Unanticipated Second Leg Bilateral Below Knee Amputation in a Diabetic Amputee: A Case Report

Foot disorders are a major cause of morbidity and mortality in diabetic patients and are the leading cause of hospitalization. Ulcers, infections, gangrene and amputations are serious complications of diabetes.^1,2 Here, we are reporting the unpredicted contralateral leg below knee amputation in an uncontrolled hyperglycaemic diabetic amputee patient.

A 46-year-old man from Hubballi, Karnataka, priorly a known case of Type II DM, which was managed on oral hypoglycaemic drug (Metformin 500 mg+Glimepiride 2 mg BD) as well as a short-acting type of insulin (Human Mixtard 50) for about 20 years. He has had other comorbidities such as hypertension for the past 20 years and is currently on a calcium channel blocker and a beta blocker (Amlodipine 5 mg+Atenolol 25 mg OD), CVA 5 years ago, eye cataracts (both eyes) 11 years ago due to which he lost his vision and is complete blind. He had undergone left leg amputation (above the knee) 4 years ago he was a chronic smoker.

All the baseline characteristic test results were normal. He had sinus rhythm with 86 beats/min, body temperature of 37.8°C, NIBP 130/80 mmHg and SpO₂ 98% at room air. The localized assessment of the left lower leg revealed a recovered scar on the AKA stump. The patient presented with chief complaints of a wound over the right lower limb, pressure sore/ulcer over the lateral part of the right foot followed by the formation of a blister that eventually ruptured to form a wound of size 4×4 cm. Positive for blackish discoloration of the leg (Figure 1), pain in the right leg which was of score throbbing type aggravating while walking and relieves on taking medication. He had similar complaints in the past on the contralateral limb for which AKA was done 4 years ago. Local examination of his right extremity revealed necrotic patches that measured 15×10 cm over the dorsum of the foot extending up to the leg with irregular borders, blackish discoloration of surrounding skin with erythema, pitting type of edema and scar lesion present and very feeble pulsation of the right anterior tibial vein and posterior tibial vein on deep palpation hence, he was diagnosed with necrotizing fasciitis. Lab reports showed raised WBC counts (18700 cells/uL) and hemoglobin was 9.8 g/dL. The GRBS ranged between 160 mg/dL and 360 mg/dL and the fasting lipid profile was normal, while the HbA1C was 6.2%.

Figure 1:
Blackish discoloration of right lower leg which led to BKA.

Physical and neurophysiological examinations were unremarkable and ECG, 2D echo, hematological biochemistry and X-ray of the chest were normal. A-V Doppler scan showed a monophasic wave pattern with low resistance flow in the right PTA and DPA arteries. He was initiated with insulin treatment promptly on admission, broad-spectrum intravenous antibiotic therapy (ceftriaxone 1 g, 12^th hourly along with metronidazole 500 mg 6^th hourly) tramadol 100 mg in 100 mL NS was initiated to manage pain, combination therapy of calcium channel blocker and a beta blocker (Amlodipine 5 mg+Atenolol 25 mg) was initiated to manage BP. The patient underwent emergency debridement (Figure 2). The microbiology report of wound swabs revealed ESBL producers (Klebsiella) which are resistant to penicillins, 1^st, 2^nd and 3^rd generation cephalosporins and monobactam except cephamycin. The patient had a transfusion of one pint of O-positive blood. He subsequently underwent right leg BKA. The daily sterile wound dressing was continued, but the patient developed surgical site infection (Figure 3) which was identified at an early stage the wound was flushed and cleaned with broad-spectrum antibiotic wash along with intravenous antibiotic therapy.

Figure 2:
Wound after emergency debridement.

Figure 3:
Patient developed surgical site infection on 8^th post operative day.

After a week the patient was stable and was managed with a combative post-amputation rehabilitation plan and was discharged on the 20^th post-operative day. The patient is on a low diabetic indexed diet, oral hypoglycaemic regimen along with insulin therapy. The routine follow-up visits by patients at the 1^st, 3^rd and 7^th week in the postoperative period showed satisfactory outcomes.

In the present case study, the subject showed a notable risk of BKA due to chronic hyperglycemia associated with poorly uncontrolled diabetes. Many studies showed that the most common complication of uncontrolled diabetes is diabetic foot syndrome.^3–6 Diabetes causes nerve damage leading to neuropathy which leads to foot ulceration and/or wounds with or without infections.⁷ Foot amputation due to DM may lead to loss in quality of life as well as cost of providing health care increases drastically.⁸ The main course of treatment for DFS such as necrotizing fasciitis is early debridement of necrotic tissues along with effective broad-spectrum antibiotics.⁹ It is found in several studies that many uropathogens such as E coli are found in diabetic patients and other organisms include Enterococcus faecalis, Klebsiella spp., Enterobacter spp., Proteus spp. and Group B Streptococci.¹⁰ The histopathology report of our patient showed the presence of Klebsiella spp., hence he was resistant to many of 1^st, 2^nd and 3^rd generation cephalosporins, penicillin and monobactam except cephamycin. The immune system of DM patients is highly compromised due to hyperglycemia.^11,12 As the immune system of DM patients is compromised, they develop various medical conditions such as ocular problems and blindness, cardiovascular problems, lower extremity amputation and renal diseases as compared to non-diabetic patients.^7,13 Once the foot ulcer is developed the risk of wound progression increases profoundly and may lead to foot amputation. Various studies have shown that diabetes influences surgical site infections and the intensity of infection is enhanced due to hyperglycemia.¹⁴ The morbidity and mortality rate in diabetic patients is high as they develop antimicrobial resistance against infections, therefore there is a high risk of developing surgical site infections.¹⁵ Cigarette smoking increases the risk of developing peripheral vascular disease and delays wound healing,¹⁶ the patient was a chronic smoker for more than 20 years, as indicated in various studies a history of smoking for 20 years or more is the key factor that leads to amputation.¹⁶ Infection is a primary cause of amputation in India¹⁷ hence, It is important to maintain appropriate hygiene conditions for patients with DM in the hospital as they are prone to develop infections.

Proper lifestyle modification along with dietary approaches is extremely needed to prevent and manage DM. We suggest routine foot examination and proper comfortable footwear are important preventive steps that should be taken by people with diabetes to control foot trauma and infections.

The authors are thankful to the Vice-Chancellor, Registrar and Dean of Pharmacy, KLE Academy of Higher Education and Research, Belagavi. We would also like to thank Medical and Hospital Staff of Vivekananda General Hospital, Hubballi for providing necessary support.