strange plantar lesions

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Hi all,
wondering if there are any brains i can pick with regards to a client i've seen recently in a rural community.

62y/o female, IDDM with history of neuropathic pressure ulcerations presents with acutely painful lesions to the plantar surfaces of both feet. Onset of symptoms were quite rapid (within 1 month of previous appointment)

O/E:
- multiple focal nodules 0.2-3mm in diameter present over plantar L/5th base of 5th metatarsal, plantar-lateral heel, plantar-middle heel, medial L/1st IPJ, R/lateral heel and R/middle heel. These nodules are palpable and have some overlying and surrounding callus, and are situated subcutaneously
- on debridement (ABI taken previously within normal limits), L/5th metatarsal and L/heel nodules/callus - a visible "core" is evident (like a HD), however on enucleation some haemoserous exudate is released, and the base of the wound presents with a white substance which is well adhered, if debrided/enucleated further it almost presents as crystalline. (almost similar in appearance to gouty tophi)
- All other nodules mentioned do not appear to have that "core", however despite debridement of overlying callus i was still able to palpate an underlying subcutaneous nodule
- some pitting odema present to both legs, no other signs/symptoms of acute inflammation present

Symptoms:
- exquisite pain on weightbearing, although this pain can also wake the client up at night --> she has responded well to Lyrica (pregabalin) commenced by GP for nocturnal symptoms
- pain is generally present in the right foot (11/10), with low grade pain (2-3/10) on the left foot
- some unilateral leg odema can be present at the end of the day, although this client has known mild venous insufficiency
- the nurses have noted that the client has been in great pain on palpation of the right medial arch during one of their visits - not associated with any of the nodules - this pain was not reproduced when i saw her yesterday

Management thus far:
- Have attempted to send of the white substance for pathology, however there were insufficient amounts to warrant a fidm diagnosis
- As mentioned, GP has commenced Lyrica which has provided some symptomatic relief at night
- Local offloading using felt donut padding has provided some pressure relief

The local GP and i had a chat, he thinks the pain is hyperalgesia and related to neuropathic pain and will continue to increase the dose of Lyrica until relief is obtained... I have also suggested XRays and bloods as a baseline investigation; did think of requesting a biopsy but didn't want to cause a greater wound due to this client's history of neuropathic ulceration.

anyone come across something similar?

Cheers
Pam

 

Great post Pam, sorry I can't assist; however it did remind me of a pt I saw 20 yrs ago who presented with systemic problems sufficient for him to be admitted to medical ward. Podiatry were referred as he had on the entire plantar surface b/f lesions ~7-8mm diameter which reminded me of octupus suckers. On a little traction they could be pulled outwards to a length (height) of ~6-8 mm, cylinder-shaped. he had a work hx of chemical factory, wet floors, wet boots all shift.
Sorry to put this post here but it reminded me of him, all the best, mark

 

Pam,

I would look at blood tests to rule out gout (Hx of neuropathy may also be linked to some nephropathy). You can also try a single dose of colgout, which if it is gout will resolve the pain short term

 

Yep, I was thinking gouty tophi also......