitis, and severe atherosclerotic changes throughout his right lower extremity with distal runoff to anterior tibial and peroneal arteries to the level of the ankle. Lab work revealed leukocytosis, hyperglycemia, hypocapnia, and mildly decreased sodium levels. The differential white blood count revealed neutrophilia of 84.4%, elevated immature granulocytes, monocytes, and decreased lymphocytes. The abnormal labs and imaging indicated a wound with a bacterial infection in the right foot, which could be used to determine differential diagnoses, such as abscess concerning for cellulitis vs necrotizing soft tissue fasciitis. 

The patient was given antibiotics, piperacillin-tazobactam, and underwent a right foot debridement where the surgeon uncovered devitalized tissue from the forefront of the foot to the heel, rendering it unsalvageable. The surgeon performed a guillotine amputation via ankle disarticulation. Post-operative labs revealed improving leukocytosis with 75.9% neutrophils, and a glucose of 150, a good response to the antibiotics. The patient is planned to return for a below-the-knee guillotine amputation. While foot pain in patients with diabetes causes concern, mild cases have hopeful sequela, whereas precarious cases can lead to life-changing and life-threatening circumstances. With trauma and infection to a diabetic foot time is indispensable, as shown in this case.

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