Case of recurrent cellulitis because of impacted plastic lid diabetic foot.
Foreign bodies may retain in the foot for a significant time, especially in patients with peripheral neuropathy before diagnosis. In addition, the foreign bodies may lead to acute or chronic infections, such as cellulitis and osteomyelitis of the foot. In a similar case, a 74-year-old presented to the emergency with pain his left leg associated with swelling and redness with a history of 5 days. There was no history of trauma or injury. He had a bilateral total knee replacement in the past. His medical history was significant for recurrent left leg and foot cellulitis, right lower limb lymphoedema, diabetic neuropathy and type 2 diabetes mellitus.
Examination showed that the patient was afebrile, whereas inspection of the left leg showed confluent erythema and oedema across the left knee to the distal phalanges. The patient’s foot further showed a ‘rocker-bottom’ deformity with absence of vibratory, temperature and distal loss of pin perception bilaterally. Doctors further assessed pressure sensation with a 10g monofilament, the findings showed an absence of pressure sensation. Laboratory investigations showed an increase in white cell count and glycated haemoglobin. Based on the findings, doctors diagnosed the patient with left lower limb cellulitis.
Initially the doctors advised a conservative treatment plan, however, the patient didn’t show any significant improvement.
Treatment included empiric intravenous flucloxacillin which helped with little improvement after a week. Doctors further advised an MRI of the left foot on the 8th day of admission which showed Charcot arthropathy with osteomyelitis of the third and fourth metatarsals. A foreign body measuring 17 x 12 x 8 mm was also seen embedded within the subcutaneous tissue of the dorsum of the midfoot with an abscess. This was not seen in any of the radiographs of the foot taken earlier.
The object was excised under general anaesthesia on the 15th day of admission. The object removed was identified as a plastic lid, measuring 1.5×1.5×1 cm. There were no signs of infections at the time of the procedure. The 74-year-old was discharged on the 14th day with intravenous antibiotics for 4 weeks. Since then the patient has made complete recovery.
While several cases of impacted insulin needles have been reported in diabetic feet, this case is a first of its kind. Foot infections are often underestimated in diabetic patients and may be because of foreign bodies. The foreign bodies are often masked because of absence of pain due to peripheral neuropathy, as in this case.
References
Recurrent cellulitis caused by an occult foreign body in a diabetic foot https://casereports.bmj.com/content/14/5/e243514
