Case history
Case history #1
A 60-year-old man with a history of diabetes, hypercholesterolemia, and heavy smoking for over 20 years presents giving a 3-week history of increasing pain in his left forefoot, which is affecting his ability to walk and is disrupting his sleep. On examination, his left foot is pale, cold, devoid of hair, and his lateral two toes are dusky and discolored. No foot pulses are palpable and are only just detectable by Doppler probe.
Case history #2
A 56-year-old man with a history of poorly controlled diabetes mellitus and alcoholism presents with severe scrotal pain and fever for 3 days. He denies perianal tenderness. His vital signs are blood pressure 125/60 mmHg, heart rate 120 beats per minute, respiratory rate 25 breaths per minute, and temperature 101.5°F (38.6°C). His scrotum is extremely tender, black, and malodorous. The adjacent perineal and femoral skin is crepitant.
Other presentations
In patients with conditions such as postsurgical infection, gunshot or knife wounds, or diabetes, the early signs and symptoms of infection may not be apparent or may be misinterpreted. For example, in patients with diabetes, pain may be reduced or absent due to neuropathy at the site of infection. In surgical patients, people with traumatic injuries, and postpartum patients, pain may be assumed to be part of the normal convalescence rather than due to acute infection. Delay in diagnosis may allow the disease to progress to later stages before treatment is initiated.[14] In immunocompromised patients, atypical organisms may be involved in the formation of gangrene. For instance, mucormycotic gangrenous cellulitis may occur in patients with diabetes mellitus or patients receiving immunosuppressive therapy. Spores of Rhizopus species may contaminate occlusive dressings. Apophysomyces elegans may infect patients with Pseudomonas bacteremia or with thermal burns.[15] Patients with chronic renal disease have extensive calcification of the small arteries of subcutaneous tissue and marked elevation of calcium-phosphate product (calciphylaxis), which can contribute to the development of gangrene by reducing blood supply to the tissues.[16]
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