Advice please

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A 64 y/o male patient underwent heart bypass surgery 3 months ago with veins taken from left leg. After recovering from anaesthesia he was aware of discomfort/hypersensitivity in right foot - around plantar aspect of hallux and 1st MTPJ. He was fitted post operatively with elasticated stockings as a precaution against DVT, however he complained that they were too tight and they were changed to a larger size after 6 days, which he wore for 8 weeks thereafter.

The discomfort in his right foot remained and intensified. He described the pain as similar to a nettle rash - more profound on light touch and now extends over the 2nd MTPJ plantar area. In recent weeks he also reports similar paresis on his left foot in the same area, but less intensive.

I initially thought he had sustained some superficial nerve damage due to the compression from the elastic stockings and hoped this would diminish once he started rehab and physiotherapy, but in recent days he has developed what appears to be a fungal infection with pustules and vesicles on the right foot around the affected area (see photograph). However, this has not responded to topical terbinafine.

Given the clinical presentation I am now considering whether he has a herpes zoster infection as his symptoms are consistent with postherpetic neuralgia and a zoster skin rash.

Can a herpes zoster infection develop symptoms in the foot - with one foot being more affected than the other - and is this a common manifestation following major surgery or just coincidental?

Any advice greatly appreciated.

Mark Russell

 

If he first noticed the pain immediately after recovering from anesthesia, my first thought is a nerve compression from improper positioning on the OR table. This happens quite often. I don't know what to make of the rash. Has he been scratching this area due to the pain/dysethesia?? The rash may be secondary.

 

Nope, the rash only appeared 10 days ago - some 3 months postoperatively. Also I think if compression syndrome was a factor it would be due to the elastic stockings rather that OR trauma, especially with bypass surgery. Hopefully Craig will upload the photographs when he is able.

Thanks anyhow

MR

 

cholesterol emboli

 

Looks like a sweat rash, Mark (similar to nappy rash) and you chaps have had pretty hot weather of late. Paraestheisa around the hallux (usually medial side) can be due to impingement on the saphenous nerve where the end of the nerve serves the great toe. It is unusual but not uncommon. Does he have a sore lower back ?

Cameron

 

Not a sweat rash Syd, more like dishydrosis (pompholyx) and there's no back pain either. It could be that the rash and the neuralgia are unrelated and that the symptoms are simply a result of nerve compression with the post operative stockings, but I would've hoped we'd see some improvement, especially now that he is attending rehab and physio. Craig - thank you for the link and will bear CCE in mind - although for the patient's sake I hope this proves otherwise.

Thanks again

Mark

 

Hi Mark,

I've had a number of patients c/o paraesthesia and/or hyperaesthesia post op (severed cutaneous nerves) where veins were used used as spares. I've seldom (if ever) seen it at the same time as the type of rash in your pic so maybe the rash isn't connected. It doesn't look to me like it is caused by scratching.

Has the patient got diabetes?

Maybe it is a reaction to new drugs?

I've aslo treated a few rashes like that as Tinea Pedis and got results (topical lamisil cream or whatever you prefer). OK I know it doesn't look like fungal infection but there ye go

Cheers
John

 

Hi John - no not diabetic and the veins were taken from the other leg. I've had him on topical lamisil for five days without any improvement and will try him on dermovate instead. I find it peculiar that the symproms started immediately post-op - if related it could be OR trauma, localised trauma from elasticated stockings or, as Craig suggests, CE from embolisation during his CABG surgery. He has arranged an appointment with his cardiologist in two weeks so I'll report back what he suggests.

Mark

 

This lesion looks like to an atopic eczema. It is a quite common condition nowadays mainly related to an allergic response. Sometimes it happens after using synthetic fibers such as the ones used on the stockings manufacturing. Anyway, it is curious the limited extension although we do not know if the lesion was larger or not.

I hope it helps.

 

Thanks Javier. Could well be atopic eczema and if so it should respond to topical dermovate. Could you explain what you meant by 'limited extension'?

Regards

Mark

 

Mark

A very nice picture what camera are you using?

Looks a bit like Tinea but a bit anterior to 'normal'.

What are the 'white shadows around the 5th toe?

A very interesting 'case', as a newish private practitioner do you find this situation difficult, no longer having the luxury of intra NHS referral?

Bob

 

Mark

Just re read most of the posts on this theme, they seem to divide into rash and Pain?

IMO possibly unrelated.

The idea of Atopic Eczema? Were there any other 'symptoms' hay fever/ asthma?

Contact dermatitis? Very strange distribution and single limb?

I would still go with Tinea, perhaps a case for buying a 'test kit'. Thing is treatments for tinea are far from 100% successful. So failure to respond is not IMO a 'wrong diagnosis'.

As a ‘ very new’ private practitioner are you finding the loss of intra NHS referrals difficult?

Bob

 

The opposite is the case. There are no restrictions the whom or what we can refer to for investigations. In addition, the general practitioners and hospital specialists are more than happy to refer on our advice, as and when required.

I'm delighted to see you posting here under your own name Bob. Are you going to do so on thatfootsite in future?

Kind regards

Mark

 

Mark

I accept your point about 'no restrictions'. But I have found in practice, once I refer a patient 'back to' their GP they are lost to 'you/me'.

Direct referal to consultants as private patients, usually requires a 'polite' letter from a GP.

The reason I asked was it always seems to me there was always a greater chance of 'joined up' healthcare 'within' the NHS system?

As far as TFS goes, that is a unique site, and hopefully it will stay that way.

So what is your camera, and what is the white shadow?

Bob

 

Bob

How and where to refer will depend on established protocols between you and the patient's GP. For example, with this particular patient, I referred back to the GP in the first instance as his symptoms appears to be a complication of his CABG surgery and the GP will likely have the discharge summary along with any other relevant notes. If, however, the patient had an appointment with the cardiologist within a few days of seeing me, then I would give him a letter for the specialist and copy it to the GP. The GP is the 'hub' in the system (even more so now with practice based commissioning) but there are times when it is appropriate to refer direct, but much depends on the relationships you build - communication is the key.

As far as joined up healthcare is concerned it should be the same whether you practice in the public or private sectors. I wish I could say the NHS was an efficient organ, but it isn't, even less so these days with secretarial work being sent overseas for typing (to save money) and the implementation of the farcical NHS IT system that doesn't work. There is also an element of "who gives a sh!t" attitude in public services that is not altogether apparent in private care and that factor alone is grossly underestimated for its impact of effective care.

Anonymity on some forums could be useful be useful where disclosures are made that may endanger a career - for example the issues covered in the Public Interest Disclosures Act - and are used to highlight bad practice or management. Where Trusts have poor performance with staff for example and where there is an element of bullying and harassment by management or restrictions on service to the detriment of patients. Whitlse-blowing in the proper circumstances, in other words. However, anonymity is being increasingly misused to level abusive, libellous, threatening, personal invective at colleagues - sometimes just for the hell of it - mostly by inadequate, insecure, sad losers who seem to revel in the snip and growl that has characterised professional relations in the UK for many years. As I commented to Bill Liggins recently, the time for burying the hatchets is long past and whilst the marketplace moves on, the profession is still introspective, and preoccupied with self abuse. Unmoderated sites like TFS (and some US forums) seem to attract a number of anally retentive people who languish in the sh!te and are content - even determined - to apply the lowest common denomitor to their writings, unconcerned to the impact they may have. Why anyone with a double-digit or higher IQ would wish to contribute at that level is beyond me, but hey, that's only my opinion. A bit off topic but there you go.

Mark

BTW Camera is a Nikon D2X with 18-200mm zoom, the white shadow is the shadow of the foot on the drapes.

 

Mark

Not too sure whether you have just called me an 'inadequate, insecure, looser' or not.

Surley TFS should be the subject of another theme?

I was encouraged a few years ago to buy a Ricoh RDC-7, it has a brilliant macro function. £350 good value in those days. Will pm you a few shots to compare.

So is it Tinea?

 

Not at all, unless you're anonymously posting abusive, libellous, threatening, personal invective at colleagues. But only you know that.

 

I mean that the lesion is restricted to a small area on the foot but it could have been larger. I do not like to use corticosteroids if other treatments are available. For such lesion, first I would try to use other dermopharmaceutical preparations for skin irritation.

 

Hi Mark,

The anti embolism stockings may have caused excessive perspiration, especially in the recent hot spell, which may have led to a fungal infection. There is frequently discomfort prior to the appearance of the rash. I wonder if this was what the patient was describing rather than nerve damage? Pain is a difficult sensation to describe and patient’s can sometimes unintentionally mislead us in their descriptions.

It certainly looks fungal to me. Can you get enough tissue to do a mycology test?

If Terbinafine has no effect try Dactacort.

Do please keep us posted on the outcome.

Regards

Anne

 

Dysihidrosis. Definately, an id reaction to a fungal infection ANYWHERE in the body. The Yahoogroup for dysihidrosis has best fotos. The drug you need is 'Toctino', not available in US.
Oral anti fungals sometimes work. Nothing topical will. The fungus/mold/yeast got a hold while he was on drugs for the operation. Candida in the gut is the most common and you have to take Nystatin.