CASE PRESENTATION DIABETES MELLITUS FOOT SYNDROME

DR DOSU (REGISTRAR)

CASE 1 69 year old retired secondary school

Principal who resides at Epe, Lagos

Christian

Married in a monogamous setting

PRESENTING COMPLAINTS Recently diagnosed with type 2 diabetes

(2/12 prior to presentation) at a private hospital

Presented at the Accident and Emergency with complaints of:

Left Leg ulcer x 4/12 Recurrent Fever x 1/12

HISTORY 4/12 prior to presentation, he sustained an

injury on the Left leg following a road traffic accident

He was the passenger of the motor bike that collided with another motor bike

There were associated burns on the left foot following contact with the silencer of the motor bike

HISTORY Burns were extensive, involving the dorso-

lateral aspect of the left fore foot extending towards the left ankle joint.

Associated pain and bleeding, but quantity of blood loss could not be adequately ascertained

There was also associated inability to walk as he sustained a fracture following the trauma to the left lower limb

At the Traditional Bone Setters Bone fracture was managed locally for

2/12 (splints fixed and analgesics given ?names)

With no improvement, he was taken to a private hospital

At the Private Hospital While on admission, he was diagnosed

with Type 2 Diabetes Mellitus

Daily wound dressing with normal saline, Tabs Metformin, Glibenclamide and analgesics

At the Private hospital Symptoms worsened with purulent foul

smelling yellowish discharge from the left foot

Associated dark discoloration of the fore foot to the distal 1/3 of the left leg

At the Private hospital High grade fever, intermittent associated

with chills and rigor.

Antibiotics given (?names) and after 3/7 with no improvement, he was referred to LUTH for expert management

HISTORY

History did not reveal symptoms suggestive of DM complications

HISTORY No significant past medical or surgical

history

No family history of diabetes mellitus

Neither smokes nor takes alcohol

Takes water-based herbal concoctions ocassionally

GENERAL EXAMINATION Significant findings revealed

a chronically ill looking elderly man, pale, afebrile (T-36.2 C), anicteric well hydrated, no pedal edema wound dressing on left foot dirty and

soaked with seropurulent fluid

MSS EXAMINATION [LEFT LOWER LIMB]

Wet gangrene of the distal 2/3 of the left leg and the foot with extensive tissue loss involving the entire fore foot

Open fracture of the tibia bone, protruding visibly at the middle third of the left leg

Multiple excoriations with patchy areas of slough on the upper third of the left leg

Only popliteal artery pulsation intact

CNS EXAMINATION Conscious and alert Well oriented in time, place and person No obvious focal neurological deficit

CVS EXAMINATION PR – 100b/m BP – 100/70mmHg JVP not raised AB – Left 5ICS MCL HS – S1 S2 only

CHEST EXAMINATION RR –20cpm Trachea central Chest expansion equal bilaterally Resonant percussion note Vesicular breath sounds

ABDOMINAL EXAMINATION Full, moves with respiration No areas of tenderness No palpable organomegaly or intra-

abdominal masses Bowel sounds normoactive

DIAGNOSIS MADE Diabetes Mellitus Foot Syndrome (Wagner

Grade V) complicated by: Anaemia Sepsis focus left lower limb Peripheral arterial disease

Left tibio-fibular fracture

INVESTIGATIONS Random blood sugar at presentation was

135mg/dl

HbA1c – 10% (3.9 – 6.1%)

Urinalysis essentially normal

INVESTIGATIONSFBC 30 / 5 / 15

Hb (g/dl) 7.5

PCV (%) 24 (40 – 54%)

WBC 17.80 (4.0 – 11.0/mm³)

Neu (%) 60

Lymp (%) 29

PLT 275

ESR (mm/hr 100

INVESTIGATIONSE / U / Cr 30 / 5 / 15

Na 135 (135 – 145mmol/l)

K 3.5 (3.5 -5.1mmol/l)

Cl 97 (98 - 110mmol/l)

HCO3 22 (22 – 30mmol/l)

Urea 2.9 (2.5 – 6.4mmol/l)

Cr 42 (57 – 113umol/l)

INVESTIGATIONSFLP 30 / 5 / 15

Total Cholesterol 2.6 (< 5.0mmol/L)

TG 0.8 (< 1.7mmol/L)

HDL 1.1 (> 1.00mmol/L)

LDL 1.7 (< 3.0mmol/L)

INVESTIGATIONS X-ray of Left leg and foot (AP & Lateral

views) showed segmental Tibio-fibular fracture with

sclerosis and cortical thickening of the involved segments;

lytic bone lesions,

osteopenia of foot bones

INVESTIGATIONS Doppler USS – requested but not done

prior to surgery due to financial constraints

Wound swab m/c/s and wound Biopsy for m/c/s – not done due to financial constraints

TREATMENT IM Tetanus Toxoid 0.5mls stat

SC Anti Tetanus Serum 1500 units stat (given after a negative test dose)

SC soluble insulin 8 units tds (30mins pre meals)

IV ceftriaxone 2g stat, then 1g daily

IV metronidazole 500mg 8hrly

Patient was allowed to eat as he could tolerate orally

TREATMENT Reviewed by the Orthopedics team who

counseled patient on the need for above knee amputation which he agreed to and was worked up for surgery

He had the procedure done 3 days after presentation

REASONS FOR DELAYED SURGERY Reasons for delay include:

Financial constraints to do investigations Delay in blood donation Delay in procuring materials for surgery

OPERATION FINDINGS1. Oedematous subcutaneous tissue and

muscle extending to the distal 1/3 of the left thigh

2. Gangrene of the left leg

3. Thickened femoral wall

He was transfused with 2 pints of blood intra-operatively and two pints of blood post operatively

INVESTIGATIONSFBC 30/5/15

(PRE-OP)8/6/15(POST-OP)

Hb (g/dl) 7.5 10.8

PCV (%) 24 35 (40 – 54%)

WBC (cells/mm³) 17.80 7.58 (4.0 -11.0/mm³)

Neu (%) 60 45.5

Lymp (%) 29 44

PLT (cells/mm³) 275 333

ESR (mm/hr) 100 51

INVESTIGATIONSE/U/Cr 30/5/15

(PRE-OP)10/6/15(POST-OP)

Na (mmol/l) 135 135 (135 –145mmol/l)

K (mmol/l) 3.5 3.8 (3.5 -5.1mmol/l)

Cl (mmol/l) 97 94 (98 - 110mmol/l)

HCO₃(mmol/l) 22 26 (22 – 30mmol/l)

Urea (mg/dl) 2.9 14 (2.5 – 6.4mmol/l)

Cr (umol/L) 42 23 (57 – 113umol/l)

POST-OP CARE IMMEDIATE POST OP CARE

IV Levofloxacin 500mg dly IV flagyl 500mg 8hrly IM Pentazocine 30mg 8hrly IM Pcm 600mg 8hrly IVF 5% D/S 500mls + 10mmol Kcl + 10units

insulin x 24hrs SC Enoxaparin 40mg dly

POST-OP CARE

GKI was changed to S/C soluble insulin 8 units tds (30 mins pre meals) as he commenced feeds orally

RBS range within 72hrs post op: 144 -221mg/dl

POST-OP CARE Left stump was inspected by the 3rd day

post op; wound healing was uneventful

He commenced physiotherapy 2 weeks post op

By 18th day post op, he was commenced on Tabs Sitagliptin/Metformin 50/500mg with good glycemic control (89 – 105 mg/dl)

DISCHARGE He was subsequently discharged after

27 days on admission (date of discharge: 25/06/2015)

Discharged to the Endocrinology clinic and Orthopedics clinic for follow up care

FOLLOW UP Yet to be seen in Endocrinology clinic since

discharge

Son has been contacted on phone since discharge and promised to re-schedule another appointment for his father, though he said his father’s health is satisfactory.

We are expecting him in our clinic any moment from now.

SUMMARY 69 yr old retired secondary school Principal who presented

with Left Leg ulcer (and tibio fibular fracture) Recurrent Fever

Initially sort help with a traditionalist

Had an above knee amputation 72 hrs post presentation on account of extensive gangrene (wagner grade V)

Post op period was uneventful

Discharged 27 days post admission.

THANKS FOR LISTENING