International Wound Journal ISSN 1742-4801
LETTER TO THE EDITOR
Unexpected complication of intralesional injection of recombinant human epidermal growth factor: diabetic foot osteomyelitis Dear Editors, A 66-year-old patient with type 2 diabetes mellitus of 13 years duration was referred to the Undersea and Hyperbaric department because of a swollen infected big toe that occurred during the course of intralesional parenteral epidermal growth factor (IP-EGF) treatment. The patient had a chronic non-healing plantar ulcer over the metatarsal head of the first toe for almost 5 years (Figure 1). He was scheduled to receive IP-EGF three times a week for 4 weeks, but experienced complication following the third application. The treatment was stopped and the patient was referred for consultation. The patient had hypertension, congestive heart failure and chronic renal failure. On examination his peripheral pulses were impalpable and he had severe loss of foot sensation. The big toe was significantly swollen with increased temperature and marked hyperaemia (Figure 2). An X-ray showed osteomyelitis of the metatarsal head and phalanges of the hallux (Figure 3). The patient was hospitalised and received parenteral piperacillin–tazobactam treatment 4.5mg/kg three times a day for 3 weeks. IP-EGF is a lyophilised formulation comprising human recombinant (rH-EGF). It has been introduced as a relatively safe drug with promising outcomes in the treatment of diabetic foot ulcers (1–3). The major concern regarding intralesional wound injections, however, is that they may have the potential to drive the superficial infection, as in our case, to deeper tissues. Alternate treatment opportunities other than intralesional approaches may be a rational approach to prevent such complications. In case of an absolute indication, changing the needle
Figure 1 Chronic non-healing plantar ulcer over the metatarsal head of the first toe.
Figure 2 Sausage toe: swollen red toe.
Figure 3 X-ray showing osteomyelitis of the metatarsal head and phalanges of the hallux.
© 2014 The Author International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd doi: 10.1111/iwj.12264
1
O. Ersen et al.
Letter to the Editor
prior to each injection may help reduce the risk for deep contamination. Omer Ersen, MD1 , Kemal Kara,2 , Ali Memis, MD3 , Mesut Mutluoglu,3 & Hakan Ay,3 1 Department of Orthopaedics and Traumatology Erzurum Military Hospital Erzurum, Turkey 2 Department of Radiology, Gulhane Military Medical Academy Haydarpasa Teaching Hospital Istanbul, Turkey 3 Department of Underwater and Hyperbaric Medicine, Gulhane Military Medical Academy Haydarpasa Teaching Hospital Istanbul, Turkey *[email protected]
Rosales F, García-Iglesias E, Berlanga-Acosta J, Silva-Rodriguez R, Garcia-Siverio M, Martinez LH. Intralesional administration of epidermal growth factor-based formulation (Heberprot-P) in chronic diabetic foot ulcer: treatment up to complete wound closure. Int Wound J 2009;6:67–72. 2. Fernandez-Montequin JI, Infante-Cristia E, Valenzuela-Silva C, Franco-Pérez N, Savigne-Gutierrez W, Artaza-Sanz H, Morejón-Vega L, González-Benavides C, Eliseo-Musenden O, García-Iglesias E, Berlanga-Acosta J, Silva-Rodríguez R, Betancourt BY, López-Saura PA, Cuban Citoprot-P Study Group. Intralesional injections of Citoprot-P (recombinant human epidermal growth factor) in advanced diabetic foot ulcers with risk of amputation. Int Wound J 2007;4: 333–43. 3. Fernandez-Montequin JI, Valenzuela-Silva CM, Diaz OG, Savigne W, Sancho-Soutelo N, Rivero-Fernández F, Sánchez-Penton P, Morejón-Vega L, Artaza-Sanz H, García-Herrera A, González-Benavides C, Hernández-Cañete CM, Vázquez-Proenza A, Berlanga-Acosta J, López-Saura PA, Cuban Diabetic Foot Study Group. Intra-lesional injections of recombinant human epidermal growth factor promote granulation and healing in advanced diabetic foot ulcers: multicenter, randomised, placebo-controlled, double-blind study. Int Wound J 2009;6:432–43.
References: 1. Fernandez-Montequin JI, Betancourt BY, Leyva-Gonzalez G, Mola EL, Galán-Naranjo K, Ramírez-Navas M, Bermúdez-Rojas S,
2
© 2014 The Author International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
LETTER TO THE EDITOR
Unexpected complication of intralesional injection of recombinant human epidermal growth factor: diabetic foot osteomyelitis Dear Editors, A 66-year-old patient with type 2 diabetes mellitus of 13 years duration was referred to the Undersea and Hyperbaric department because of a swollen infected big toe that occurred during the course of intralesional parenteral epidermal growth factor (IP-EGF) treatment. The patient had a chronic non-healing plantar ulcer over the metatarsal head of the first toe for almost 5 years (Figure 1). He was scheduled to receive IP-EGF three times a week for 4 weeks, but experienced complication following the third application. The treatment was stopped and the patient was referred for consultation. The patient had hypertension, congestive heart failure and chronic renal failure. On examination his peripheral pulses were impalpable and he had severe loss of foot sensation. The big toe was significantly swollen with increased temperature and marked hyperaemia (Figure 2). An X-ray showed osteomyelitis of the metatarsal head and phalanges of the hallux (Figure 3). The patient was hospitalised and received parenteral piperacillin–tazobactam treatment 4.5mg/kg three times a day for 3 weeks. IP-EGF is a lyophilised formulation comprising human recombinant (rH-EGF). It has been introduced as a relatively safe drug with promising outcomes in the treatment of diabetic foot ulcers (1–3). The major concern regarding intralesional wound injections, however, is that they may have the potential to drive the superficial infection, as in our case, to deeper tissues. Alternate treatment opportunities other than intralesional approaches may be a rational approach to prevent such complications. In case of an absolute indication, changing the needle
Figure 1 Chronic non-healing plantar ulcer over the metatarsal head of the first toe.
Figure 2 Sausage toe: swollen red toe.
Figure 3 X-ray showing osteomyelitis of the metatarsal head and phalanges of the hallux.
© 2014 The Author International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd doi: 10.1111/iwj.12264
1
O. Ersen et al.
Letter to the Editor
prior to each injection may help reduce the risk for deep contamination. Omer Ersen, MD1 , Kemal Kara,2 , Ali Memis, MD3 , Mesut Mutluoglu,3 & Hakan Ay,3 1 Department of Orthopaedics and Traumatology Erzurum Military Hospital Erzurum, Turkey 2 Department of Radiology, Gulhane Military Medical Academy Haydarpasa Teaching Hospital Istanbul, Turkey 3 Department of Underwater and Hyperbaric Medicine, Gulhane Military Medical Academy Haydarpasa Teaching Hospital Istanbul, Turkey *[email protected]
Rosales F, García-Iglesias E, Berlanga-Acosta J, Silva-Rodriguez R, Garcia-Siverio M, Martinez LH. Intralesional administration of epidermal growth factor-based formulation (Heberprot-P) in chronic diabetic foot ulcer: treatment up to complete wound closure. Int Wound J 2009;6:67–72. 2. Fernandez-Montequin JI, Infante-Cristia E, Valenzuela-Silva C, Franco-Pérez N, Savigne-Gutierrez W, Artaza-Sanz H, Morejón-Vega L, González-Benavides C, Eliseo-Musenden O, García-Iglesias E, Berlanga-Acosta J, Silva-Rodríguez R, Betancourt BY, López-Saura PA, Cuban Citoprot-P Study Group. Intralesional injections of Citoprot-P (recombinant human epidermal growth factor) in advanced diabetic foot ulcers with risk of amputation. Int Wound J 2007;4: 333–43. 3. Fernandez-Montequin JI, Valenzuela-Silva CM, Diaz OG, Savigne W, Sancho-Soutelo N, Rivero-Fernández F, Sánchez-Penton P, Morejón-Vega L, Artaza-Sanz H, García-Herrera A, González-Benavides C, Hernández-Cañete CM, Vázquez-Proenza A, Berlanga-Acosta J, López-Saura PA, Cuban Diabetic Foot Study Group. Intra-lesional injections of recombinant human epidermal growth factor promote granulation and healing in advanced diabetic foot ulcers: multicenter, randomised, placebo-controlled, double-blind study. Int Wound J 2009;6:432–43.
References: 1. Fernandez-Montequin JI, Betancourt BY, Leyva-Gonzalez G, Mola EL, Galán-Naranjo K, Ramírez-Navas M, Bermúdez-Rojas S,
2
© 2014 The Author International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd
