Uncontrolled Diabetes Mellitus type 2
Patient Presentation:
C.C., a chronically homeless 46 year old obese female arrived at the ED with complaints of severe onset of pain in her left leg and foot, chills, and appeared obtunded. Her initial vital signs were BP: 97/42, HR: 117, T: 38.2, RR 30. Assessment revealed edema, several deep ulcerations (from her left foot to tibia), and skin with a dark blue/black appearance. The wounds had a brown-red as well as purulent discharge, and a foul smelling odor. The foot and ankle also exhibited crepitus when lightly palpated for pedal pulses.
Differential diagnosis:
Septic Shock, gas gangrene, necrotizing fasciitis
Co-morbid diagnoses:
Peripheral vascular disease, chronic kidney failure, diabetes mellitus type 2
Tests:
CBC, LFTs, wound and blood cultures x2, later X-ray, CT, and ABGs, and lactate levels.
Notable results: WBC 17,000; H/H 7.5, 27%; BUN 68; creatinine 6.7; K+ 7.2; + Clostridium perfringens; lactate 4; pH 7.35; CO2 46; HCO3 17; blood glucose 267.
Treatment:
C.C. was immediately admitted inpatient and underwent a left BKA for gas gangrene. Subclavian central line was inserted allowing IV administration and subsequent hemodialysis. She was given IV Zosyn®, vancomycin, Flagyl® to control the infection, as well as PRBCs. Wound care/dressing changes for her stump were performed by an MD.
Outcome:
The patient’s medical background indicated that C.C. had chronic uncontrolled DM2; she never was adherent to insulin, oral anti-hyperglycemic, or antihypertensive medication therapy. She admitted to not understanding or being concerned about her disease. When discussing events preceding hospitalization, C.C. stated that she did not feel pain or ulcerations initially until the pain became very severe. Nor did she inspect her feet, despite being treated for “diabetic foot” in the past. Most of the time, she wore the same layers of socks, and clothes for weeks at a time. C.C.’s main focus was survival - finding shelter and eating.
Impaired circulation and compromised vascular supply secondary to DM had progressed to peripheral neuropathy and consequently ischemia and necrosis. Poor wound healing contributed to these ulcerations, which had become severely infected. Gas gangrene is not common in diabetic patients; but was a complication of the disease and its subsequent peripheral vascular disease.
Case created by Crystal Chappell, 2011.