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 ).