Diagnosis and management of the acute hot diabetic foot

Diabetes is an increasing problem in the modern world. Along with the rise in prevalence of the disease the number of diabetic complications presenting is increasing and amongst these is diabetic foot issues. Foot infection and Charcot arthropathy are the two key pathologies that present acutely with a hot swollen foot. Both require timely diagnosis and management to prevent disastrous long-term sequelae.Acutely presenting foot infections are both limb and life threatening and require urgent intervention to improve the chance of limb salvage. The ability to recognize and acutely deal with a diabetic foot requiring urgent surgical drainage is relevant to all orthopaedic surgeons with an on-call commitment and not solely to the foot and ankle specialist.Charcot arthropathy results in foot deformity that increases the likelihood of future ulceration and infection. The differentiation and acute management of the two conditions will be discussed.     

The diabetic foot and ankle

Diabetes mellitus is a common malady of our time with ever increasing numbers of patients presenting with diabetic foot and ankle pathology. Diabetes requires treatment by a multidisciplinary team and vascular disease requires management involving vascular surgeons. There is, however, an increasing burden on the orthopaedic surgeon with ulceration, foot deformity, osteomyelitis and Charcot osteo-arthropathy being direct complications of diabetes. Potential severe complications following fracture and elective surgery require an understanding of diabetes and its effects on soft tissue and bone. The key topics are: Pathophysiology - effects of hyperglycaemia on vascular, neuronal and immune systems, Assessment - examination of diabetic foot pathology and how to spot the ‘at risk foot’, Ulceration - management of foot and ankle ulceration and indications for intervention, Charcot osteo-arthropathy - brief overview of Charcot-type foot and ankle disease, and Management of ankle fractures - overview of current trends in options for conservative and surgical intervention.     

Oral mucosal ulceration due to cytomegalovirus associated with human immunodeficiency virus infection. Case report and brief review

Reports of oral lesions associated with cytomegalovirus (CMV) infection in human immunodeficiency virus (HIV) infected patients are uncommon¹. In this article a case of CMV infection associated with oral mucosal ulceration and a brief review of the subject is presented. Establishing the cause of ulceration is important in determining a definitive diagnosis and prescribing appropriate therapy. It is important to recognize that CMV associated oral mucosal ulceration may be the initial manifestation of human immunodeficiency virus (HIV) infection.     

Gingival ulceration in HIV infection

Abstract. All cases of HIV-associated gingival ulceration seen at a dedicated dental clinic in a 5-ycar period were reviewed and compared against other patients attending the clinic. 94 (7.1%) of 1308 patients had 146 episodes of gingival ulceration. 89 patients had 140 episodes similar to acute necrotising ulcerative gingivitis (ANUG) and responded well to conventional treatment for ANUG. The cases were compared with 269 controls in logistic regression. Gingival ulceration was associated with oral candidiasis, lower age and lack of AIDS diagnosis possibly due to a protective effect of co-trimoxazole medication. 5 patients with neutropenia had extensive ulceration without the microflora of ANUG. Histopathology, viral and bacterial culture revealed non-specific changes. The ulcers did not respond to the treatment regimen for ANUG but responded to treatment of their neutropenia. Gingival ulceration is not common in HIV infection. Most cases resemble severe ANUG. It is more frequent in younger people, those with oral candidiasis and without AIDS. Co-trimoxazole may be protective. A minority of cases with ulceration and associated neutropenia resembled the non-specific oral ulceration associated with HIV.     

Host pathogen interaction and the development of oral lesions

The aetiologies of oral ulceration, disseminated interstitial lymphocytosis syndrome and oral lymphomas have been reviewed, with emphasis on the role of HIV infection in the primary causation or modification of the presentation of these entities. There is a paucity of evidence to explain why oral ulceration is so severe in HIV infection, and why major ulceration affects the oropharynx. A number of mechanisms have been proposed to account for the development of lymphomas in patients with HIV infection, including a genetic predisposition, decreased immunosurveillance due to HIV infection, alteration of endothelial cell function and dysregulation of cytokine networks. From this review, it was concluded that there is a need for a prospective multicentre study, to elucidate the aetiological mechanisms involved in lymphomas of the oral regions in this patient group. It was concluded that, although there is anecdotal evidence implicating tobacco use in the aetiology of the lesions reviewed, this is insufficient to allow definitive statements to be made and further systematic evaluation is indicated.     

Severe oral ulceration in patients with HIV infection: A case series

OBJECTIVE: Oral ulceration occurs in an estimated 2–4% of patients with HIV infection. This retrospective observational study describes the aetiology and characteristics of 94 HIV-positive patients with either severe and/or recurrent oral ulceration presenting at a dedicated HIV dental unit over a 4-year period. METHODS: Case records were reviewed for diagnosis investigations, CD4 count, CDC stage and treatment modality. RESULTS: Of the 94 patients 50% had an AIDS diagnosis. In patients with asymptomatic HIV disease minor recurrent oral ulceration was the commonest diagnosis whilst large non-specific neutropenic ulcers were more frequently seen in patients with symptomatic disease with low CD4 counts. A variety of treatment modalities were used including thalidomide. An algorithm is presented for the management of patients with severe oral ulceration.     

Oral herpes simplex infection in bullous pemphigoid

A case of recurrent oral herpes simplex virus infection complicating bullous pemphigoid is described. The possibility of herpesvirus infection should always be considered in immunosuppressed patients with oral ulceration, including those patients with bullous disorders.     

HIV感染者和AIDS患者口腔非特异性溃疡

目的:口腔非特异性(NOS)溃疡是一类与H IV感染有关的口腔病变,其临床表现不同于常见口腔溃疡。通过对NOS口腔溃疡临床特征的分析,为临床医师提供鉴别诊断。方法:回顾性分析72例H IV/AIDS患者,NOS口腔溃疡有3例,探讨其临床特征并与复发性阿弗他溃疡、单纯疱疹性口炎进行比较,探讨其发病机制。结果:NOS口腔溃疡的好发部位为软腭、口咽及舌腭弓处,常为1~2个,病程较长,CD4 细胞明显减少,多伴发白色念珠菌感染。结论:NOS口腔溃疡的发病部位、病程与预后较为特殊,与AIDS的病程进展有一定的联系。     

Acute midfoot injuries and their management

Acute injuries of the midfoot are uncommon and can be challenging to diagnose and manage. These injuries are frequently overlooked, as the initial plain radiographs, can be difficult to interpret or are misleading. As the consequences of a missed midfoot injury can be devastating for the patient and are so difficult to treat, all orthopaedic surgeons should be highly suspicious when managing patients with midfoot trauma. This article summarizes the current literature about the midfoot injuries and focuses in their management. Non-displaced fractures and stable injuries can be treated conservatively with immobilization for 4–6 weeks. Displaced fractures, unstable or high-energy complex injuries should be treated surgically. Extra care should be given to maintain the length of the medial and lateral columns, in order to avoid long-term deformity and disability. In general the achievement of anatomic reduction and stable fixation of these injuries leads to good functional long term outcomes.     

(ii) The cavo-varus foot

Cavo-varus foot deformity has many causes but the final common pathway is an imbalance of the muscles acting on the foot. The commonest cause of bilateral deformity is Charcot Marie Tooth disease. Unilateral deformity may arise from spinal pathology. Symptoms range from ankle instability and fatigue fractures to abnormal gait and the effects of joint overload.As well a clinical assessment, patients may require neuro-physiological investigation, and foot and spinal imaging. Treatment ranges from footwear modifications and orthoses to surgical treatment which may include combination of soft tissue releases, tendon transfers or a variety of osteotomies. Severe or recurrent deformities may require joint arthrodesis.     

Complicating mucosal reactions in patients receiving radiation therapy for head and neck cancer

Radiation mucositis is characterized by erythema, pseudomem-branes, and ulceration of mucosa in the irradiated field. We present two cases of oral mucosal changes in patients treated with radiotherapy in the head and neck region, which included mucosal erythema and ulceration outside of the radiated fields. One case was confirmed as herpes virus infection, and the other was diagnosed as Sweet's syndrome. When mucositis extends beyond the radiation fields, the clinician should consider other causes of mucosal inflammation and erythema in order to begin appropriate management.     

Nicorandil-induced tongue ulceration with or without fungal infection

Oral ulceration is one of the common adverse effects of nicorandil in European countries. In Japan, however, only 9 cases of nicorandil-induced oral ulceration have been reported. Here, we report 3 cases of nicorandil-induced oral ulceration, one of which exhibited a unique clinical course associated with Candida infection. In this case, the initial discontinuation of nicorandil failed to ameliorate the lesion. However, the second discontinuation of the drug after the control of the Candida infection overlying the surface of the ulcer produced a favorable effect. This patient was diagnosed with nicorandil-induced tongue ulceration with Candida infection.     

Spontaneous oral ulceration with bone sequestration: its relevance in current clinical practice

Oral ulceration associated with bony exposure and sequestration is uncommon and often related to well-recognised conditions. In a small group of patients no obvious aetiological factors can be elucidated, and various terminologies have been utilised to describe these lesions. We report six cases of spontaneous oral ulceration with bone sequestration as a specific entity and review the pertinent literature. We retrospectively reviewed patients presenting in the period 2013-2018. Data collected included demographic details, relevant medical, drug, and radiotherapy history; presentation, investigations, management, and outcome. Six patients with an age range of 49-65 years were identified with spontaneous oral ulceration with bone sequestration in the study period. All were males, and none had any relevant history. Five lesions occurred over the mylohyoid ridge and one was related to a lingual mandibular torus. The most common presentation was a painful ulcer with exposed bone, which had been present for 6 - 12 weeks. Occlusal radiographs demonstrated focal rarefaction in two patients. All were managed conservatively and by removal of the loose sequestrum. Healing occurred successfully in all cases, and this was earlier when the loose sequestrum was removed. Spontaneous oral ulceration with bone sequestration is a distinct lesion that most often presents over the prominence of the mylohyoid ridge. It is currently an uncommon entity (0.02%), but this could well be due to a lack of recognition and under-reporting. It should be considered as a diagnosis only when other causes have been excluded. Lesions heal successfully with conservative management and surgical intervention, and this occurs earlier following removal of the loose sequestrum.     

Oral complications of high-dose melphalan in multiple myeloma

Four patients with multiple myeloma refractory to conventional chemotherapy received high-dose melphalan. All experienced multiple oral complications. Extensive neutropenic ulceration and orofacial herpes simplex virus infection caused considerable morbidity in three patients during prolonged periods of neutropenia.     

Oral ulcerations in HIV infection

Oral ulceration in HIV infection may be due to: (1) mycotic; (2) bacterial, protozoan; (3) and viral infections; (4) oral neoplasia; (5) aphthous ulceration/ulceration not otherwise specified (NOS); or (6) ulceration of iatrogenic origin. Of particular significance are oral ulcerations caused by viruses of the herpes virus group (HSV 1/2, CMV, VZV) and ulcerations of the aphthous type. It was shown recently that coinfection of viral ulcers occurs. The aetiopathogenesis of the aphthous type of ulcerations including the still debated ulceration NOS is not clear. Further basic and clinical research is necessary in order to better understand ulceration particularly in relation to immunoregulation, tissue breakdown and repair.     

Oral Fusarium infection in a granulocytopenic patient with acute myelogenous leukemia: a case report

The fungus Fusarium moniliforme causes fusariosis, which can be invasive and fatal in immunocompromised patients. We report a case of oral Fusarium infection in a granulocytopenic patient with acute myelogenous leukemia who developed necrotic ulceration of the gingiva, extending to the alveolar bone, but was otherwise free of any active systemic lesions. Fusarium moniliforme was identified, by histopathology and culture, to be present in the lesion and was deduced to be the causative organism for this invasive oral infection.     

Histoplasmosis in Australia: a report of a case with a review of the literature

Histoplasmosis is a rare but serious fungal infection commonly presenting as mucosal ulceration of the oral cavity. It is increasingly recognized in Australia but the source of infection remains obscure and it is likely to be under-diagnosed. We report a case of chronic mucosal ulceration which failed to fully respond to periodontal therapy. Histology and culture of a gingival biopsy was consistent with histoplasmosis, and the patient responded favourably to treatment with oral itraconazole. Histoplasmosis may present to general dental practitioners as chronic mucosal ulceration and should be considered in the differential diagnosis of such lesions. Diagnosis is best made by culture and histology of biopsy specimens.     

Navicular fractures: aetiology and management

Fractures of the tarsal navicular are relatively uncommon, and generally are a result of acute trauma or chronic overload in the form of stress fractures. Their importance arise from being somewhat difficult to detect, and if missed can result in significant morbidity with midfoot arthrosis, especially since its complex anatomy and blood supply make the navicular susceptible to osteonecrosis. It is recommended to have a high index of suspicion along with the use of advanced imaging techniques to ensure fractures are not missed. The aetiology and current management concepts of tarsal navicular fractures are reviewed in order to guide optimal treatment for patients. Salvage options for delayed diagnosis and ongoing pain and functional limitation include arthrodesis of the midfoot which will also be discussed.     

Oral infections in the immunocompromised patient.

The number of immunocompromised patients is increasing because of iatrogenic immunosuppression and HIV infection. Most have T lymphocyte defects and are prone to develop persistent and severe fungal and viral infections. Oral candidosis and peri-oral herpes simplex infections are particularly common. Other oral lesions may be seen: mouth ulceration is common and periodontal health is impaired.     

Oral ulceration and iatrogenic disease in HIV infection.

Ulcerative lesions of oropharyngeal mucous membranes are less commonly seen than other lesions in HIV infection and may be associated with mycotic, bacterial, and viral infection, as well as neoplasia. Differential diagnosis may be difficult because of the clinical similarity of ulcerations that can represent various causes. The term "atypical ulceration" has been suggested because it may be impossible to differentiate some of the oral ulcerations from each other. Iatrogenic ulceration is seen occasionally, as the consequence of chemotherapy or irradiation.