SLR - December 2012 - Parise

Cellulitis May Present as Foot Drop in a Diabetic Patient

Reference: Walid MS, Ajjan M, Patel N, Guta T: Cellulitis may present as foot drop in a diabetic patient. The Internet Journal of Neurology. 2007 Volume 7, Number 1. DOI: 10.5580/e0e.     

Scientific Literature Review

Reviewed by: Dan Parise, DPM
Residency Program: UHHS - Richmond MC

Podiatric Relevance:
In large part, the patient population of podiatrists consists of diabetics. It is not uncommon to encounter a patient that is afflicted with drop foot and it is even more common to encounter a patient that has a cellulitis infection. It is useful to be aware that cellulitis can cause an acute foot drop in a diabetic patient as outlined by the double crush phenomenon when all other common differential diagnoses have been ruled out.

Methods:
This article is a case presentation of a diabetic patient who was admitted with right hemiparesis because of a stroke and after a few days in the hospital developed left foot drop where they were unable to dorsiflex their ankle or extend their toes. A full clinical exam was performed including muscle strength testing, sensation perception, presence of palpable pulses, range of motion, inspection of Achilles tendon as well as extensor hallucis longus, extensor digitorum longus and peroneal tendons. Plain x-rays, CT and MRI imaging were performed on the problematic foot in question. A venous doppler and triphasic bone scan were also performed.

Results:
After a thorough investigation, it turned out to be a complication of a silent cellulitis around the left ankle. Patient demonstrated decreased sensation to light touch in the first web space but had normal sensation throughout the dorsum of their foot as well as the remainder of the leg. Pulses were palpable and were +1 in nature, overlying skin appeared normal but there was generalized tenderness throughout the hindfoot and dorsum of foot. There was no acute swelling to the foot, ankle or lower leg. There were no palpable defects to the tendons noted, and the patient had a negative Thompson/Simmonds test. X-rays imaging, CT and MRI were inconclusive for a probable cause. The venous doppler exam was negative. The triphasic bone scan however, showed increased flow throughout the afflicted leg, ankle and foot region with a similar appearance on the blood pool images and delayed images without any real discrete focal intense abnormal areas of uptake about the left ankle to strongly suggest focal osteomyelitis. Clinical knowledge thus lead to suspect cellulitis.

Conclusions:
After a thorough clinical exam that included extensive laboratory work and imaging modalities, it was determined that this patient was suffering from cellulitis. Upon this discovery, a treatment regimen of Vancomycin was initiated and symptoms quickly resolved.

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