Recurrent cellulitis caused by an occult foreign body in a d
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A 74-year-old farmer presented to the emergency department (ED) with a 5-day history of left leg pain, swelling and redness. He denied trauma or injury. Background medical history included type 2 diabetes mellitus, diabetic neuropathy, right lower limb lymphoedema, recurrent left leg and foot cellulitis and bilateral total knee replacements. He was a non-smoker and occasional drinker.

On examination, the patient was afebrile. Inspection revealed confluent erythema and oedema from the left knee to distal phalanges. A ‘rocker-bottom’ deformity of the foot was evident. Distal loss of pin, temperature and vibratory perception were evident bilaterally. Pressure sensation was absent when assessed with a 10 g monofilament. Laboratory investigations showed a white cell count of 14.6×109/L and a Glycated Haemoglobn (Haemaglobin A1c) of 50 mmol/mol.

Left lower limb cellulitis was diagnosed. Empiric intravenous flucloxacillin was commenced. This yielded little improvement after 1 week. An MRI study of the left foot on day 8 of admission showed extensive Charcot arthropathy with osteomyelitis of the third and fourth metatarsals. A foreign body was seen embedded within the subcutaneous tissue of the dorsum of the midfoot, with a reported abscess measuring 17×12×8 mm extending to the proximal intermetatarsal space. This was not reported on or appreciable in prior plain-film radiographs (X-rays) of the foot.

The object was excised under general anaesthetic on admission day 15. A 3-cm longitudinal incision was made over the object. A plastic lid measuring 1.5×1.5×1 cm was identified and dissected free. There was no evidence of any surrounding infection or collection at time of surgery. The wound was washed with betadine and closed with interrupted 3–0 nylon sutures. The patient was discharged on postoperative day 14 and received outpatient intravenous antibiotics for further 4 weeks. He has since made a complete recovery.