Bone infection, osteomyelitis, in this diabetes patient with poor sugar control.

CLINICAL INFORMATION:
45-year-old diabetic patient in renal failure. Reportedly picking on plantar callus at the level of the metatarsal head of the 2nd or 3rd right toe. This was later infected and draining pus with staphylococcus infection. Later there was diffuse swelling of the right forefoot, especially in the dorsal aspect and lateral aspect of the right foot. There is clinical concern for osteomyelitis.
COMPARISON:
Plain film radiograph of the right foot on May 14, 2008 and October 6, 2014.
FINDINGS:
Since May 14, 2008, there is significant progression of extensive arteriovascular calcification of the right foot. There is increased atrophy of the subcutaneous tissue since prior study. Previous subcutaneous tissue thickness measured approximately 9.2 mm at the level of the proximal phalanx of the great toe. It currently measures approximately 7 mm.
The joint space of the navicular-middle cuneiform articulation also becomes slightly irregular, new since prior study.
A skin marker was placed over the area of skin defect in the dorsal aspect of the right forefoot. There is approximately 3.5 x 2.7 cm skin defect over the 4th and 5th metatarsophalangeal joint region, best seen on axial image #18 series #1001 and sagittal image #18 series #601. There is extensive adjacent cellulitis, most prominently seen inferior and lateral to the 5th metatarsophalangeal joint region. No focal fluid collection to suggest abscess.
There is marrow signal abnormality of the middle phalanx, proximal phalanx and head of the metatarsal bone of the 5th toe, consistent with osteomyelitis. No bony erosion visualized. There is moderate 5th metatarsophalangeal joint effusion suggestive of septic arthritis.
Incidentally noted is degenerative changes of the talonavicular joint, navicular-middle cuneiform articulation and middle cuneiform-2nd metatarsal articulation. I suspect this may represent early development of Charcot's joint.
There is extensive soft tissue edema of the intrinsic musculature of the foot and dorsum of the right foot, suggestive of cellulitis.
The extensor tendons, flexor tendons and plantar fascia are grossly unremarkable.
IMPRESSION:
3.5 cm diameter skin defect in the dorsum of the right forefoot overlying the 4th and 5th metatarsophalangeal joint region. There is extensive forefoot cellulitis, worse in the inferolateral aspect of the 5th metatarsophalangeal joint region. There is evidence of osteomyelitis of the middle phalanx, proximal phalanx and metatarsal head of the 5th toe with marrow signal abnormality. Septic arthritis of the 5th metatarsophalangeal joint is also suspected. No frank abscess seen.
Degenerative changes of the tarsal articulations and metatarsal articulation of the 2nd ray, may represent premature degenerative osteoarthritis versus early development of Charcot's joint.

[@drgadham]

Very good presentation and commentary 👏😀

[@2ndamendment383]

That looks like infected tophaceous gout. That joint is where most gout occurs. They should have taken some of the pus and put it under a polarized light microscope to look for gout crystals. That joint is where most gout occurs and on an MRI, the gout crystals will mimic osteomyelitis.

[@tortoisetom1]

I am going thru this now,it sucks!

[@Tnkiller1899]

How r u nw??

[@jade14116]

sorry & speedy recovery dude !

[@BrianPatronie]

( At TortoisTom1)
So am I brother, I'm in the hospital right now awaiting the final call if I'm losing half my foot or not...
This sucks!!!

[@angeloudarllconcepcion1123]

Any update of yours?

[@cuti_e_world]

Update

[@jade14116]

sorry & speedy recovery dude !

[@AliAhmed-nq3bb]

God help u bro