THE CASE
A 82 years old female presented with fever from last 10 days and
swelling of the left foot from last 7 days . Initially, she was managed
at a nearby general hospital for the fever but the condition did not
improve and she was referred to us after development of swelling in the
foot. After proper history taking and physical examination, it was found
that she had coronary artery disease, hypertension and chronic kidney
disease. Foot was diffusely swollen and non-fluctuant and red on lateral
aspect. She was started on intra-venous antibiotics (third generation
cephalosporin, fluoroquinolone and metronidazole). Her fever did not
subside and next day she developed abscess on lateral aspect of the
foot.
Immediate decision was made to decompress the abscess though the skin
over the foot started necrosing gradually. Pus culture from the abscess
was sent and found to be infected with Staphylococcus aureus and
intravenous antibiotics were started as per the antibiotics sensitivity.
Though the skin continued to necrose and started involving dorsum and
medial side of the ankle too. Repeat debridement was done and necrose
skin was removed (Figure 1 a, b, c ). Two days later, plantar
surface of the foot around the heel also developed the abscess and it
was drained on the same day.
Even with multiple attempts of debridement and intravenous antibiotics,
her condition was not improving so it was decided to combine the
treatment with Negative Pressure Wound Therapy (NPWT) (Figure 1
d, e, f ). Dressing was changed after every five days and status of the
wound was inspected (Figure 2 a) . Though it sucked the fluid
literally out of the patient and the canister was filling in only two
days. Total 4 dressings were done and the condition of the wound
improved drastically with the NPWT. Adequate granulation tissue was
formed and wound turned reddish (Figure 2 b, c ). Now, Megaheal
(Nano silver colloid) Placental extract gel was applied on the wound
daily to produce adequate granulation tissue so that exposed bone could
be covered. Meanwhile, patient was advised to undergo flap coverage of
the wound, however she and her relatives denied to undergo the surgery
considering the age and comorbidities. Compressive dressing with
Placentex and Megaheal was done on alternate day. A below knee slab was
also applied to correct impending equinus and ankle varus as lateral
ligaments became attenuated because of infection. With passing time,
neo-epithelialization started from periphery and gradually wound was
being covered with the new epithelial tissue (Figure 3 a, b) .
Meanwhile, patient was given 4 unit of human albumin and three unit of
packed red blood cells on different time. She was put on high protein
diet, vitamin C and zinc tablets. It around took 7 months for the
complete coverage of the wound and patient and her relatives were
satisfied with the outcome as she achieved the functional foot without
any deformity (Figure 3 c, d ).