Diabetic infection cause can be mystery

Dr. Conway McLean, Journal columnist

In the course of an average day, a physician may see people with a variety of problems and pathologies. Naturally, this will depend on the specialty of the doctor, with a neurologist seeing different conditions than a dermatologist. In the field of podiatric medicine, we have the good fortune of addressing numerous pathologies, from skin to bone, biomechanical to biochemical. Great variety is inherent in the field.

Diabetes is frequently associated with foot problems and lower extremity infections. The appearance of any infection-like signs or symptoms in a diabetic is a cause for alarm. One particular individual comes to mind when considering the topic. Let’s call him Kent, who’s late middle aged and definitely on the hefty side of the scale. Kent had been diagnosed with adult-onset diabetes a decade ago and subsequently made a concerted effort to practice good diabetic foot care. This included daily foot inspections, use of professionally-fit diabetic shoes, and regular visits to a podiatrist.

Despite the good foot care, Kent had a lower leg problem: he experienced recurrent bouts of cellulitis. This has become a common place word, cellulitis, used casually in every publication, ladies’ journals to “weekly entertainment” gossip rags. Indeed, it is a bacterial infection, primarily of the soft tissues beneath the skin. How does this develop, ie how do they get in there? Bacteria are everywhere, present on everyone’s skin, although usually not causing any harm. If they are able to enter the skin, as with a cut or scrape, an infection can result.

Technically-speaking, cellulitis involves the dermis and subcutaneous fat. It often starts as an area of redness which typically increases in size over time. The borders of this reddened area are often vague and not well defined. There is frequently swelling of the region, which is noticeably tender, all the way to distinctly painful. Because there is no collection of fluids, it is difficult to obtain a sample containing the invading organism. Thus, an antibiotic is chosen simply because of the bacteria most often causing cellulitis, not because we have any information on the bacteria in each particular case.

Cellulitis can start suddenly and can, potentially, become life threatening without prompt treatment. How quickly a cellulitis infection spreads depends mostly on how strong the person’s immune system is. Hospitalization is necessary only when a high fever develops, there is vomiting, or the symptoms are becoming more severe. This infection does not generally produce severe complications unless someone is immune-compromised, as in diabetes, or when immediate and appropriate treatment is not obtained. Some of these complications are medical emergencies, and immediate attention is paramount.

Kent had experienced his first bout of cellulitis years ago, and continued to have these attacks regularly, at least twice a year. He had even been hospitalized once or twice because of a case of cellulitis, which led to severe chills, as well as disturbances in both his pressure and his “sugars.” But he took really good care of his skin, even wore shoes inside (as repeatedly instructed by his podiatrist). His blood sugars were pretty good (no, not great), blood pressure well controlled, and his diet was adequate. And he still had his own knees (which seemed to be a rarity amongst his friends). The only other problem causing any symptoms at all was the ingrown big toenails he suffered from occasionally.

The mystery remained: why was this fellow suffering from these recurrent attacks? He didn’t have difficulties with any other infectious conditions. He practiced good hygiene and had a very clean home environment. But he did have diabetes so his immune system was impaired. Although not getting the attention of limb loss or blindness, reduced immune system function has many repercussions to the life of someone with diabetes. Whenever Kent was in the earliest stages of a cellulitis attack, he would be started on an antibiotic immediately, and generally it would consequently resolve.

Because of their impaired immune system, the skin on the feet of a diabetic is of great importance. Our skin is an amazing organ, with so many vital functions, one of them being protection from the myriad and potentially dangerous organisms present in our world. Recurrent cases of cellulitis can mean there is some opening in this protective layer. It seemed plausible in Kent’s case, there was a less obvious solution: eradication of the chronically ingrown nails.

These are a common problem, and there many different treatments. I couldn’t help but wonder if this was the source of Kent’s infections. With ingrown nails, the edges of the nail plate are sometimes buried deep within that fold of skin, and therefore impossible to visualize. With shoe pressure and the forces exerted on the big toes, the edge of nail can easily irritate the skin. Additionally, the nail unit as a whole is a great place for bacteria to hang out. You really can’t clean it well.

The possibility was discussed, and since this had been a nagging issue for him for many years, permanent removal of the offending edges of both big toenails was performed. Healing, as is typical with the technique used, was simple, uneventful, and expedient. Luckily for Kent, the technology utilized enabled us to provide relief from the ingrown nails, safely, relatively painlessly, and with great confidence in the results.

The answer for Kent was radio waves. This is a growing technique in medicine, a technology that emits controlled but powerful, high intensity radio waves from a box-like unit with a handle of some sort. One of the many attributes of this device is the absence of burned tissue. The energies emitted lead to vaporization of the cells of the nail root, but only in that part of the nail desired, since it is very precise. It can be the whole nail but, more often, just the edges are permanently removed, as it was here.

In contrast, many health care providers, of various specialties, use an acid, attempting to achieve this goal, of permanent eradication of the buried edge. But this liquid burns all the tissue it contacts. To a senior or someone with poor circulation, this can and has led to a non-healing wound, sometimes even resulting in amputation. When no tissue is burned, the healing process is significantly easier and faster. Just as important, the recurrence rate with the radio wave technique is fantastic.

Did you put the hidden clues together? Was the conclusion clearly etched across the headlines? In case you haven’t figured out the punch line, Kent suffered no more bouts of cellulitis. (At least as of this writing, 2 years later.) It would seem this uncomfortable but insignificant condition, an everyday experience for millions of Americans, caused the repeated development of a dangerous infection.

But much of the illness experienced by humans has roots that are obtuse and not easily identified. Unfortunately, many specialists naturally develop a sort of tunnel vision, focusing so closely on their particular specialty. They are thus unaware of the connections between all the systems of the human body, both the more obvious, as in this case, and the occult. We need to learn more about the unimaginably complex interplay of the energies and elements, the cells and the chakras, the neurons and nephrons, that compose the functioning, the miraculous, the human body. Making these connections between systems and structures is what will lead us to a real picture of health.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.


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