Medical Mystery - A Woman's Painful Little Toe Leads to Big Problem
Tuesday, March 3, 2009
When Karen K. Abrams told her foot doctor the result of a second opinion she'd obtained about the surgery he had been recommending for months, he erupted.
"That's the most ridiculous thing I ever heard!" the podiatrist told her, dismissing a specialist's recommendation that she undergo an MRI of her increasingly enlarged and painful toe before any operation. "I told you, you need surgery!"
Cowed and unnerved, Abrams slunk out of the office and immediately booked the operation to correct what the podiatrist had diagnosed as a hammertoe, a crooked joint that was causing painful swelling.
A clinical psychologist with a busy practice and three children, Abrams, then 47, had been reluctant to undergo hammertoe surgery, which seemed overly aggressive.
But three months later, in July 2006, Abrams was forced to consent to a different operation, one she'd never imagined. The painful digit many doctors seemed to regard as trivial had become a serious problem, landing her in the hospital with medical bills that totaled $60,000.
"It was a very frightening experience," recalled Abrams, who is called Kay and lives in Montgomery County. For a long time, she said, "everyone seemed to think, well, it was just a little toe."
An avid walker, Abrams first noticed the problem in February 2005, when she developed a painful corn on the top of what podiatrists refer to as the "left fifth toe." A foot doctor at a sports medicine clinic near her home took an X-ray and, finding nothing broken, gave her a cortisone shot to ease the pain. The doctor advised her to avoid wearing narrow, tight shoes.
"I never wear them," Abrams said, but "that became their mantra. Every podiatrist I saw told me the same thing."
A few months later, when the pain, sharper but still intermittent, hadn't gone away, Abrams consulted a second podiatrist. He told her the problem was caused by a hammertoe and recommended surgery.
Taken aback by the proposed treatment, Abrams's internist referred her to a third foot doctor, who had a thriving practice and a good reputation. Podiatrist No. 3 agreed with Podiatrist No. 2. Because both baby toes appeared crooked, the third doctor said he could operate on the pair.
The timing couldn't have been worse, but there seemed to be no rush. Abrams was about to accompany her 80-year-old father on what she called "the trip of a lifetime" to Vienna and Brussels, where he had grown up. She bought a pair of fleece-lined clogs and padding for her toe, and hoped for the best. To treat periodic flare-ups, she tried smoothing down the corn with a pumice stone.
By March 2006, her toe was clearly worse: It was more swollen and hurt constantly, even in the clogs. Abrams went back to Podiatrist No. 3, who reiterated his recommendation of hammertoe surgery.
When she told a friend about her upcoming surgery, he suggested that Abrams consult his son, Washington podiatrist M. Joel Morse, for another opinion. "He's not one of those guys who jumps to surgery," Abrams remembers being told.
After examining Abrams, Morse thought her primary problem was not a hammertoe but a "sausage toe," a term podiatrists use to describe swelling often due to injury or infection. He asked Abrams if she had injured her toe; she didn't remember doing so. Morse suggested she undergo an MRI to check for an abscess or other problem before any surgery.
When Podiatrist No. 3 erupted, mocking Morse's recommendation, Abrams scheduled surgery for June, after her son's high school graduation. But by Memorial Day weekend, her toe had gotten dramatically worse. It felt hot and was so painful she could not stand the pressure of even a bedsheet.
"I just wanted to chop it off, it hurt so much," Abrams recalled. A cardiologist friend dropped by, took one look at her toe and told her it was infected and required urgent treatment. In a panic, she reached Morse, who told her to report to Sibley Memorial Hospital the next morning, without eating breakfast in case she needed surgery.
"I had no idea what I was about to face," she said. Within hours she underwent an MRI and a procedure that opened the toe to look for an abscess. Afterward several grim-faced doctors filed into her room and told her to forget about any hammertoe operation. She had osteomyelitis, an infection that was eating away at the bone in her toe.
There were two treatment options: several weeks of intravenous antibiotics to see if the infection would clear up, or amputation.
Osteomyelitis, which affects about two of every 10,000 people, is typically caused by bacteria, often staphylococcus, according to the Cleveland Clinic. It can result from an injury, such as a fracture in which a bone pierces the skin. Sometimes a long-standing infection can penetrate to the surface of the bone. Untreated, osteomyelitis can become chronic and lead to the death of the affected bone. A 2000 article by British physicians in Diabetic Medicine found that sausage toe is a reliable indicator of underlying osteomyelitis.
The infection is more common among people with diabetes, those on kidney dialysis, intravenous drug users, the elderly and patients with weakened immune systems. Abrams fit none of those categories.
Shocked by the news, Abrams chose to try to save her toe. Doctors implanted an intravenous line in her chest through which she would receive antibiotics; after two days, they sent her home.
She remembers the next five weeks as awful. Unable to eat because the antibiotics made her nauseated, she developed an allergy to two of the drugs and had to be rushed back to the hospital twice. Worst of all, the medicines didn't seem to be working.
What she wasn't told at the time was that doctors had become concerned that she might have MRSA, methicillin-resistant staphylococcus aureus, the flesh-eating bacteria. While recuperating at home, Abrams called her internist. The physician told her she needed to have the toe amputated and referred her to a prominent orthopedic surgeon in Baltimore who specializes in foot problems. "Come back tomorrow and we can take the toe off," the orthopod told her. "You can live without it, and the antibiotics are doing nothing for you."
Abrams said she burst into tears, then called Morse for a second opinion. "He said, 'You're making the right decision,' " she recalled.
The next morning she was given a local anesthetic and wheeled into an operating room at Baltimore's Mercy Medical Center, where her baby toe was amputated.
Abrams said she still wonders whether it could have been saved. Self-conscious about her missing toe at first, she later developed a shoe obsession. "For a while I couldn't stop buying shoes," she recalled.
Although it is clear what was wrong with her toe, the cause of the osteomyelitis remains a mystery.
To Morse, Abrams is "a very unfortunate case. Had [the MRI] been ordered earlier, she might not have lost her toe."
Abrams said it took her a long time to get over her fear that any injury might conceal a smoldering infection. She remains grateful to Morse, who, she said, "was the first doctor who really listened and was thoughtful."
These days when something goes wrong, she does more research and is less easily intimidated. Her attitude toward doctors has also changed.
"In your gut if you feel dismissed," she said, "keep looking."