Letter to the Editor
Necrotizing diabetic foot infection: A limb-threatening emergency
Infección necrotizante en el pie diabético: una urgencia que amenaza la pérdida de la extremidad
José Antonio Rubioa,e,
, Sara Jiméneza,b, M. Ángeles Martínez-Izquierdoc, Gregorio Guadalixd
Corresponding author
a Servicio de Endocrinología y Nutrición, Consulta de Pie Diabético, Spain
b Fundación para la Investigación Biomédica, Spain
c Servicio de Anatomía Patológica, Spain
d Servicio de Cirugía General, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
e Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
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La úlcera quedó expuesta tras la deslaminación de la hiperqueratosis circundante, hecho típico en las lesiones neuropáticas. Superior derecha, vista dorsal del pie donde se aprecia enrojecimiento de medio pie y necrosis del 3.<span class="elsevierStyleSup">er</span> dedo.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Imágenes inferiores: inferior izquierda se observa congestión y dilatación de los vasos sanguíneos así como tejido de granulación; también se aprecia ulceración y aspecto necrótico de la epidermis y dermis. Inferior derecha se observa un intenso infiltrado inflamatorio de predominio neutrofílico, con eosinófilos, que afecta al tejido óseo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "José Antonio Rubio, Sara Jiménez, M. 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Ángeles Martínez-Izquierdo, Gregorio Guadalix" "autores" => array:4 [ 0 => array:4 [ "nombre" => "José Antonio" "apellidos" => "Rubio" "email" => array:1 [ 0 => "jrubio.hupa@salud.madrid.org" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Sara" "apellidos" => "Jiménez" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Ángeles Martínez-Izquierdo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Gregorio" "apellidos" => "Guadalix" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Servicio de Endocrinología y Nutrición, Consulta de Pie Diabético, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Fundación para la Investigación Biomédica, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Spain" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Cirugía General, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Universidad de Alcalá, Alcalá de Henares, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infección necrotizante en el pie diabético: una urgencia que amenaza la pérdida de la extremidad" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1334 "Ancho" => 1000 "Tamanyo" => 328776 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Upper images: top left, plantar view of foot showing an ulcer on the head of the 3rd metatarsal, with marked perilesional reddening and a necrotic 3rd toe. Ulcer was exposed after delamination of the surrounding hyperkeratosis, which is typical in neuropathic lesions. Top right, dorsal view of foot showing reddening of midfoot and 3rd toe necrosis. Lower images: bottom left, blood vessel congestion and dilation, as well as granulation tissue. Ulceration and a necrotic appearance of epidermis and dermis are also seen. Bottom right, intensive, predominantly eosinophilic inflammatory infiltrate with eosinophils involving bone tissue.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The adequate management of diabetic foot, both uncomplicated or at risk because of complications such as ulcer, infection, or gangrene,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> is a professional challenge inherited from the past century which continues to be a pending subject.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> Relatively frequently, infections concomitant with diabetic foot lesions may lead to lower limb amputation. Necrotizing infections are among the most serious of such infections. Soft tissue necrotizing infection or necrotizing fasciitis is an infection involving any soft tissue layers associated with necrotizing changes and causing significant tissue destruction.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> When infection involves the lower limbs of diabetic patients, it is sometimes called wet gangrene; the term ‘necrotizing infection’ is however more adequate. The frequency of necrotizing infection in the diabetic population is not well known. Surgical series have recently reported that up to 30% of infections associated with diabetic foot are necrotizing infections,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> but their frequency is much lower (7%) according to other reports.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> These differences may possibly be due to differences in the type of series analyzed, with infection being more common, and thus more serious, in surgical series, and less common when all infected diabetic foot ulcers or lesions are analyzed. We report below the case of a diabetic patient with necrotizing infection which demonstrates the difficulties involved in the diagnostic and therapeutic approach to these patients.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our patient was a 48-year-old male with type 2 diabetes mellitus (T2DM) diagnosed three years before. The patient did not regularly return for clinical monitoring and was being treated with glimepiride 2<span class="elsevierStyleHsp" style=""></span>mg/day. Prior disease control was not known. He smoked 30<span class="elsevierStyleHsp" style=""></span>cigarettes/day and drank 120<span class="elsevierStyleHsp" style=""></span>g of alcohol daily. His known complications included moderate diabetic retinopathy.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient attended the clinic reporting a plantar ulcer on the head of the 3rd metatarsal of his left foot from an unknown date, which had started to be associated with pain in the whole foot and necrosis of the 3rd toe approximately two weeks before. Treatment with amoxicillin/clavulanic acid was started at primary care. No discharge from the lesion was found at this visit. Lower limb examination showed preserved distal pulses, no sensitivity as assessed using the 10<span class="elsevierStyleHsp" style=""></span>g Semmes-Weinstein monofilament, and decreased vibratory sensitivity using the Rydel-Seiffer graduated tuning fork. The left foot showed necrosis in the third toe, cyanosis in the fourth toe, and plantar ulcer with significant exudate, edema, erythema, and increased perilesional temperature (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, upper images). Ulcer examination showed positive probing to the bone.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">After initial evaluation, hospital admission for definitive treatment was decided upon, based on suspicion of necrotizing infection. Baseline laboratory test results included a WBC count of 11,000 with a left shift, blood glucose of 199<span class="elsevierStyleHsp" style=""></span>mg/dL, a sodium level of 124<span class="elsevierStyleHsp" style=""></span>mmol/L, and glycosylated hemoglobin of 8.4% (normal range, 4.2–6). All other results were unremarkable. The patient underwent transmetatarsal amputation of the 3rd and 4th rays, with good postoperative outcome. A microbiological study showed the presence of methicillin-resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> (MRSA). Antibiotic therapy was therefore switched to sulphametoxazole-trimethoprim. A histological study showed necrosis in the epidermis and dermis, predominantly neutrophilic severe inflammatory infiltrate with eosinophils affecting the area from the epidermis up to the vicinity of bone tissue (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, lower images).</p><p id="par0025" class="elsevierStylePara elsevierViewall">As is shown by this case, necrotizing infections require a rapid diagnostic approach and urgent medical and surgical treatment.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The patient probably had the disease for a longer time than since diagnosis, as he had moderate diabetic retinopathy and a loss of sensitivity from advanced sensory neuropathy, resulting from poor prior glucose control. His history of alcohol consumption probably contributed to the occurrence of neuropathy, as it is usually found in daily practice. The initial infection occurred in the plantar neuropathic ulcer, which is usually indolent until it commonly becomes complicated with infection. In these patients, a lack of education about lesion prevention in an insensitive foot (which is therefore at risk), combined with an absence of pain, usually prevent patients from seeking the help of a healthcare professional until more advanced stages. If we add to this the occasional lack of adequate expertise of some of the professionals in charge of these patients, the result may be a more severe and infected lesion. The presence of pulses ruled out ischemia as the cause of the lesion, and concomitant necrosis suggested a serious infection, even in the absence of signs of systemic impact such as fever, hyperglycemia, leukocytosis and/or an increased erythrocyte sedimentation rate, which is typically found in diabetic patients when infection exists, but may sometimes be absent when a foot is affected.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In an infected ulcer, a positive probe-to-bone test normally leads us to suspect bone involvement,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> as it was confirmed in this case by the histological study. The isolation of MRSA is relatively common in these infections and may partly account for lesion severity and aggressiveness and for the lack of an initial response to empirical antibiotic therapy. <span class="elsevierStyleItalic">S. aureus</span> is the germ detected in approximately 50% of these infections, and MRSA strains are found in almost half of them.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Toe necrosis results from arteriolar septic necrosis, caused in turn by neutrophilic vasculitis due to infection itself, and is therefore not caused by ischemia. Revascularization is thus not indicated in cases like this, but should be replaced by extensive surgical debridement and antibiotic coverage, either broad spectrum or specifically directed against the responsible pathogen.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The patient underwent minor amputation. It should be noted, however, that amputation is required in more than 75% of cases because of the severity of these infections. Several surgical procedures and a major amputation, with the resultant high morbidity, are not uncommonly required to save a limb or prevent the risk of death.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Other crucial issues in the management of these patients include glycemic and co-morbidity control.</p><p id="par0030" class="elsevierStylePara elsevierViewall">To sum up, the presence of necrosis in the foot of a diabetic patient without ischemic involvement should lead to suspicion of necrotizing infection. An aggressive approach including systemic, broad spectrum antibiotic therapy, and urgent surgical treatment consisting of extensive debridement and/or adequate amputation may save the limb and/or life of the patient. Prior identification of a foot at risk, such as an insensitive foot, should prompt preventive measures aimed at avoiding ulcers, which are the harbingers of future amputation.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Rubio JA, et al. Infección necrotizante en el pie diabético: una urgencia que amenaza la pérdida de la extremidad. Endocrinol Nutr. 2012;59(7):466–468.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1334 "Ancho" => 1000 "Tamanyo" => 328776 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Upper images: top left, plantar view of foot showing an ulcer on the head of the 3rd metatarsal, with marked perilesional reddening and a necrotic 3rd toe. Ulcer was exposed after delamination of the surrounding hyperkeratosis, which is typical in neuropathic lesions. Top right, dorsal view of foot showing reddening of midfoot and 3rd toe necrosis. Lower images: bottom left, blood vessel congestion and dilation, as well as granulation tissue. Ulceration and a necrotic appearance of epidermis and dermis are also seen. Bottom right, intensive, predominantly eosinophilic inflammatory infiltrate with eosinophils involving bone tissue.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Algoritmo diagnóstico y terapéutico del paciente diabético con infección en los pies. Pie diabético" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Tébar" 1 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 148 | 1 | 149 |
| 2024 October | 899 | 14 | 913 |
| 2024 September | 988 | 5 | 993 |
| 2024 August | 814 | 13 | 827 |
| 2024 July | 827 | 13 | 840 |
| 2024 June | 564 | 16 | 580 |
| 2024 May | 556 | 14 | 570 |
| 2024 April | 631 | 23 | 654 |
| 2024 March | 694 | 16 | 710 |
| 2024 February | 683 | 20 | 703 |
| 2024 January | 848 | 25 | 873 |
| 2023 December | 583 | 28 | 611 |
| 2023 November | 650 | 29 | 679 |
| 2023 October | 758 | 19 | 777 |
| 2023 September | 475 | 11 | 486 |
| 2023 August | 441 | 15 | 456 |
| 2023 July | 440 | 12 | 452 |
| 2023 June | 424 | 14 | 438 |
| 2023 May | 506 | 10 | 516 |
| 2023 April | 387 | 6 | 393 |
| 2023 March | 413 | 14 | 427 |
| 2023 February | 404 | 16 | 420 |
| 2023 January | 325 | 4 | 329 |
| 2022 December | 222 | 10 | 232 |
| 2022 November | 318 | 22 | 340 |
| 2022 October | 265 | 15 | 280 |
| 2022 September | 340 | 17 | 357 |
| 2022 August | 316 | 14 | 330 |
| 2022 July | 216 | 13 | 229 |
| 2022 June | 197 | 14 | 211 |
| 2022 May | 287 | 16 | 303 |
| 2022 April | 299 | 13 | 312 |
| 2022 March | 367 | 25 | 392 |
| 2022 February | 314 | 15 | 329 |
| 2022 January | 329 | 12 | 341 |
| 2021 December | 220 | 28 | 248 |
| 2021 November | 306 | 31 | 337 |
| 2021 October | 368 | 34 | 402 |
| 2021 September | 324 | 28 | 352 |
| 2021 August | 336 | 22 | 358 |
| 2021 July | 300 | 18 | 318 |
| 2021 June | 241 | 12 | 253 |
| 2021 May | 336 | 20 | 356 |
| 2021 April | 725 | 32 | 757 |
| 2021 March | 372 | 34 | 406 |
| 2021 February | 248 | 23 | 271 |
| 2021 January | 199 | 14 | 213 |
| 2020 December | 247 | 23 | 270 |
| 2020 November | 170 | 13 | 183 |
| 2020 October | 111 | 4 | 115 |
| 2020 September | 121 | 21 | 142 |
| 2020 August | 145 | 5 | 150 |
| 2020 July | 112 | 25 | 137 |
| 2020 June | 86 | 11 | 97 |
| 2020 May | 87 | 8 | 95 |
| 2020 April | 95 | 9 | 104 |
| 2020 March | 85 | 5 | 90 |
| 2020 February | 69 | 11 | 80 |
| 2020 January | 89 | 11 | 100 |
| 2019 December | 93 | 10 | 103 |
| 2019 November | 60 | 16 | 76 |
| 2019 October | 95 | 5 | 100 |
| 2019 September | 98 | 6 | 104 |
| 2019 August | 125 | 6 | 131 |
| 2019 July | 76 | 5 | 81 |
| 2019 June | 111 | 18 | 129 |
| 2019 May | 193 | 27 | 220 |
| 2019 April | 147 | 17 | 164 |
| 2019 March | 26 | 8 | 34 |
| 2019 February | 45 | 4 | 49 |
| 2019 January | 28 | 8 | 36 |
| 2018 December | 27 | 1 | 28 |
| 2018 November | 37 | 5 | 42 |
| 2018 October | 57 | 1 | 58 |
| 2018 September | 27 | 6 | 33 |
| 2018 August | 14 | 2 | 16 |
| 2018 July | 18 | 3 | 21 |
| 2018 June | 12 | 5 | 17 |
| 2018 May | 27 | 6 | 33 |
| 2018 April | 28 | 3 | 31 |
| 2018 March | 24 | 0 | 24 |
| 2018 February | 24 | 0 | 24 |
| 2018 January | 30 | 0 | 30 |
| 2017 December | 22 | 0 | 22 |
| 2017 November | 39 | 3 | 42 |
| 2017 October | 37 | 0 | 37 |
| 2017 September | 24 | 2 | 26 |
| 2017 August | 28 | 3 | 31 |
| 2017 July | 21 | 2 | 23 |
| 2017 June | 20 | 3 | 23 |
| 2017 May | 49 | 3 | 52 |
| 2017 April | 47 | 2 | 49 |
| 2017 March | 72 | 19 | 91 |
| 2017 February | 59 | 1 | 60 |
| 2017 January | 30 | 1 | 31 |
| 2016 December | 28 | 4 | 32 |
| 2016 November | 28 | 3 | 31 |
| 2016 October | 41 | 3 | 44 |
| 2016 September | 41 | 6 | 47 |
| 2016 August | 29 | 1 | 30 |
| 2016 July | 20 | 2 | 22 |
| 2016 June | 26 | 4 | 30 |
| 2016 May | 21 | 21 | 42 |
| 2016 April | 25 | 5 | 30 |
| 2016 March | 22 | 3 | 25 |
| 2016 February | 22 | 10 | 32 |
| 2016 January | 23 | 8 | 31 |
| 2015 December | 24 | 6 | 30 |
| 2015 November | 29 | 7 | 36 |
| 2015 October | 33 | 7 | 40 |
| 2015 September | 29 | 3 | 32 |
| 2015 August | 44 | 9 | 53 |
| 2015 July | 55 | 0 | 55 |
| 2015 June | 12 | 1 | 13 |
| 2015 May | 13 | 3 | 16 |
| 2015 April | 25 | 8 | 33 |
| 2015 March | 23 | 6 | 29 |
| 2015 February | 26 | 0 | 26 |
| 2015 January | 51 | 5 | 56 |
| 2014 December | 48 | 8 | 56 |
| 2014 November | 33 | 1 | 34 |
| 2014 October | 38 | 6 | 44 |
| 2014 September | 29 | 6 | 35 |
| 2014 August | 35 | 8 | 43 |
| 2014 June | 1 | 0 | 1 |
| 2014 April | 1 | 0 | 1 |
| 2013 July | 3 | 2 | 5 |
| 2013 June | 1 | 0 | 1 |
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