Non-healing Ulcer on the Foot as Cellulitis: A Case Report

Introduction: Cellulitis is a serious bacterial skin infection. The skin is swollen and red, and it feels warm and uncomfortable to the touch. Cellulitis is most commonly found in the lower legs, although it can also appear on the face, arms, and other regions of the body. Bacteria enter the body through a crack or break in the skin. The infection can spread to your lymph nodes and bloodstream if left untreated, creating a major health danger. It is rarely passed down from one generation to the next. 
Clinical Findings: The patient presented with a non-healing ulcer for 30days, due to the insect bite 1month ago on right foot which is being developed into non-healing ulcer on right foot. A 20x6cm wound over the right foot was seen on a plain film radiograph of the knee. It consists of necrotic debris, underlying tendons exposed, peripheral cold and pigmentation. Foul smelling is not present. Based on the appearance of the spreading erythema and radiographically confirmed findings, cellulitis was diagnosed.  
Diagnostic Evaluation: Blood test- Hb-8.6gm%, MCV-91.1fl, MCH-30.9Pico-gm, MCHC-33.9%, Total RBC Count-2.78 millions/cu.mm, RDW-16.8%, HCT-25.3%, Total WBC Count-7400 cu.mm, Monocytes-04%, Granulocytes-75%, Lymphocytes-20%, Eosinophills-01%, Basophills-00%, Total Platelet Count-2.06lacs/cu.mm Peripheral Smear: RBCs-Normocytic hypochromic Platelets Adequate on smear, No Haemoparasite seen. 
Therapeutic Intervention: Inj. Ceftriaxone 1gm IV BD; Inj. PAN 40mg IV OD; Inj. Emset 4 mg IV TD; Inj. Neomal 100 ml IV TDS; Inj. MVI IV OD; Tab. Dolo 650 mg TDS; Tab Limcee 500 mg OD; Cap. Becosute OD; Protein powder; Tab Shelcal 500 mg OD; Tab. Duphalac 15 ml.  
Conclusion: My patient was admitted to Surgery Ward, A.V.B.R.H with a known case of Cellulitis and he had a complaint of non-healing-ulcer over the right limb. After getting appropriate treatment his condition was approved.


INTRODUCTION
Cellulitis is an infection of the skin and subcutaneous tissues that spreads quickly. It is diagnosed clinically when a non-purulent erythemic rash with uneven borders, edema, and local tenderness is observed [1]. The patient was admitted to Surgery Ward A.V.B.R.H with a known case of Cellulitis and he had a complaint of non-healing ulcer over right knee limb. After getting appropriate treatment his condition was approved.

Patient Identification
An 88 Year old male was admitted in Male Surgery Ward in Acharya Vinoba Bhave Rural Hospital, Wardha with a complaint of non-healing ulcer over the right limb.

Present Medical History
An 88 Year old male was admitted to Male Surgery Ward in Acharya Vinoba Bhave Rural Hospital, Wardha with a complaint of erythematous, non-healing ulcer over right knee with no foul smelling.

Past Medical History
An 88Year old male was admitted to Male Surgery Ward in Acharya Bhave Rural Hospital with no past medical history.

Family History
There are six members in his family. My patient was diagnosed to have Cellulitis and his family is disease free i.e, healthy .All the other members of the family were not having any complaints in their health except for my patient who was being admitted to the hospital.

Past Intervention and Outcome
One month ago due to the bite of an insect, an ulcer being developed on the right limb. Hence he takes the Ayurvedic medicines for the treatment of ulcers. But the ulcer is not being healing due to which he is being admitted to A.V.B.R Hospital.

ETIOLOGY
Cellulitis in the lower limbs is most commonly observed as a secondary condition produced by trauma, which is most often found in sportsrelated or foreign-body-related wounds. Other common observations include people with a BMI of more than 31, geriatric individuals, and people with a history of diabetes or immunological impairment.

Physical Examination
There is an abnormality found in the head to foot assessment, the male is lean and thin and has dull look. There is a non-healing ulcer on the right foot, slough/necrotic debris, underlying tendons exposed, peripheral cold and pigmentation are being present on the right foot.

DISCUSSION
An 88Years old male from Umarkhed, Yavatmal was admitted to Male Surgery Ward, AVBRH on 8 th October 2021 with a complaint of non-healing ulcer on the right foot and Hb% less than normal (Anemia). He has an insect bite one month ago; Due to some complications, he took the Ayurdvedic treatment but inspite of that the ulcer is not being healed, due to which he was admitted in the AVBR Hospital for the treatment. Investigations began as soon as he was admitted to the hospital and Cellulitis has been diagnosed. With the consideration of the disease, the treatment is being begun He improved dramatically after receiving treatment, and treatment continued until my last day of care.
Cellulitis is a clinically diagnosed skin infection of the subcutaneous tissues by a non-purulent erythematous rash with striations and uneven borders, swelling, and local discomfort, as well as pigmentation that was the situation in this instance [2]. It can also quickly spread to other sections of the body in close proximity to the original dermatologic outbreak [3]. An 88-yearold man's health could be jeopardized by an infection that spreads via the fascia and skin. The likelihood of toxic shock should not be ignored or treated lightly because the ulcer has transformed in a matter of hours [4].
Since its discovery in humans in the midtwentieth century, methicillin-resistant S aureus has been a topic of discussion. Between 2007 and 2010, skin infections accounted for around 3.2 percent of all ED visits in the United States, with 68 percent of those treated with anti-MRSA medicines. Invasive MRSA 4 is thought to be responsible for about 10% of cellulitis cases [5]. Hospitals are now treating abscesses that develop into NF, cellulitis, and/or MRSA more aggressively as a result of an increase in the frequency of abscesses that turn into NF, cellulitis, and/or MRSA [6-9]. The first line of treatment for an infection, according to the literature, is determined by the regional risk associated with each illness. As a result, the therapy of choice available to the physician will be determined by the increased number of cases in each region [10].
A complete blood count and blood cultures are the most basic laboratory procedures for detecting the source of infection. Cellulitis is most commonly caused by infections with staphylococcal or streptococcal bacteria [11][12][13]. Because of each organism's non-purulent properties, obtaining a positive cell culture in these two species is difficult. In this situation, a blood culture was not ordered as part of the diagnostic test during the initial evaluation in the ED [14].

CONCLUSION
For an 88-month-old man, cellulitis of the knee is a typical occurrence. The majority of initial symptoms could be mistaken for an allergic reaction, delaying diagnosis and treatment in this situation. If there is a history of trauma or bug bites, or if the medical history is impaired, the progression of any skin infection should be closely monitored. Prompt diagnosis and referral to the ED, as well as patient or guardian education and fast therapy, are critical for improving the prognosis of any patient with nonconventional dermatologic signs and symptoms. My patient show great improvement after getting the treatment; the treatment continued until my last appointment.

NOTE
The study highlights the efficacy of "Ayurdvedic" which is an ancient tradition, used in some parts of India. This ancient concept should be carefully evaluated in the light of modern medical science and can be utilized partially if found suitable.

DISCLAIMER
The products used for this research are commonly and predominantly use products in our area of research and country. There is absolutely no conflict of interest between the authors and producers of the products because we do not intend to use these products as an avenue for any litigation but for the advancement of knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors.

CONSENT
As per international standard or university standard, patient's written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).