Streptococcus anginosus (SAG) is a known human pathogen and member of the Streptococcus milleri group. SAG is a known bacterial cause of soft-tissue abscesses and bacteremia and is an increasingly prevalent pathogen in infections in patients with cystic fibrosis. We describe a rare case of SAG as an infectious agent in a case of nonclostridial myonecrosis with soft-tissue emphysema. This is the only case found in the literature of SAG cultured as a pure isolate in this type of infection and was associated with a prolonged course of treatment in an otherwise healthy patient.
Stevens-Johnson syndrome and toxic epidermal necrolysis are rare; however, when they occur, they usually present with severe reactions in response to medications and other stimuli. These reactions are characterized by mucocutaneous lesions, which ultimately lead to epidermal death and sloughing. We present a unique case report of Stevens-Johnson syndrome and associated toxic epidermal necrolysis in a 61-year-old man after treatment for a peripherally inserted central catheter infection with trimethoprim-sulfamethoxazole. This case report reviews a rare adverse reaction to a commonly prescribed antibiotic drug used in podiatric medical practice for the management of diabetic foot infections. (J Am Podiatr Med Assoc 100(4): 299–303, 2010)
Most fungal infections primarily occur in immunocompromised patients. We describe a case of osteomyelitis involving the first metatarsal head due to Cryptococcus neoformans in a previously healthy immunocompetent patient. She was treated with surgical debridement combined with antifungal drug therapy for 6 months. At 5-year follow-up, she remained symptom free with full range of motion of the first metatarsophalangeal joint. Fungal osteomyelitis should be considered as a possible cause in osteolytic lesions in the metatarsal bone.
Acute rheumatic fever is a delayed inflammatory disease that follows streptococcal infection of the throat. Poststreptococcal reactive arthritis is a sterile arthritis associated with antecedent streptococcal infection in patients not fulfilling the Jones criteria for acute rheumatic fever. Poststreptococcal reactive arthritis has been reported to have lower-extremity predominance and, therefore, should be included in the differential diagnosis of patients with lower-extremity arthritis. A review of the literature, distinguishing poststreptococcal reactive arthritis from acute rheumatic fever, and treatment options are discussed here. A case report is also presented. (J Am Podiatr Med Assoc 96(4): 362–366, 2006)
This study investigated the resistance of bacteria isolated from diabetic foot ulcers (DFUs) to antibiotics frequently used in the management of the diabetic foot infections, at a range of pH values (pH 6.5, 7.5, and 8.5) known to exist in DFU wound fluid. This study aimed to determine whether changes (or atypical stasis) in wound fluid pH modulate the antibiotic resistance of DFU isolates, with potential implications in relation to the suppression/eradication of bacterial infections in DFUs.
Thirty bacterial isolates were recovered from DFU wound fluid, including Staphylococcus spp, Staphylococcus aureus, Escherichia coli, Streptococcus spp, Pseudomonas spp, and Pseudomonas aeruginosa. The resistances of these isolates to a panel of antibiotics currently used in the treatment of infected or potentially infected DFUs, ie, ciprofloxacin, amoxicillin-clavulanate, doxycycline, and piperacillin-tazobactam, at the previously mentioned pH values were determined by a modification of the Kirby-Bauer assay.
The resistance of DFU isolates to clinically relevant antibiotics was significantly affected by the pH levels in DFU wound fluid.
These findings highlight the importance of a more comprehensive understanding of the conditions in DFUs to inform clinical decision making in the selection and application of antibiotics in treating these difficult-to-heal wounds. The scale of the differences in the efficacies of antibiotics at the different pH values examined is likely to be sufficient to suggest reconsideration of the antibiotics of choice in the treatment of DFU infection.
Background: Transmetatarsal amputations are limb salvage surgical procedures that preserve limb length and functional ankle joints. Indications for transmetatarsal amputations include forefoot trauma, infection, and ischemia. Prior research demonstrates patients who undergo transmetatarsal amputations have a lower 2-year mortality rate compared to those who undergo more proximal amputations. The aim of this study was to determine whether primary closure of a transmetatarsal amputation is a superior treatment compared to secondary healing of a transmetatarsal amputation for forefoot abnormality of infection, gangrene, or chronic ulceration.
Methods: A retrospective chart review was performed on patients aged 18 years or older requiring a transmetatarsal amputation because of forefoot abnormality between September of 2011 and December of 2019. Foot and ankle surgeons performed transmetatarsal amputations. Outcome variables measured included healing time of transmetatarsal amputation site, recurrent infection, recurrent gangrene, and the need for revision surgery or higher level amputations.
Results: Of the original 112 patients, 76 met the inclusion criteria; 47 of these had primary closure of transmetatarsal amputation and 29 of these had an open transmetatarsal amputation performed. Primarily closed transmetatarsal amputations resulted in a significantly greater overall healing rate of 78.8% (37 of 47) compared to open transmetatarsal amputations, with a healing rate of 37.9% (11 of 29) (P < .01). Closed transmetatarsal amputations were statistically significantly less likely than open transmetatarsal amputations to have recurrent gangrene, require revision pedal operations, or progress to higher level amputations.
Conclusions: Our research demonstrated that primary closure of transmetatarsal amputations is a superior treatment compared with secondary healing of transmetatarsal amputations in specific cases of infection, dry gangrene, or chronically nonhealing ulcerations.
Osteomyelitis secondary to diabetic foot infections can lead to proximal amputation if not diagnosed in a timely and accurate manner. The authors have found no studies to date that correlate a specific erythrocyte sedimentation rate with osteomyelitis. A retrospective chart review of 29 diabetic patients admitted to the hospital with diagnoses of osteomyelitis or cellulitis of the foot during a 1-year period was performed. Of the various lab values and demographic factors compared, erythrocyte sedimentation rate was the only measure that differed significantly between the two groups. A receiver operating characteristic curve was used to obtain the optimal cutoff value of 70 mm/h, a level above which osteomyelitis was present with the highest sensitivity (89.5%) and highest specificity (100%), along with a positive predictive value of 100% and a negative predictive value of 83%. This study shows that in combination with clinical suspicion in diabetic foot infections, the erythrocyte sedimentation rate is highly predictive of osteomyelitis, and that the value of 70 mm/h is the optimal cutoff to predict accurately the presence or absence of bone infection. (J Am Podiatr Med Assoc 91(9): 445-450, 2001)
Onychomycosis is a chronic fungal infection of the nail that is recalcitrant to treatment. It is unclear why normally effective antifungal therapy results in low cure rates. Evidence suggests that there may be a plethora of reasons that include the limited immune presence in the nail, reduced circulation, presence of commensal microbes, and fungal influence on immune signaling. Therefore, treatment should be designed to address these possibilities and work synergistically with both the innate and adaptive immune responses.
Necrotizing fasciitis is a soft-tissue infection characterized by extensive necrosis of subcutaneous fat, neurovascular structures, and fascia. In general, fascial necrosis precedes muscle and skin involvement, hence its namesake. Initially, this uncommon and rapidly progressive disease process can present as a form of cellulitis or superficial abscess. However, the high morbidity and mortality rates associated with necrotizing fasciitis suggest a more serious, ominous condition. A delay in diagnosis can result in progressive advancement highlighted by widespread infection, multiple-organ involvement, and, ultimately, death. We present a case of limb salvage in a 52-year-old patient with type 2 diabetes mellitus and progressive fascial necrosis. A detailed review of the literature is presented, and current treatment modalities are described. Aggressive surgical debridement, comprehensive medical management of the sepsis and comorbidities, and timely closure of the resultant wound or wounds are essential for a successful outcome. (J Am Podiatr Med Assoc 96(1): 67–72, 2006)
We report an unusual case of Aeromonas hydrophilia septicemia in a nonmobile diabetic patient secondary to contaminated well water used for bathing with a portal of entry through chronic forefoot and heel ulcers. To date, there are no documented cases similar to this patient's presentation. Aeromonas hydrophilia is commonly distributed among aquatic environments and tends to be found during warmer months. It is a rare cause of disease but can be life threatening and deadly, as in our case, in immunocompromised individuals. As podiatric physicians, we must remain diligent and have a high index of suspicion to identify patients at risk for this rare but serious infection and administer treatment aggressively to limit morbidity and mortality.