Gas gangrene and osteomyelitis of the foot in a diabetic patient treated with tea tree oil

The lifetime incidence of diabetic foot ulcers may be as high as 25% [1]; however, gas gangrene is not common in these patients. The most common causative organism in gas gangrene is Clostridium perfringens [2]. It is also important to rule out underlying osteomyelitis. In patients with diabetic foot ulcers, Streptococcus group A, Staphlococcus aureus and Pseudomonas may be present. If surgical debridement and antibiotics are not effective, amputation may be required.Tea tree oil, the essential oil of Melaleuca alternifolia, is a commonly available, naturally derived, topical antiseptic. Tea tree oil is known to possess antibiotic activity toward a broad spectrum of pathogens, including methicillin-resistant Staphylococcus aureus (MRSA) and Candida albicans [3].A 44-year-old female with a history of diabetes presented to the Emergency Department complaining of increased right foot pain for 3-4 days with redness and swelling. She had been applying tea tree oil to the wound. Her vital signs were blood pressure: 91/50, heart rate: 111, respiratory rate: 20, temperature: 36.4°C and oxygen saturation: 100% on room air. There were swelling and inflammation to the right foot and a foul-smelling odor. Dark blisters were noted with erythema tracking up the lateral aspect of the leg. There was a 4 × 3 × 2.5 cm ulcer plantar surface of the foot with maceration of the periwound skin and a serosanguinous drainage that had a mild odor. She was able to plantar and dorsiflex, and had diminished fine sensation. The patient had 1+ dorsalis pedis pulses and normal capillary refill. Laboratory studies showed a WBC of 14.7, neutrophils 74% with 17% bands. Radiographs of the right foot showed subcutaneous and deep fascial emphysema of the foot with extension along the plantar surface. Irregularities consistent with osteomyelitis of the distal first metatarsal and distal second proximal phalanx were noted.After admission, the patient was treated with clindamycin and underwent a transmetat