Rhizobium radiobacter wound infection in a patient with diabetes--fact, factitious or just plain unlucky?

A 43-year-old man with a 28-year history of type 1 diabetes presented to our foot clinic in February 2008 with a fractured left second proximal phalanx due to trauma. His diabetes control was poor, with an HbA1c of 79mmol/mol (9.4%) [reference range <42mmol/mol (<6.0%)] at presentation. He was known to have diabetic peripheral neuropathy, and had previously undergone bilateral pan retinal photocoagulation for proliferative retinopathy. His medications were insulin aspart, and insulin glargine, ramipril, simvastatin, esomeprazole, amitriptyline, aspirin, fluoxetine and indapamide. He was seen by the orthopaedic team for his fracture and treated with standard offloading. Two months later he was admitted due to ulceration and ascending infection in the same toe. This necessitated digital amputation and intravenous antibiotics. One month later, he was again admitted with a swollen foot and on X-ray had a fractured proximal phalanx of the hallux. This was initially treated conservatively, but he represented with infection at his surgical wound site. This settled with another course of intravenous antibiotics and a fibreglass backslab while he was an inpatient. He was discharged with his foot in a total contact cast. He was kept under regular review in the diabetes foot clinic. Three months later, he presented to our podiatry team with a metal foreign body, thought to be a carpentry nail, in the apex of his hallux. He admitted to laying a carpet while in his total contact cast. The distal phalanx showed evidence of osteomyelitis and required amputation. Over the next few months, he presented with a succession of wounds affecting his left foot and ankle. It was noted that as one was about to heal, another appeared. He eventually presented with what appeared to be an unfolded, broken paperclip in his ankle joint (Figure 1). Neither the patient nor his wife could explain how it got there, and he had never had a surgical procedure at that site. The surgeons felt that these were not appropriate to remove as they were deeply embedded and did not appear to be responsible for his current problems. His all unusual series of wounds eventually healed; however, in autumn 2009 he presented with pain in his foot. A radiograph showed the presence of a metal foreign body (Figure 2). He claimed to have walked barefoot on a newly laid driveway at a neighbour’s house. This object was surgically removed; however, his foot continued to have repeated infections and the patient eventually opted for a below knee amputation. The wound site was healing well, but he was readmitted a few weeks after his amputation feeling