A 44-year-old female with a history of diabetes presented to the Emergency Department complaining of increased right foot pain for 3-4 days with redness and swelling. She had been applying tea tree oil to the wound. Her vital signs were blood pressure: 91/50, heart rate: 111, respiratory rate: 20, temperature: 36.4°C and oxygen saturation: 100% on room air. There were swelling and inflammation to the right foot and a foul-smelling odor. Dark blisters were noted with erythema tracking up the lateral aspect of the leg. There was a 4 × 3 × 2.5 cm ulcer plantar surface of the foot with maceration of the periwound skin and a serosanguinous drainage that had a mild odor. She was able to plantar and dorsiflex, and had diminished fine sensation. The patient had 1+ dorsalis pedis pulses and normal capillary refill. Laboratory studies showed a WBC of 14.7, neutrophils 74% with 17% bands. Radiographs of the right foot showed subcutaneous and deep fascial emphysema of the foot with extension along the plantar surface. Irregularities consistent with osteomyelitis of the distal first metatarsal and distal second proximal phalanx were noted.
After admission, the patient was treated with clindamycin and underwent a transmetatarsal amputation. Blood cultures were negative, and wound cultures were deemed inconclusive. Wound infection developed, and the patient was treated with vancomycin and moxifloxacin. An ankle disarticulation was performed. The wound did well at that point and the rest of the hospital course, and outpatient management was unremarkable.