Dear Editors,
1.
Diabetic foot osteomyelitis (DFO) is the most challenging complication of diabetes mellitus (DM). It delays wound healing, prolongs hospitalisation and increases the duration of antimicrobial treatment, and bears a high risk of amputation.1 Early diagnosis and prompt management can reduce the rate of these complications. Histopathological and microbiological examination of bone culture is the gold standard of diagnosis;2 however, this procedure necessitates obtaining a bone biopsy, which is an invasive and demanding procedure that requires experience. Alternately, diagnosis is usually made using a combination of physical examinations (sausage toe), probe to bone testing, laboratory studies (particularly erythrocyte sedimentation rate), and imaging techniques (most frequently plain radiograph and magnetic resonance imaging).2
A 60‐year‐old man with type 2 DM for 21 years presented with a swollen red big toe that occurred 1 month prior. On physical examination, the big toe was hyperaemic, oedematous, and warm to the touch (Figure 1A). The pedal pulses were palpable. Laboratory studies at presentation were as follows: white blood cell: 9.4 × 103/mm3, erythrocyte sedimentation rate: 51 mm/h, and C‐reactive protein: 14·4 g/dl, HbA1c: 9·1%. A plain radiograph revealed medullary heterogeneity of the first distal phalanx, accompanied by erosive changes, bone fragmentation, and thickening of adjacent soft tissue (Figure 1B). A diagnosis of DFO was made, and the patient was treated with oral ciprofloxacin (500 mg every 12 hours for 4 weeks) combined with oral rifampicin (600 mg every 24 hours for 4 weeks), followed by oral fucidic acid (500 mg every 8 hours for 12 weeks). Throughout the healing process, the toe hyperaemia and oedema, as well as radiographic pathologies, gradually resolved, and the patient successfully healed, without recurrence at 3‐year follow‐up (Figure 1C,D).
Figure 1.
A typical view of the “sausage toe”. B, Plain radiography showing medullary heterogenity associated with erosive changes and bone fragmentation of the first distal phalanx as well as thickening of the adjacent soft tissue. C,D, Three years later, note the normal toe appearance and the regenerated bone
Several clinical findings, such as an exposed or visible bone or a bone that may be contacted with a sterile metal probe and/or a red swollen toe, namely the “sausage toe”, are highly suggestive of DFO.2 Although none of these findings have yet been defined as conclusive signs of DFO, they should prompt the physician to further analyse for DFO because early diagnosis and management of DFO may provide a chance to heal without amputation.3
REFERENCES
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