Unsuspected Osteomyelitis in Diabetic Foot Ulcers: Title and subTitle BreakDiagnosis and Monitoring by Leukocyte Scanning With Indium In 111 Oxyquinoline FREE

Lisa G. Newman, MD; John Waller, MD; Christopher J. Palestro, MD; Myron Schwartz, MD; Michael J. Klein, MD; George Hermann, MD; Elizabeth Harrington, MD; Martin Harrington, MD; Sheila H. Roman, MD; Alex Stagnaro-Green, MD

[+] Author Affiliations

Reprint requests to Mount Sinai Medical Center, Box 1087, One Gustave L. Levy Place, New York, NY 10029 (Dr Newman).

JAMA. 1991;266(9):1246-1251. doi:10.1001/jama.1991.03470090080036

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ABSTRACT

ABSTRACT | REFERENCES

Objective. —The prevalence of osteomyelitis in diabetic foot ulcers is unknown. Early diagnosis of this infection is critical, as prompt antibiotic treatment decreases the rate of amputation. We therefore assessed the prevalence of osteomyelitis in 35 diabetic patients with 41 foot ulcers. We compared results of roentgenograms, leukocyte scans with indium In 111 oxyquinoline, and bone scans with the diagnostic criterion standards of bone histologic and culture findings. Leukocyte scans were repeated at 2- to 3-week intervals during antibiotic treatment.

Design. —Cohort study.

Setting. —Institutional and private, ambulatory and hospitalized patients.

Patients. —Consecutive sample of 54 diabetic patients. Thirty-five patients with 41 foot ulcers were included.

Results. — As determined by bone biopsy and culture, osteomyelitis was found to underlie 28 (68%) of 41 diabetic foot ulcers. Only nine (32%) of the 28 cases were diagnosed clinically by the referring physician. Underscoring the clinically silent nature of osteomyelitis in these ulcers, 19 (68%) of 28 occurred in outpatients, 19 (68%) of 28 occurred in ulcers not exposing bone, and 18 (64%) of 28 had no evidence of inflammation on physical examination. All patients with ulcers that exposed bone had osteomyelitis. Of the imaging tests, the leukocyte scan had the highest sensitivity, 89%. In patients with osteomyelitis, the leukocyte scan image intensity decreased by 16 to 34 days of antibiotic treatment and normalized by 36 to 54 days.

Conclusion. —The majority of diabetic foot ulcers have an underlying osteomyelitis that is clinically unsuspected. Leukocyte scans are highly sensitive for diagnosing osteomyelitis in diabetic foot ulcers and may be useful for monitoring the efficacy of antibiotic treatment. We recommend that diabetic patients with foot ulcers that expose bone should be treated for osteomyelitis. Diabetic patients with foot ulcers that do not expose bone should undergo leukocyte scanning, which eliminates the risk of bone biopsy in diagnosing osteomyelitis and allows for the diagnosis and treatment of this well-known but often silent precursor of lower extremity amputation.(JAMA. 1991;266:1246-1251)

REFERENCES

ABSTRACT | REFERENCES

National Institutes of Health. A Report of the National Diabetes Advisory Board . Bethesda, Md: National Institutes of Health; 1980;:5. NIH publication 81-2284.

Sher KS, Steele FJ. The septic foot in patients with diabetes. Surgery . 1988;;104:661-666.

Bamberger DM, Daus GP, Gerding DN. Osteomyelitis in the feet of diabetic patients: long-term results, prognostic factors, and the role of antimicrobial and surgical therapy. Am J Med . 1987;;83:653-660.

Wheat J. Diagnostic strategies in osteomyelitis. Am J Med . 1985;;78( (suppl 6B) ):218-224.

Thakur ML, Segal AW, Louie L, Welch MJ, Hopkins J, Peters TJ. Indium-111-labeled cellular blood components: mechanism of labeling and intracellular location in human neutrophils. J Nucl Med . 1977;;18:1020-1024.

Seldin DW, Heiker JP, Feldman F, Alderson PO. Effect of soft-tissue pathology on detection of pedal osteomyelitis in diabetics. J Nucl Med . 1985;;26:988-993.

Wheat J, Allen SD, Henry M, et al. Diabetic foot infections: bacteriologic analysis. Arch Intern Med . 1986;;146:1935-1940.

Keenan AM, Tindel NL, Alavi A. Diagnosis of pedal osteomyelitis in diabetic patients using current scintigraphic techniques. Arch Intern Med . 1989;;149:2262-2266.

Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: a review of clinical features, therapeutic considerations, and unusual aspects. N Engl J Med . 1970;;282:316-322.

Park HM, Wheat LJ, Siddiqui AR, et al. Scintigraphic evaluation of diabetic osteomyelitis. JNucl Med . 1982;;23:569-573.

Sinha S, Munichodappa CS, Kozak AP. Neuroarthropathy (Charcot joints) in diabetes mellitus. Medicine (Baltimore) . 1972;;51:191-210.

Maurer AH, Chen DC, Camargo EE, Wong BF, Wagner HN, Alderson PO. Utility of threephase skeletal scintigraphy in suspected osteomyelitis. JNucl Med . 1981;;22:941-949.

Eymonti MJ, Alavi A, Dalinka MK, et al. Bone scintigraphy in diabetic osteoarthropathy. Radiology . 1981;;140:475-477.

Ratopoulos V, Doherty PW, Goss TP, King MA, Johnson K, Gantz NM. Acute osteomyelitis: advantage of white cell scans in early detection. AJR Am J Roentgenol . 1982;;139:1077-1082.

Gelfand MJ, Silverstein EB. Radionuclidic imaging: use in the diagnosis of osteomyelitis in children. JAMA . 1977;;237:245-247.

Maurer AH, Millmond SH, Knight LC, et al. Infection in diabetic osteoarthropathy: use of indium-labeled leukocytes for diagnosis. Radiology . 1986;;161:221-225.

Schauwecker DS, Park HM, Burt RW, Mock BH, Wellman HN. Combined bone scintigraphy and indium-111-leukocyte scans in neuropathic foot disease. J Nucl Med . 1988;;29:1651-1655.

Alazraki N, Fierer J, Resnick D. Chronic osteomyelitis: monitoring by 99mTc phosphate and Ga citrate imaging. AJR Am J Roentgenol . 1985;;145:767-771.

Kolyvas E, Rosenthal L, Ahronheim GA, et al. Serial Ga-citrate during treatment of acute osteomyelitis in childhood. Clin Nucl Med . 1978;;3:461-466.

McCarthy K, Velchik MG, Alavi A, Mandell GA, Esterchai JL, Goll S. Indium-111-labeled white blood cells in the detection of osteomyelitis complicated by a pre-existing condition. J Nucl Med . 1988;;29:1015-1021.

Norrby SR. Ciprofloxacin in the treatment of acute and chronic osteomyelitis: a review. Scand J Infect Dis . 1989;;60( (suppl) ):74-78.

Waldvogel FA. Use of quinolones for the treatment of osteomyelitis and septic arthritis. Rev Infect Dis . 1989;;2( (suppl 5) ):S1259-S1263.

Hoogkamp-Korstanje JAA, van Bottenberg HA, van Bruggen J, et al. Treatment of chronic osteomyelitis with ciprofloxacin. J Antimicrob Chemother . 1989;;23:427-432.

Greenberg RN, Kennedy DJ, Reilly PM, et al. Treatment of bone, joint, and soft-tissue infections with oral ciprofloxacin. Antimicrob Agents Chemother . 1987;;31:151-155.

Beam TR, Gurrtierrez I, Powell S, et al. Prospective study of the efficacy and safety of ciprofloxacin IV/po in the treatment of diabetic foot infections. In: Abstracts of the Second International Symposium on New Quinolones ; 1988;; Geneva, Switzerland.

Peterson LR, Lissack LM, Canter K, Fasching CE, Clabots CC, Gerding DN. Therapy of lower extremity infections with ciprofloxacin in patients with diabetes mellitus, peripheral vascular disease, or both. Am J Med . 1989;;86:801-808.

Leslie CA, Sapico FL, Bessman AN. Infections in the diabetic host. Compr Ther . 1989;;15:23-32.

Fierer J, Daniel D, Davis C. The fetid foot: lower extremity infections in patients with diabetes. Rev Infect Dis . 1979;;1:210-217.

Rosenblatt DS. Principles of evaluation and treatment of osteomyelitis in the diabetic foot. Clin Diabetes . 1989;;7:85-91.

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