Volume 33 Number 4

Introduction

Diabetic foot ulcers (DFUs) remain a formidable challenge in the clinical management of individuals with diabetes, often predisposing them to severe complications such as infections, delayed wound healing, amputations, and even death.¹ The 2024 guidelines by Gallagher et al² highlight the importance of early diagnosis in DFU management but focus predominantly on conventional imaging modalities (such as radiographs and MRI) for infection and osteomyelitis detection. Although Gallagher et al emphasise the importance of multidisciplinary approaches in DFU management, their work does not address how point-of-care ultrasonography (POCUS) can be seamlessly integrated into these workflows, particularly in emergency settings for high-risk complications, such as infections with gas formation.² Gas gangrene presents a particularly insidious threat due to its rapid progression and life-threatening nature.³ However, gas gangrene is not explicitly discussed in Bahebeck et al (2010), despite its severe implications. Additionally, while they propose translation for treatment strategies, the absence of a detailed focus on advancements in diagnostic technologies for detecting concealed threats like gas gangrene represents a significant knowledge gap.

The injury in this report was seemingly innocuous, yet clinically significant. The patient had a penetrating wound and, unaware of the subtle threat of this kind of complication, inadvertently introduced gas gangrene-producing microorganisms to the susceptible soft tissue. The presented case underscores the imperative role of POCUS in the early detection of gas gangrene within a closed DFU. Through this illuminating case, the report emphasises the crucial importance of timely and precise diagnostic tools like POCUS in mitigating the devastating consequences associated with DFUs, ultimately advocating for proactive and informed clinical interventions.

Case presentation

A 61-year-old male complained of pain and a swollen foot from an unknown cause, one day before the clinic visit. Upon examination, the affected leg exhibited palpable hardness from the foot to the popliteal area, with the heel producing a drum-like sound upon percussion. The dorsalis pedis arteries were palpable on both feet. The random blood glucose was found over the device detection range (>500 mg/dL) revealing the presence of undiagnosed diabetes mellitus. A complete blood count was carried out with results of white blood cells: 16,400 (normal range: 3500–10,000 cells/dL), red blood cells: 3,510,000 (3,800,000–5,800,000 cells/dL), hemoglobin level: 8.4 g/dL (11–16.5 g/dL), hematocrit: 24.8% (35%–50%), platelet: 218,000 (150,000–390,000).

Further examination using B-mode ultrasonography (M-Turbo, Fujifilm, Japan) with a linear probe (15–6MHz) is shown in Figures 1A to 1J. Gangrene gas was remarkable on the right foot plantar region extending to the Achilles tendon and below the calf (Figures 1F, D, H, and J). The extent of gangrene gas within the plantar site and the Achilles tendon compartment can be observed in Video 1 and 2. Despite the extensive gas invasion within the soft tissue, there was no substantial tissue damage or pus collection observed upon the POCUS assessment. On the dorsal foot, the ultrasonographic image only shows hypoechoic regions, indicating soft tissue edema without the gas (Figure 1B). An aggressive wound debridement on the heel was then carried out to allow gas release from the subcutaneous tissue followed by oral dua broad-spectrum antibiotics.

 

 

Discussion

This case represents the usefulness of POCUS in detecting gas gangrene before the ulcer presents tissue damage and/or purulent collection. Although an ideal imaging modality for gas gangrene detection is computed-tomography scan,⁴ POCUS can be efficiently conducted at the bedside within minutes, requiring no prior preparation and with no risk of radiation exposure. Furthermore, the utilisation of POCUS allows for the assessment of vascular and nervous structures involved or in close proximity to the infection sites, guiding careful attention to promptly evaluate the extent of soft tissue necrosis or purulent collection during wound debridement.⁵

Gas gangrene is a limb- and life-threatening complication of foot ulcers commonly caused by Clostridium perfringens but can also be caused by other microorganisms such as Staphylococcus aureus and Peptostreptococcus sp.^5-7 It is a rapidly deteriorating condition that leads to extensive tissue damage and sepsis if not immediately identified. The treatment requires emergency surgery, releasing the gas, followed by dual antibiotic therapy, and negative pressure wound therapy.^8,9 Delayed intervention may necessitate more extensive surgical procedures, resulting in prolonged hospitalisation, increased costs, and heightened risks of further disabilities or death.

Despite these merits, a notable drawback is the high observer-dependency of POCUS, which may lead novice users to overlook crucial details during assessments. Counteracting this challenge, a preceding study highlights that in the hands of experienced clinicians, it could yield better diagnostic value than with plain radiographs for detecting diabetic foot infections.^10,11 This context sets the stage for the present case, underscoring the irreplaceable utility of POCUS in unveiling concealed threats of gas gangrene as one of diabetic foot complications.

Conclusions

This study underscores the critical importance of early detection using POCUS in mitigating the devastating consequences of gas gangrene, providing a valuable tool for prompt decision-making and intervention in clinical practice. By averting delayed intervention, this proactive approach not only prevents extensive tissue damage and sepsis but also minimises the need for more invasive and costly surgical procedure, diminishes the risks of further disabilities or mortality associated with advanced stages of gas gangrene. Thus, emphasising the pivotal role of POCUS in early detection contributes significantly to optimising patient outcomes and healthcare resource utilisation.

Acknowledgment

The author expresses gratitude to Professor Hiromi Sanada (Ishikawa Prefectural Nursing University, Japan) and Professor Gojiro Nakagami (The University of Tokyo, Japan) for generously providing the ultrasonography device. Special appreciation is extended to Associate Professor Suriadi (Kitamura Clinic, Indonesia) for granting the author the privilege to conduct this study at his clinic.

Level of evidence

Diagnostic, 4

Conflict of interest

The authors declare no conflicts of interest.

Ethics statement

A written informed consent was obtained from the patient before data collection. The study received ethical approval from the Institutional Review Board at the Faculty of Medicine, Tanjungpura University, Indonesia (No. 3092/UN22.9/DL/2019).

Funding

This study was funded by Ministry of Research, Technology and Higher Education of Indonesia.

Author contribution

AA conceptualised the study, designed the methodology, conducted the ultrasonographic assessments, interpreted the findings, and led the manuscript writing and revisions. BM contributed to data collection and assisted in manuscript preparation. RAP critically reviewed the manuscript for important intellectual content. All authors have read and approved the final version of the manuscript.

Author(s)

Adam Astrada¹*, Budi Mulyana¹, Rian Adi Pamungkas^2
1Department of Medical-Surgical, Emergency and Critical Care Nursing, School of Nursing, Faculty of Health Sciences,
Esa Unggul University, Jakarta, Indonesia
²Department of Community and Mental Health Nursing, School of Nursing, Faculty of Health Sciences, Esa Unggul University, Jakarta, Indonesia
*Corresponding author email adam.astrada@esaunggul.ac.id

References

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Supplementary information

Video 1: Dynamic Ultrasonographic Evaluation of the Achilles Tendon and Calf: The blue bars denote the transverse probe position and the direction is indicated by a white arrow.

 

 

Video 2: Dynamic Ultrasonographic Assessment of the Plantar Region of the Right Foot: The blue bars represent the transverse probe position and the direction is indicated by a white arrow.