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43-Year-Old Male with Pain and Itching in Left Foot

Can you diagnose this case?

David L. Kaplan, MDSeries Editor

Signs and Symptoms

A 43-year-old homeless man presented in midwinter in upstate New York with significant pain and an “itching and burning” sensation in his left foot. He stated that the symptoms had been going on for 2 weeks. Most of the patient’s time was spent outdoors, and he had a past medical history notable for schizophrenia, hypertension, and diabetes.

During the physical examination, the patient’s boots and socks were noted to be waterlogged. He was in severe pain while removing his footwear. His left foot was macerated, with white and yellow discoloration, was tender to palpation, and had diminished sensation and prolonged capillary refill.

Which one of the following is the most likely diagnosis?

Choose one to reveal diagnosis and discussion

Tinea pedis
Immersion foot
Frostbite
Candidiasis
Diabetic neuropathy

ANSWER: Immersion Foot

See the full case at Consultant360

A 43-year-old homeless man presented in midwinter in upstate New York with significant pain and an “itching and burning” sensation in his left foot. He stated that the symptoms had been going on for 2 weeks. Most of the patient’s time was spent outdoors, and he had a past medical history notable for schizophrenia, hypertension, and diabetes.

During the physical examination, the patient’s boots and socks were noted to be waterlogged. He was in severe pain while removing his footwear. His left foot was macerated, with white and yellow discoloration, was tender to palpation, and had diminished sensation and prolonged capillary refill.

The man’s history of homelessness was concerning for prolonged exposure to the harsh local winter conditions. Finding the patient’s boots and socks to be waterlogged made the diagnosis of immersion foot (trench foot) most likely.

Discussion:

Immersion foot is a cold-exposure injury that was first documented in the 1900s during World War I. It occurred in the feet of soldiers who spent significant time in water-filled trenches or life rafts.1 It has since been reported in civilians, ranging from elderly persons who have been immobilized to children who have been placed in plaster casts or hip spica casts.2,3

Immersion foot differs from frostbite in that it results from continuous exposure to temperatures greater than 0°C.1 Two major factors that result in the development of immersion foot are moisture and pressure, which together have been shown to induce inflammation and damage to the vasculature at a microscopic level.4 Water can cause a notable inflammatory response in the absence of an infectious organism. Prolonged water exposure can cause contact dermatitis and disrupt the protective barrier function of the skin.5

In addition, cold-induced vasodilation (CIVD) contributes to the pathogenesis of immersion foot. CIVD functions to initially conserve heat and then, after a short time, reverses in order to return blood flow to the extremities. With sustained exposure to cold water, the reversal process in CIVD does not occur, resulting in tissue and nerve damage related to a lack of adequate oxygen supply.6-8

Treatment of immersion foot involves assessment of the patient for hypothermia, which if present must be treated immediately.9 Rapid rewarming of the injured area can markedly worsen edema and must be avoided.4 The patient should be educated on the importance of keeping the feet dry and changing socks frequently. Bed rest, nonsteroidal anti-inflammatory drugs, and improved footwear are also important treatment measures.9

Outcome of the Case

The patient was educated about the immersion foot, was given acetaminophen for the pain, and was given new socks and boots. Foot hygiene was explained to the patient, with an emphasis on keeping his feet dry.

Multiple hidrocystoma papules are associated with certain syndromes, including Schöpf-Schulz-Passarge syndrome and focal dermal hypoplasia (also called Goltz-Gorlin syndrome).8 Schöpf-Schulz-Passarge syndrome is an autosomal recessive disorder whose characteristic features are hidrocystoma of the bilateral upper and lower eyelids in conjunction with palmoplantar hyperkeratosis, hypodontia, and hypotrichosis.8 Multiple periocular hidrocystomas are one of the many cardinal features of focal dermal hypoplasia, along with microcephaly, microphthalmia, cognitive impairment, skeletal abnormalities, and papillomas of the lip, tongue, axilla, and anus.1,7 Multiple hidrocystomas have also been reported in association with Graves disease.1,3

Diagnosis. Hidrocystomas are typically diagnosed clinically. Dermoscopy can be a useful tool to increase clinical diagnostic confidence. A nonpolarized dermoscopic examination of a lesion may demonstrate a homogenous bluish-purplish center surrounded by a pale halo.10 Biopsy may be required for a definitive diagnosis in more clinically ambiguous cases.

The patient was seen 2 months after his initial presentation, at which time the condition of his foot had significantly improved.

Benjamin Meath, BS, is a student at State University of New York Upstate Medical University College of Medicine in Syracuse, New York.

Melissa M. Helm is a student in the Rensselaer Polytechnic Institute/Albany Medical College BS/MD Physician Scientist Program in Albany, New York.

Stefanos Haddad, MD, is a resident physician in the Department of Orthopaedic Surgery at the Albany Medical Center in Albany, New York.

References

    1. Golant A, Nord RM, Paksima N, Posner MA. Cold exposure injuries to the extremities. J Am Acad Orthop Surg. 2008;16(12):704-715.
    2. Williams GL, Morgan AE, Harvey JS. Trench foot following a collapse: assessment of the feet is essential in the elderly. Age Ageing. 2005;34(6):651-652.
    3. Macgregor DM. An unusual presentation of immersion foot. Br J Sports Med. 2004;38(4):E11.
    4. Smith JL, Ritchie J, Dawson J. On the pathology of trench frost-bite. Lancet. 1915;186(4802):595-598.
    5. Willis I. The effects of prolonged water exposure on human skin. J Invest Dermatol. 1973;60(3):166-171.
    6. Thomas JR, Shurtleff D, Schrot J, Ahlers ST. Cold-induced perturbation of cutaneous blood flow in the rat tail: a model of nonfreezing cold injury. Microvasc Res. 1994;47(2):166-176.
    7. Bhaumik G, Srivastava KK, Selvamurthy W, Purkayastha SS. The role of free radicals in cold injuries. Int J Biometeorol. 1995;38(4):171-175.
    8. Jia J, Pollock M. The pathogenesis of non-freezing cold nerve injury: observations in the rat. Brain. 1997;120(pt 4):631-646.
    9. Olson Z, Kman N. Immersion foot: a case report. J Emerg Med. 2015;49(2):e45-e48.