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Foot Amputation in a Patient With Diabetes and a History of COVID-19, Peripheral Vascular, and Renal Complications
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19) and is responsible for the ongoing worldwide pandemic, which has killed more than 4 million humans worldwide. We know little about this virus other than the speed at which it spreads and its association with respiratory failure, sepsis, cardiac failure, kidney injury, and/or coagulopathy. Among its systemic manifestations, hematological complications such as venous and arterial thrombosis—which result in myocardial infarctions, strokes, or limb ischemia—are linked with a high mortality rate from COVID-19.1 Many COVID-19 complications may be caused by a condition known as cytokine release syndrome or a cytokine storm. This is when an infection triggers the immune system to flood the bloodstream with inflammatory proteins called cytokines. Cytokines can kill tissue and damage organs.2
COVID-19 infections range from asymptomatic to severe. Symptoms usually include fever, cough and dyspnea. The disease may evolve over the course of weeks or suddenly within days, often resulting in admission to the ICU. COVID-19 has particularly affected patients with comorbidities such as diabetes, peripheral vascular disease, and end-stage renal disease.3 These types of patients are at high risk of acquiring COVID-19. As a result, they have avoided continuing medical care, clinic, and hospital visits.
Patients with diabetes are particularly prone to lower extremity infections and gangrene while often seeking medical attention towards the later stages.4 Within a pandemic, this only delays a visit to a health care professional. This is a case study of a patient diagnosed and treated for COVID-19 in April 2021. This patient was later admitted in May 2021 with gangrene of the right foot.
A Closer Look at the Patient Presentation
A 26-year-old African-American female presented to Ascension Providence Hospital at Southfield with right foot dry gangrene of the second and third digits without cellulitis. She had a recent history of COVID-19 infection, type 2 diabetes, end-stage renal disease on peritoneal dialysis, hypertension, and asthma. She had biphasic dorsalis pedis and posterior tibialis pulses bilaterally by Doppler, along with palpable popliteal and femoral pulses. Imaging shows no signs of osteomyelitis. Gangrene is likely secondary to ischemic changes supplying the second and third right digits (Figure 1 and Figure 2).
The vascular team decided to perform an aortogram with bilateral lower extremity runoff and found the patient to have disease-free popliteal arteries with three-vessel runoff of the right lower extremity to the ankle. No further surgical intervention occurred, and the patient was discharged in stable condition and to follow up as an outpatient to monitor the demarcation of gangrene by podiatry.
The patient returned and was admitted to the hospital 3 days after the previous discharge with a painful right foot and wet gangrene in the second, third and fourth right digits. The patient demonstrated 3-vessel runoff of the right lower extremity to the level of the right ankle. Vascular consultation determined that the patient did not require vascular surgical intervention. Podiatry was consulted and decided to perform open transmetatarsal amputation in the right foot. Intraoperative bone specimens all 5 metatarsals sent to pathology revealed acute osteomyelitis. Soft tissue specimens showed Enterobacter cloacae complex from microbiology.
Postoperatively, continued monitoring showed a stable surgical site and healing. The surgical site looked healthy, had no purulent discharge, had no malodor, and was bleeding well. Podiatry decided to perform remodeling of the surgical wound with partial metatarsectomy of metatarsals all 5 metatarsals, delayed primary closure of the open surgical wound on the right foot, and open gastrocnemius recession right on the lower extremity. Again, intraoperative bone specimens of all of the metatarsals revealed acute osteomyelitis by pathology and soft tissue specimens were found to have Enterobacter cloacae complex by microbiology (Figure 3).
The patient’s foot worsened following the first delayed primary closure of the transmetatarsal amputation. She had increased signs of ischemia, infection with active drainage, malodor, purulent discharge, and liquefactive necrosis. The patient had an open midfoot disarticulation, incision and drainage of the right foot, followed by sharp excisional debridement of the open surgical wound with partial excision of the medial cuneiform of the right foot. The last procedure was remodeling of the surgical site, peroneal brevis/longus and anterior tibial tendon transfers, delayed primary closure, and modified Chopart amputation of the right foot (Figure 4).
All three procedures took place within a span of 8 days. Prior to each procedure, the patient received bedside daily wound care, a betadine-diluted sterile saline flush with local debridement, and sterile dressing changes. During all procedures, bone specimens were sent to pathology, and all but the last procedure had resulted in positive acute osteomyelitis.
The patient’s hospital stay was a total of 36 days. White blood cell counts and serum glucose remained high throughout, only to decrease after the last procedure on June 25. Numerous blood cultures did not indicate any growth. The patient was dialyzed three times per week. Infectious disease, nephrology, and vascular services consulted. Internal medicine rendered medical and pain management (Figure 5).
How COVID-19 Is Changing How We Treat Patients
Although we have gathered much information from the cause, complications, and treatment of COVID-19 disease over the last several months of the pandemic, there is very little information gathered from the resulting complications of those who have survived.
It is well known that patients recovering from COVID-19 have had long-term effects of damaged lung, heart, brain, and blood vessels. Patients who presented with multiple comorbidities had a greater chance of acquiring and dying from the disease.5 Patients with diabetes, who are no different than others who acquired COVID-19, in fact had a higher risk of post-COVID treatment complications. Increased risks include pulmonary embolism, deep vein thrombosis, infections, delayed healing, autoimmune response, and rate of osteomyelitis.6
The patient in this case study initially presented with dry gangrene with no signs of infection. Vascular physicians performed a procedure to increase blood flow to the foot. Vascular, internal medicine, podiatry, and infectious disease services all agreed to discharge the patient and wait for the demarcation of gangrene. The patient was to follow up as an outpatient with daily, local wound care and observation. A few days later, the patient readmitted and stayed an additional 30+ days with the end result of a Chopart amputation (Figure 6).
Leaving a patient in the hospital during a pandemic would be counterproductive and costly if no immediate surgical treatment were to occur. Has COVID now changed hospital protocol for patient treatment under normal circumstances? Do health professionals need to be more aggressive when encountering a patient who was previously successfully treated for COVID-19 and lower limb ischemia with gangrene?
During the peak COVID-19 pandemic, there has been an increase in the number of positive lower extremity computed tomography angiograms (CTA) in patients presenting with leg ischemia. COVID-19 has been associated with lower extremity arterial thrombosis characterized by greater clot burden and a more dire prognosis.7 As a result, the incidence of death and amputation in COVID-19 patients is more common (Figure 7).
Throughout the pandemic, hospital-wide policies have changed based on the hospital bed capacity, safety of patients and staff, limited staff, severity of illness, and other factors. Elective procedures, particularly foot and ankle surgeries, have been cancelled, rescheduled or eliminated outright. As 5% of primary patient care visits are related to the foot and ankle, podiatry definitely plays a role in meeting a patient’s needs.8 Medical professionals, administrative staff, and patients must understand continuous outpatient care and follow up will need to be aggressive. Patient education, communication, and response to patient concerns, particularly those who have had previous COVID-19 infection, will need to be modified. In order to make better treatment decisions, all parties will need to have a clear understanding of the higher effects of COVID-19’s correlation to lower extremity infection and amputation.
Dr. Stefansky is at attending at Ascension Providence Hospital in Southfield, MI.
Dr. Patel is a foot and ankle surgeon at Ascension Providence Hospital in Southfield, MI.
Dr. Husein is a third-year resident in the Department of Podiatric Surgery at Ascension Providence Hospital in Southfield, MI.
Dr. Flynn is the Director of Scholarly Inquiry in the Department of Medical Education at Ascension Providence Hospital in Southfield, MI.
References
1. Suh YJ, Hong H, Ohana M, et al. Pulmonary embolism and deep vein thrombosis in COVID-19: A systematic review and meta-analysis. Radiology; 2021; 298(2):E70–E80.
2. Tang L, Yin Z, Hu Y, Mei H. Controlling cytokine storm is vital in COVID-19. Frontiers Immunol. 2020; 11:570993.
3. White-Dzuro G, Gibson LE, Zazzeron L, et al. Multisystem effects of COVID-19: a concise review for practitioners. Postgrad Med. 2021; 133(1):20–27.
4. Bellosta R, Luzzani L, Natalini G, Pegorer MA, et al. Acute limb ischemia in patients with COVID-19 pneumonia. J Vasc Surg. 2020; 72(6):1864–72.
5. Ejaz H, Alshani A, Zafar A, et al. COVID-19 and comorbidities: Deleterious impact on infected patients. J Infect Public Health. 2020; 13(12):1833–39.
6. Feldman EL, Savelieff MG, Hayek SS, Pennathur S, Kretzler M, Pop-Bosu R. COVID-19 and diabetes: A collision and collusion of two diseases. Diabetes. 2020; 69(12):2549–65.
7. Goldman IA, Ye K, Scheinfeld MH. Lower extremity arterial thrombosis associated with COVID-19 is characterized by greater thrombus burden and increased rate of amputation and death. Radiology. 2020; 297(2):E263–E269.
8. Richter M. Foot and ankle surgery during COVID-19 pandemic. Foot Ankle Surg. 2020; 26(4):357.
