Discussion

Critical limb ischemia (CLI) is the most advanced stage of peripheral artery disease (PAD) and is associated with significant morbidity and mortality.^7,8 A 2019 report estimates the U.S. prevalence of CLI to be 1.3 percent in patients above the age of 40 (2 million people), while PAD affects more than 200 million people worldwide.^8,9 

The “5 P’s” of CLI are pain, pulselessness, pallor, paresthesia, and paralysis. These features are found in 48 to 90 percent of the acute presentations of limb ischemia.^10,11 Rarely, progression to severe ischemia leads to ulceration of the digits of the foot (8.5 percent of cases) and frank gangrene (5.2 percent of cases).^7,11 

Smoking and diabetes are the most significant risk factors of CLI, but others include African American race, male sex, being more than 40 years old, hypertension, dyslipidemia, elevated C-reactive protein, hypercoagulable states, hyperhomocysteinemia, chronic renal insufficiency, and history of cardiovascular disease.^7,9,10 The one-year mortality in CLI patients with gangrene is 33.2 percent, which jumps to 68.5 percent over four years.¹²

The COVID-19 pandemic has resulted in fear of seeking health care, which can contribute to preventable morbidity and mortality. 

This case describes a significant delay in seeking medical care due to fear of COVID-19, resulting in worsening osteomyelitis and gangrene and ultimately requiring multiple surgical interventions and prolonged antibiotic therapy. Although our patient had risk factors for PAD, the development of severe and life-threatening CLI potentially could have been mitigated with early intervention.

Many local and national organizations are working to educate the public about seeking appropriate medical care.^13–17 Continued patient education at the local and national level is necessary to ensure timely and appropriate medical treatment.

Mr. Asarpota is a medical student; Dr. Wyss is chief resident, emergency medicine; and Dr. Marco is professor of emergency medicine at the Wright State University Boonshoft School of Medicine in Dayton, Ohio.

References

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