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Smelly Foot*

 

History of Present Illness:

A man in his 60’s with a history of DM and left BKA is brought to the ED by his wife for a pink smelly right foot that has been getting gradually worse for 2 weeks.  He did not want to see a doctor but the smell got so bad that his wife finally called 911.   He denies any fever, recent trauma or other complaints though he says he broke the same foot a long time ago in a motorcycle accident.

Vital Signs & Physical Exam:

Vital signs are normal except for  a pulse of 118. Physical exam is otherwise normal except for a BKA on the other leg and a stinky right foot with a large black eschar.

Initial Diagnostic Testing:

  • Labs: glucose 350, bicarb normal, lactate 2.5, creatinine 2.1, WBC 32K, 12 bands
  • Imaging: See below

What is the most likely acute diagnosis?

    • A) Cellulitis
    • B) Necrotizing Fasciitis
    • C) Osteomyelitis
    • D) Foot fracture

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

 

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ANSWER

    • A) Cellulitis – it sounds like cellulitis is present, but there is more sinister disease here as well
    • B) Necrotizing Fasciitis –  x-ray shows gas in the soft tissues concerning for necrotizing fasciitis
    • C) Osteomyelitis – the x-ray is equivocal for this
    • D) Foot fracture – the x-ray does show degenerative changes and a possible old fracture but these are not acute.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: He was started on vancomycin, Zosyn and clindamycin.  Orthopedics was consulted and they took him emergently to the OR to perform a BKA

CASE LESSONS:

  • Always think “could this be nec-fasc” when you care for a patient with cellulitis or abscess.  Know the risk factors and red flags in the sample page above and perform imaging when indicated.
  • Beware of pitfalls such as cases that present indolently or other atypical features.
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