The Management of Diabetic Foot Ulcers in Patients with SARS-CoV-2 During the COVID-19 Pandemic

Abstract

Objective. The COVID-19 pandemic continues to wreak havoc in all sectors of society one year after it was declared by the World Health Organization. This retrospective study aims to describe the clinical picture, management, and initial outcomes of patients with infected diabetic neuro-ischemic foot ulcerations (NIFU) afflicted with SARS-CoV-2 managed at a government tertiary hospital during the pandemic; and to compare those who survived from those who did not from this combination of diseases.

Methods. Chart review of patients with combined infected diabetic NIFU and COVID-19, admitted at the Philippine General Hospital serving as a COVID-19 referral center, from April 1 to December 31, 2020 was performed. Data collected included patient demographics, clinical presentation including NIFU grade and stage, and severity of COVID-19, coagulation and inflammatory laboratory results, management, and initial outcomes.

Results. A total of 59 patients with diabetic foot ulcer were co-managed by the Department of Orthopedics during this period of the pandemic. Nine of these patients were COVID-19 positive of which six patients did not survive their illness. The non-survivors were slightly older (58.33 vs. 52.67 y/o), had more co-morbidities, and presented with more severe COVID-19 (3 patients had critical COVID-19) than the survivors. All nine patients had deranged coagulation parameters including elevated D-dimer levels, and elevated inflammatory markers (CRP, Ferritin, LDH). Procalcitonin levels were increased in four of the non-survivors, and normal in all three survivors. Seven of the patients had severe (Grade II or III) and infected/ischemic (Stage B or D) NIFUs that required surgery; however, two patients succumbed to their illness prior to any surgery. Four of the six non-survivors died due to acute myocardial infarction.

Conclusion. The presence of NIFU and COVID-19 in a patient generally results in progression to a turbulent hospital course. This is due to the hypercoagulable and hyperinflammatory states that each disease entity produces, which when combined, are exacerbated. Levels of D-dimer and inflammatory markers, especially procalcitonin, may be used as a predictor of poor outcome, even mortality, in this group of patients.