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Cultures are more sensitive than stains, and can reliably identify mycobacteria in a
concentrationof103 organismspermLofspecimen.Aspecimenofatleast1 mLshouldbe
sentforculture.Incasesofmultiplebonelesions,itisimportanttoobtainculturesfromeach
focusofinfection.DifferentstrainsofM.tuberculosis,eachwith differentsensitivities,may
resideineachfocusofinfection.
AnegativePPDdoesnotexcludethepossibilityofTB.Thequestionarisesastowhethera
negativereactioniscausedbylackofinfectionwithM.tuberculosisorthepatient’sinability
tomountaresponsetotheskintestantigen.Indeed,patientswithimmuneabnormalities(such
as advancedHIVdisease),advancedage, andevenoverwhelmingTBinfection may havea
false-negativePPD.
ItisimportanttorememberthatpyogenicbacteriasuchasS.aureuscancoexistwithM.
tuberculosis in infected bone and soft tissue.85 Mycobacterial osteomyelitis should be
suspected when improvement does not occur with appropriate antibiotic therapy directed
toward pyogenic bacteria.Unless acid-faststains andcultures arespecificallyperformed, a
mycobacterialinfectionwillbemissed.Ahighindexofsuspicionisneeded.
OSTEOMYELITISINSICKLECELLDISEASE
Sickle cell disease is a congenital hemolytic anemia caused by inheritance of abnormal
hemoglobingenes.Itisoneofthemostcommoninheritedblooddiseases,andhasworldwide
distribution.86Sicklecelldiseaseischaracterizedbyacuteepisodesofpainfulvaso-occlusive
crises.
87
Osteomyelitisisawell-knowncomplicationofsicklecelldisease.Bonesarethesecond
mostaffectedorgansafterthespleen.Duringsicklecellcrises,boneandmuscleinfarctswith
necrosisoccur,providinganidusforinfection.Recurrentvascularinfarctionscauseend-organ
damage to the bone, lung, liver, kidney, skin, and spleen.87 Autosplenectomy and surgical
splenectomy render sickle cell disease patients susceptible to various types of infections,
mainlyfromencapsulatedbacteria.
88
A French study of a cohort of 299 patients followed in four Parisian centers found a
prevalenceofosteomyelitisof12%.89Inanotherstudy,arelativerateofoccurrenceofalmost
18%wasfoundforosteomyelitisand7%forsepticarthritis.
90
Osteomyelitismostcommonlyaffectsthelongbones,butcaninvolveotherbonesincluding
thoseofthefoot87;multifocalboneinvolvementhasbeenrecognizedtooccurinasmanyasa
quarterofpatientsdiagnosedwithsicklecellosteomyelitis.
91
ThemostcommoncauseofosteomyelitisinsicklecelldiseaseisSalmonella(especially
the nontypical serotypes Salmonella typhimurium, Salmonella enteritidis, Salmonella
choleraesuis,andSalmonellaparatyphiB),followedbyS.aureusandGram-negativeenteric
bacilli, perhaps because intravascular sickling of the bowel leads to patchy ischemic
infarction.
92
Osteomyelitis caused by vancomycin-resistant Enterococcus faecium has also been
reported.
91
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1.
2.
3.
Dactylitis, also knownas hand–foot syndrome, is an acute vaso-occlusive complication
characterized by pain and edema in both hands and feet, frequently with increased local
temperatureanderythema.
93
Sickling crisis are thought to be manytimes more commonthan bacterial osteomyelitis.
Distinguishingbetweenacuteosteomyelitisandvaso-occlusivecrisisboneinfarctionremains
challenging, particularly in culture-negative cases.94 Failure to correctly diagnose
osteomyelitisinsicklecelldiseasemayresultinseverebonedamage,whereasanerroneous
diagnosissubjectsthepatienttounnecessarylong-termantibiotictherapy.
Bloodcultureispositivein50%ofcasesofacuteosteomyelitisandisoftenrequiredto
diagnoseinfectionaccurately. Ifinfection isnotsuspectedandbloodis sampledlaterinthe
courseofmanagement,culturesusuallyareunhelpful.Eventhecultureofbiopsyspecimensis
not completely reliable.95 Ultrasound and advanced imaging modalities such as MRI and
single-photonemissioncomputedtomography(SPECT)/CT87incombinationwithC-reactive
proteinandWBCcountmayassistindistinguishingboneinfarctfromosteomyelitis.
94
HUMANIMMUNODEFICIENCYVIRUS
In the earlystagesoftheHIV epidemic, itwasestimated thatmore than halfof allpatients
infectedwithHIVwouldexperiencesome boneorjointsymptom during thecourse oftheir
disease.96 With recent advances in antiretroviral therapy, these numbers have undoubtedly
declined.
Nonetheless, HIV infectionhasbeenassociatedwithseveral typesofarthritis, ofwhich
reactive arthritides are the most common. Although it is questionable that HIV infection is
capable of initiating reactive arthritis, it undoubtedly increases the severity of reactive
arthritis.97 HIV-associated reactive arthritis frequentlyfollows an accelerated course witha
strong tendency to relapse, develop early erosions and joint deformity, and become
chronic.
98–100
Septic arthritis caused by fungal and mycobacterial organisms (e.g., Candida species,
Cryptococcusneoformans, Histoplasma capsulatum, Mycobacterium avium-intracellulare,
Sporothrixschenckii,andM.tuberculosis)alsohasbeenassociatedwithHIV infectionand
mayoccurasaresultofhematogenousdisseminationofsystemicinfection.
Itisthereforerecommendedthatwhendealingwithanyinfectiousprocessinapatientwith
HIV,aerobic,anaerobic,acid-fast,andfungalstainsandculturesbeincluded.
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M
anagement of diabetes in the past century has significantly changed diabetes from a
primarycausetoasecondarycauseofmortality.Withtheintroductionofinsulininthe
1920s,notonlycouldmortalityfromdiabetesbeprevented,butindividualswereabletolivea
longer and more normal life. Although life span had increased with the advent of insulin,
complications such as infections of lower extremity not previously seen began to emerge.
These complications were even more apparent in patients with uncontrolled diabetes. The
ramifications of uncontrolled diabetes include blindness, renal failure, stroke, and lower
extremityamputations.
1
The staggering growth of obesity in the United States directly influences the birth and
growth of type 2 diabetes mellitus as an epidemic. Studying the past couple of decades
confirmsthat90%ofindividualsdiagnosedwithdiabetesmellitushavetype2.Researchhas
demonstrated that there is a 4.5% increased risk of developing type 2 diabetes for every
kilogramofbodymassgained.
2
Withregardtofootcomplication,footulcersandamputationisthemainpreventiongoal.
Over85%ofalldiabetic-relatedlowerextremityamputationswereprecededbyulceration.It
iswellnotedthatquickresolutionofa footulcer combinedwithappropriateinterventionto
reducetherateofrecurrencecanlowertheriskofdevelopingasecondaryinfectionandcan
decreasetheprobabilityoflowerextremityamputationinthepatientwithdiabetes.
3
Themultidisciplinaryhealthcareteamapproachforthetreatmentofthediabeticfootulcer
isefficaciousandmayimprovetheoutcomeandlong-termprognosisofthesepatients.Thefoot
specialistorprimarycareproviderisoftenthefirstprofessionalcontactedforevaluationand
managementofthediabeticfootulcerandthereforecanserveasaneffective“gatekeeper”for
thepurposeofintegratingtheotherspecialtiesinthetreatmentofthispathology.4Thischapter
incorporatesthe essentialprinciples ofdiabeticwound care recommendedby theAmerican
DiabetesAssociation(ADA),theAgencyforHealthCarePolicyandResearch,theCenterfor
DiseaseControl(CDC),andtheU.S.DepartmentofHealthandHumanServices(HHS).
EPIDEMIOLOGY
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Diabetes is the sixth leading cause of death in the United States. From 1990 to 2014, the
prevalenceofdiabetesincreasedfrom4.9%to9.3%.Accordingtotheneweststatisticsfrom
the 2014CDC,29.1 millionAmericanshavediabetes,whichisabout1inevery11people,
and 1 out of 4 diabetics do not know they have the disease; 86 million Americans have
prediabetes,whichis1outof3adultsintheUnitedStates,andofthose86million9outof10
donotrealizetheyhaveprediabetes.
5
Thetotalmedicalcostsandlostworkandwagesforpeoplediagnosedwithdiabeteswere
estimatedat245billiondollars.Theriskofdeathforadultswithdiabetesis50%higherthan
foradultswithoutdiabetes.
5
In2010,about73,000nontraumaticlowerlimbamputationswereperformedinadultsaged
20yearsorolderwithdiagnoseddiabetes.
5
In 1991, theHHS,Public Health Service, publishedareport on“Diabetesand Chronic
DisablingConditions.”HealthyPeople2000listedthenationalhealthpromotionanddisease
prevention objectives. One goal of the Healthy People 2000 initiative was to reduce the
incidenceofdiabetesto2.5casesper1,000peopleandreducetheprevalenceto25casesper
1,000people.Theseobjectiveswere nevermet.Healthy People 2010soughttocontinueon
thosegoalsandtheytoowerenevermet.WeareawaitingHealthyPeople2020.
6,7
NEUROPATHY
Manytypesofneuropathiescanbeassociatedwithdiabetesincludingpolyneuropathy(many
nerves affects both limbs), mononeuropathy (asymmetric and localized to one or several
branches of a nerve trunk), and multifocal neuropathy (startinspecific parts of the limb—
usuallythesymptomsaremoresevereononesideofthebody).8Peripheralneuropathyisthe
most common type of neuropathy affecting diabetic patients. It is a key factor in the
development of diabetic foot ulcerations. Neuropathy is generally considered to be a
multifactorialdisorder.
9
Overthepast20years,therehavebeenthreemaintheoriestoexplaindiabeticneuropathy:
thepolyolpathwaytheory,themicrovasculartheory,andtheglycosylationendproducttheory.
It has become increasingly apparentthat several pathophysiologic factors probably operate
simultaneously, and it may be too simplistic to attempt to explain the many clinical
presentationsandpathologicfindingsofdiabeticneuropathybyasingletheory.
10
Thecausesareprobablydifferentfordifferenttypesofdiabeticneuropathy.Nervedamage
is likelycaused bya combinationoffactors: metabolic factors,suchashigh blood glucose,
long duration of diabetes, abnormal blood fat levels, and possibly low levels of insulin11;
neurovascularfactorsleadingtodamagetothebloodvesselsthatcarryoxygenandnutrientsto
nerves; autoimmune factors that cause inflammation in nerves; mechanical injurytonerves,
such as carpaltunnel syndrome;inheritedtraitsthatincreasesusceptibility tonervedisease;
lifestyle factors such as smoking or alcohol use all may play a role in the cause of
neuropathy.
12
Theeffectsofthesemechanismsproduceacombinationofsensory,motor,andautonomic
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deficits.
Characteristicsofdiabeticneuropathyaresymmetrical,stockingandglovedistributionthat
starts distal and progresses proximally. Symptoms may notbe present atdiagnosis and are
usuallyfoundonclinicalexam.Itisalength-dependentprocess,anditssensorymanifestations
aremostpronouncedinthelowerlimbsand,inmoreseverecases,inthefingersandhands.
13
Sensory deficiency as a result of diabetic peripheral polyneuropathy is a commonly
associatedfindingandhasbeenidentifiedas animportant riskfactorinthe developmentof
diabetic foot ulcers. The probability of developing wounds increases dramatically when
sensationislostinthepresenceoffaultybiomechanicsandresultantdeformity.
Variousdiagnostictestsareemployedwhentheclinicianisassessingthelevelanddegree
ofperipheralsensoryneuropathy.Twoofthemorecommonlyusedtestsarethe5.07SemmesWeinsteinMonofilamentandtheVibrationPerceptionThresholdexam.TheSemmes-Weinstein
deviceisasimplemonofilamentofnylonthatdelivers10gofforcewhenappliedtotheskin
and is an easily reproduced exam. A number of cross-sectional studies have assessed the
sensitivity of the 10-gmonofilamenttoidentify feet at riskof ulceration. Sensitivities vary
from86%to100%.
14
TheVibrationPerceptionThresholdexamiscommonlyperformedwithagraduatedRydelSeiffertuningfork.15Thisforkusesavisualopticalillusiontoallowtheassessortodetermine
theintensityofresidualvibrationona0to8scaleatthepointofthreshold(disappearanceof
sensation),16butismoreaccuratelyperformedwithacalibratedelectricaldeviceknownasthe
Biothesiometer.These tests should be repeated two tothree times yearly for progressively
developingneuropathicconditionsandforthoseatidentifiedhighriskfordevelopinglossof
protectivesensationintheirfeet.
17
A smallfiberneuropathyoccurs whendamagetotheperipheralnerves predominantlyor
entirelyaffectsthesmallmyelinated(Aδ)fibersorunmyelinatedCfibers.Thespecificfiber
typesinvolvedinthisprocessincludebothsmallsomaticandautonomicfibers.Thesensory
functions of these fibers include thermal perception and nociception. These fibers also are
involvedinanumberofautonomicandentericfunctions.
18
Diagnosis ofsmall fiber neuropathy isdeterminedprimarilyby thehistoryand physical
exam,specificallyaskingquestionssuchas,Doyourfeeteverfeelnumb?Dotheyevertingle?
Dotheyeverburn?Dotheyeverfeelasifinsectsarecrawlingonthem?
17
Functional neurophysiologic testing and skin biopsy evaluation of intraepidermal nerve
fiberdensitycanprovidediagnosticconfirmation.
19
Thatistheabsenceofprotectivesensationwithnosignificantvasculardisease,nohistory
ofulcerationorCharcotarthropathy,andnofootdeformity,apatientis1.7timesmorelikelyto
ulcerate.
17
Type 2 diabetic patients may have muscle weakness at the ankle and knee related to
presenceandseverityofperipheralneuropathy.Motordeficitisexemplifiedbyweaknessof
the anterior tibial compartment and pedal intrinsic muscular atrophy, leading to digital
instability and associated increased peak pressures around the resultant deformities. High
compressiveandfrictionalforcesoccuraroundtheareasofdeformity.Thesedeformitiescan
includesimplefootailmentssuchasbunions,hammertoes,andprominentmetatarsals.20Long-
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term insulin-dependent diabetes mellitus patients have increased endurance but reduced
strengthandworkperformanceoflegmuscles.Thecombinedeffectofthemotorabnormalities
is suggested to give rise to functional impairment, including anincreased risk of falls and
injuries.21Patientswithabsentprotectivesensation,nosignificantvasculardisease,nohistory
ofulcerationor Charcotarthropathy, andafootdeformity present(focus ofstress) are 12.1
timesmorelikelytoulcerate.
17
Recognizing biomechanically altered gait patterns and prescribing the appropriate offloadingis imperative if oneis toattain healing ofan ulcer anddecrease theprobability of
developinganewone.
22
Hyperkeratosisoftenformsatthesiteofpressureorshearandrepetitiveinjury.Calluses
onthesoleofthefeetandcornsonthetoporsidesoftoesareimportantcluesthatanareamay
be at risk of ulceration. The presence of callus formation was associated with an 11-fold
increased risk of developing an ulcer. Likewise, simple debridement of the callus tissue
achieveda26%reductioninpeakpressureatthesiteofthecallus.
23
Clinicalsymptomsofautonomicneuropathygenerallydonotoccuruntillongaftertheonset
ofdiabetes.Subclinicalautonomicdysfunctioncan,however,occurwithinayearofdiagnosis
intype2diabeticpatientsandwithin2yearsintype1diabeticpatients.Autonomicneuropathy
affects bodily functions including cardiovascular (resting tachycardia, exercise intolerance,
orthostatic hypotension, silent myocardial ischemia), genitourinary (incontinence, frequent
urination),gastrointestinal(difficultyswallowing,gastroparesis—stomachisslowtoempty),
andreproductive(erectiledysfunction).
24
Sudomotor foot complications including dry, fissured skin are secondary to insufficient
sweatglandactivity. Thefissuredskincanlead toulcerationandinfection ifleftuntreated.
Bounding pedal pulses and a pathologic increase in pedal perfusion can develop from
decreased arteriolar tone and the resultant uncontrolled vasodilatation reactive to the
autonomicdysfunction.
25
VASCULARDISEASE
Theriskfactorsassociatedwithdevelopmentofperipheralatherosclerosisdiseasearesimilar
tothoseassociatedwiththedevelopmentofcoronaryatherosclerosis.26Theseare:
Genetics
Obesity
Diabetes
Smoking
Dyslipidemia
Hypertension
Hypercoagulability
Hyperhomocysteinemia
Cardiovascular disease is the leading cause of morbidity and mortality in patients with
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