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White paste oozing from wound

Discussion in 'Diabetic Foot & Wound Management' started by mgrig, May 18, 2011.

  1. mgrig

    mgrig Active Member

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    I have been treating a pt with a sinus like wound on her R3rd toe, it is slightly proximal and lateral to the lateral sulci. Upon light incidental compression while cleaning the wound a white/cream paste oozed out of the sinus, it has a similar consistency to toothpaste. (Imagine squeezing toothpaste out of a tube)

    The same paste was also present deep to HK on the apex of left 3rd toe, This appeared post debridement, unlike the right foot the distribution was more cyst like approx 5x3mm and i was able to probe to bone.

    A swab + sample of paste has been sent off. to pathology as signs point to a possible infection, however, I was curious as to what some of the differential diagnoses may be??? Sebum? lymph issues? Evidence of previous infection? Infection? I have not seen this before and being new to the profession and on a rural visit to a hospital, I did not have anyone to discuss with.
  2. Any Photos ?

    Proud of me Bel ?

    Does the patient have Gout ?
  3. mgrig

    mgrig Active Member

    No photos sorry.

    It does not appear to be gout or joint related given history and location. There is some history of previous infection which was treated with ABs 6/12. Appologies for being vague (long day) When you hear "white-paste like exudate" what springs to mind?
  4. Sounds like gouty tophi to me.
  5. Gouty tophi and then take some photos and ask Bel- she will be along soon.
  6. blinda

    blinda MVP

    Smells like gouty tophi...but as yer man says; pic please! ;)

  7. W J Liggins

    W J Liggins Well-Known Member

    Pic please. However, I excised a chronic bursa 2 weeks ago which exuded a white mottled purulent looking fluid which the histo-pathology department reported as degeneration of the bursal sac. Depends (amongst other things) on the consistency of the exudate.

    Let us know the diax when you receive the report.

    All the best

  8. Tkemp

    Tkemp Active Member

    Sounds like gouty tophi. Patients with severe tophaceous gout will still produce this exudate even when no apparant attack is present.
    From experience, dont debride down as it'll just lengthen the healing time. cleanse the exudate and dont squeeze to remove if the skin is so stretched it is in danger of splitting due to underlying pressure.
    The patient needs to carry out daily redressings as when it hardens on the skin surface it becomes very painful to remove.
    Hope that helps...... just healed a client with severe T.gout - was a sharp learning curve!
  9. stoken

    stoken Member

    I'd think it was gout tophi, I'm dealing with a patient at the moment who has gout trophi of the 2nd digit pipj right, I've have a student onlooking at the moment so was good to show her something a bit different from our usual patient load.

    Just as a bit of a curve-ball differential diagnosis, you mentioned that it was like 'squeezing toothpaste out of a tube.' have you considered anearobic bacterial build up with a dehydrated or very thick pus.... similar to that seen in acne?? just something from left field.
  10. I'd have said the opposite! I generally evacuate as much tophus as I can get at and fill the cavity with someithing like intrasite gel or moistened aquacell.
  11. hann

    hann Active Member

    Its gouty tophi - Id leave them intact
  12. W J Liggins

    W J Liggins Well-Known Member

    We don't know what the condition is and it is counter productive to guess at treatment when we are guessing at the diagnosis. The op will post (hopefully) when the histo-path department have determined what the presenting complaint is.

    All the best

    Bill Liggins
  13. Tkemp

    Tkemp Active Member

    As the patient I am seeing will probably end up having a chair named after him due to the severity of his condition and recurrent breakdowns :D
    I am interested in as much information and experience as you have had with this type of gout.
    I did find that keeping as much of the skin intact as possible was best but I appreciate each client is different. It was just that his epithelialisation was so slow that debridement caused the wound to regress, whereas gently coaxing tophi out of the surface of the wound to reduce immediate pressure and working with the GP in respects to his Uric Acid levels was most beneficial.

    I have looked for research on T. gout but was not able to uncover much - maybe I was having a kid's look ("mum its not there and I've looked everywhere"..... mum opens fridge and takes jar from front of shelf) :rolleyes:

    So yes any info would be most gratefully appreciated.
  14. hann

    hann Active Member

    I have a patient or two with tophi in my experience if they are left they reduce in size eventually. the one I tried to drain took ages to heal and caused the patient more discomfort. The tophi seem to come and go but we noticed more during the hot weather ? dehydration made this problem worse
  15. I have nothing on the evidence. Quite a lot of experience with this type of wound. I tend to open them up as far as possible for several reasons.

    1. I find that after a day or two it makes the lesion much more comfortable with the internal pressure reduced.

    2. I find that the wounds heal over much faster and better with the tophi removed. Also, as the tophi increases I find that the "pocket" can become larger in response to the increasing pressure.

    3. I've seen these ulcers (and I consider it an ulcer even if there is a layer of skin over the tophi accretion) rumble on for years. If its "static" I prefer to do something than wait and hope.

    But I emphasise that this is purely my own experience of these wounds. I'd be interesting in input from others. Also, one has to take it on a patient by patient basis. Some people I simply dress and protect. Others are more courageous. I think its important to inform the patient and involve them in the decision making.

  16. Aims

    Aims Member

    Gout tophi is a top contender in this case, though it is interesting that he was on a course of Antibiotics for 6 months for a condition in the area. I would keep in mind Osteomyelitis as a direction to look in to. As being able to probe to bone and have something white come out it not an ideal sign.
    It will be interesting to find out the swab results, but you may consider an X-ray to look at the integrity of the bone, or for rat-bite gout markings.
    Vascular, Neuro status would also be interesting to find out about.
  17. mgrig

    mgrig Active Member

    Dont think I will be able to provide pics. However, having looked at some pics of T.gout, it does appear to be very similar...but have you ever seen it on the apex of a digit (R3rd case)?

    Depending on how the swab turns out...How would you progress from there?

    I was thinking of an xray to assess joint/bony damage and referral to GP for review of medication/ gout meds
  18. mgrig

    mgrig Active Member

    Ps thanks for all of your replies!
  19. The above treatment options sound a very good start.

    You also have to decided how the treat the wound or not, I guess Robert and Tracey have given you differing options.
  20. Aims

    Aims Member

    As far as treating the wound, playing it safe would be my theory.
    Regardless of what the white stuff is, it shouldn't be there. But don't be too hasty with opening up a wound that may only expose OM bone with non healing edges.
    Clean out as much as possible with as little damage to surrounding edges as possible, until the time you find the etiology of the "toothpaste".
    1- clean out
    2- X-ray
    3- Swab results

    That should lead nicely to meet up with a more focused approach with in 3-4 days.

    Im sure you have already assessed the vascular supply but making sure there is adequate flow may be the difference between simple wound and :butcher:

    Is the diabetes in check?

    good luck

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