A 47-YEAR-OLD WOMAN was admitted to our hospital for intravenous antibiotic treatment of recurrent cellulitis with ulceration of her left second and third toes. Previous outpatient management with trimethoprim-sulfamethoxazole followed by clindamycin had failed.
The patient had been treated repeatedly over the previous 10 years for similar episodes of methicillin-resistant Staphylococcus aureus cellulitis with ulceration of the same toes. These episodes began after the patient had been in multiple car accidents and had sustained lower extremity trauma.
When the patient was admitted, she was afebrile and had normal vital signs. The ulcerations on her left second and third toes (FIGURE) were painful. The distal dorsal foot was warm, erythematous, and indurated without fluctuance or crepitus. There were diffuse spider veins on the lower extremities and the peripheral pulses were 2+ symmetrically. Electrolytes, including calcium, phosphate, and alkaline phosphatase, were within normal limits, the white blood cell count was 4.9 × 103/mm3 and C-reactive protein was 1.0 mg/dL. There was an elevated erythrocyte sedimentation rate of 46 mm/h, mild transaminitis (ALT>AST), and a finding of chronic hepatitis C infection (a few months prior).
FIGURE
Ulcerated toes in a nondiabetic patient
Wound and blood cultures were negative for infection. Radiologic examination of the left foot showed no signs of osteomyelitis or other bony abnormality. We sent punch biopsies out for pathologic assessment.
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