The Cost of Delay: Amputation Secondary to Osteomyelitis in an Undiagnosed Diabetic
Abstract
Emily Chac
SIU Physician Assistant Program Master’s Project Abstract
Faculty Chair: Halley Barke, DMSc, PA-C
The Cost of Delay: Amputation Secondary to Osteomyelitis in an Undiagnosed Diabetic
This poster covers a unique presentation of type 2 diabetes mellitus in an otherwise healthy, non-English speaking, young male. While a diabetic foot ulcer is a common complication among diabetics, one that results in osteomyelitis and subsequent toe amputation in an individual without classic symptoms of diabetes is not commonly encountered. Osteomyelitis is a bone infection and, when secondary to a diabetic foot ulcer, it’s spread is nonhematogenous. A pathogen will inoculate the bone due to direct spread from soft tissue infection. Left untreated, the risk of amputation is high. This case and presentation highlight the importance of routine healthcare to screen for and manage chronic health conditions which can prevent devastating outcomes. Additionally, it is crucial for providers to recognize the barriers to healthcare minorities and non-English speaking patients face thereby providing proper resources and education. This can aid in increasing treatment compliance outside of the hospital and prevention of future complications due to chronic disease.
The case is that of a 30-year-old male who presented to the emergency department five days after kicking a wall causing minor injury to his left great toe that was worsening. He reported 5/10 pain, swelling, and discharge. He kept the site covered with a dressing made from home using cotton balls and duct tape for the last few days. Upon removal, his left first digit was edematous and a medial ulcer with green purulence, erythema, and maceration with whiteness in the area was seen. Blood work was obtained with lab values significant for glucose of 391 mg/dL, hemoglobin A1c of 9.9%, and elevated acute phase reactants. Blood cultures were sent. An x-ray of the left foot revealed a comminuted fracture, periosteal lifting, and erosive changes at the first interphalangeal joint suggesting osteomyelitis. Intravenous (IV) fluids using 0.9% normal saline was initiated along with broad spectrum antibiotics consisting of Piperacillin-Tazobactam and Vancomycin. Podiatry was consulted. The patient was then admitted to the hospital for further wound care with a diagnosis of osteomyelitis and new onset diabetes.
The patient was admitted to the general medical floor with cardiology and podiatry involved in care. Magnetic resonance imaging (MRI) of the left foot confirmed multifocal osteomyelitis secondary to an open wound. After a discussion with the patient about his treatment options, amputation of the left great toe with bone biopsy and soft tissue debridement was recommended. Multiple blood cultures demonstrated no growth of bacteria, so antibiotic therapy with IV Piperacillin-Tazobactam was continued throughout his stay. A diabetic foot ulcer is frequently polymicrobial in nature and broad-spectrum antibiotics are necessary, validating this treatment option. His diabetes was managed inpatient with metformin and insulin lispro using a sliding scale. Post amputation, the patient was evaluated by physical therapy. He was able to be discharged four days later on oral amoxicillin/clavulanate for ten days for any residual infection, metformin twice daily for diabetes, and oxycodone/acetaminophen every four hours as needed for severe pain. He was instructed to change bandage dressings daily and keep the incision dry and clean. An appointment with a primary care provider (PCP) was made for follow up that week and he was given a number to the recommended clinic for management of his diabetes.
This case demonstrates a devastating outcome of osteomyelitis as a complication of diabetes. It emphasizes the importance of primary care and its role in screening for and managing chronic disease. The United States Preventive Services Task Force (USPSTF) recommends screening for prediabetes and type 2 diabetes in asymptomatic adults aged 35-70 years who have overweight (body mass index ≥ 25 kg/m2) or obesity (body mass index ≥ 30 kg/m2). Screening can be completed using fasting plasma glucose, hemoglobin A1c level, or an oral glucose tolerance test. The USPSTF also recommends yearly foot exams in all diabetic patients. Should this patient have received regular care by a PCP, amputation, or osteomyelitis itself may have been prevented. It is important to note that this patient is a minority and English is not his first language. It has been studied that language barriers lead to worse healthcare quality and outcomes, as well as decreased access to preventive services and cancer screening. A bedside translator was used to ensure understanding during his time at the hospital. His treatment plan may or may not have been different should he have access to regular follow up, consisting of shorter antibiotic duration and more conservative management without the need for amputation. This case stresses the need for cultural sensitivity training for clinicians, expanding the availability of medical interpreters, making consent forms and educational materials available in multiple languages, and expanding outreach to communities.