Picture Quiz Poll: A Man With Alcoholism and Cold Feet

Information sourced from BMJ:

BMJ 2016;354:i4584
[Free full-text BMJ article PDF]


Spot Diagnosis

Cold feet

Andrew McDonald Johnston, Joseph Singleton

Correspondence to: A McD Johnston amcdjohnston@gmail.com

A man in his 70s presented to hospital with delirium and hypothermia. He had a history of alcohol misuse and had not been seen for three days. He was found in the bathtub with wet clothing. The outside temperature on the days before admission was 10°C. He had loss of sensation in his feet with areas of ulceration and necrosis. What is the diagnosis?


Non-freezing immersion injury—“trench foot”


The patient was hypothermic, with a temperature of 32.3°C. He was bradycardic and hypotensive, requiring intravenous vasopressors. He was treated for community acquired pneumonia and alcohol withdrawal. His loss of sensation with areas of ulceration and necrosis are all features of “trench foot” or non-freezing immersion injury. Trench foot occurs after prolonged exposure to cold and wet conditions in soldiers or patients with physical or mental health problems. During rewarming the feet are extremely painful, and some patients develop long term pain and impairment of vascular function. Management includes adequate analgesia for neuropathic pain and treating any associated illnesses. The patient was given warmed intravenous fluid and a forced air warming blanket, with care being taken to keep his feet outside of the warm air flow to avoid further damage due to overheating poorly perfused tissue. Careful nursing care by specialist tissue viability nurses improved his altered sensation and resolved any pain by day 10. The patient was discharged seven weeks later and was able to walk 80 m. Two months later he was abstinent of alcohol and had recovered, apart from some healing foot ulcers.

Patient consent: Obtained.

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