Factors Associated With Foot Self-Care in Patients With Diabetes-Related High-Risk Feet: A Cross-Sectional Design.

Foot self-care has been commonly studied among people with diabetes. Previous research on foot self-care among those with diabetes-related high-risk feet is almost unavailable or very limited. The current study aims to fill this gap and provide a contemporary unprecedented analysis of this area of specialization. To assess the levels of, and factors associated with foot self-care among people with diabetes-related high-risk feet. A multi-center cross-sectional study from Jordan assessed the foot self-care of 107 participants with diabetes-related high-risk feet. Multiple socio-demographic, physiological, and psychosocial factors were collected, and the Arabic version of the diabetes foot self-care behavior scale was used to estimate the foot self-care of the study population. A multiple linear regression model was employed to identify factors associated with foot self-care. The mean score of foot self-care was 25.4 ± 7.1 (35 is the highest) indicating ~73% of adherence to foot self-care. Factors associated with higher foot self-care were being treated at the King Abdullah University Hospital (ß = .30, P < .01) and reporting higher scores of patients' interpretations about neuropathy physical causes of foot ulcers (ß = ".22," P = .02). People with diabetes-related high-risk feet reported a relatively adequate foot self-care practice. However, clinicians are still required to enhance foot self-care among this population. Health promotion programs may benefit from engaging people in understanding the pathophysiology of diabetes-related foot ulcers to improve foot self-care practices.

Acupuncture for rheumatoid vasculitis complicated by refractory foot ulcer: A case report.

INTRODUCTION: Rheumatoid vasculitis (RV) is a frequently encountered complication of rheumatoid arthritis (RA), wherein skin vasculitis lesions are observed as a common clinical manifestation, encompassing skin purpura, erythema, vascular occlusion, ulcers, and gangrene. As a matter of fact, it marks the most severe extra-articular manifestation of RA. And the resultant ulcers tend to pose a greater challenge with regard to therapeutic interventions. We report a case of RV complicated by refractory foot ulcer that was successfully treated with puncture. CASE PRESENTATION: A 62-year-old man with RV caused by RA developed refractory foot ulcers. Despite the application of topical antibiotics, the wound gradually expanded and remained unhealed for 7 months. Consequently, the patient sought an integrated therapeutic approach involving Traditional Chinese Medicine and was subsequently treated with acupuncture. After 12 weeks of acupuncture, the foot ulcers healed completely. CONCLUSION: Acupuncture has the potential to facilitate wound healing and may serve as a viable alternative treatment modality for wounds unresponsive to traditional therapeutic interventions.

Health Literacy predicts incident foot ulcers after 4 years - the SHELLED cohort study.

AIMS/HYPOTHESIS: To determine whether health literacy is associated with an index diabetes-related foot ulcer (DFU). METHODS: The SHELLED Study is a 4-year prospective study of people with diabetes aged over 40 with no history of DFU. The primary outcome was development of a first foot ulcer. Health Literacy was measured using the short form Test of Functional Health Literacy in Adults (s-TOFHLA) and nine domains of the Health Literacy Questionnaire (HLQ). RESULTS: Of 222 participants, 191 (86.0%) completed the study, of whom 13 (5.9%) developed an incident ulcer. In multivariable models, every unit increase in S-TOFHLA was associated with a reduced odds of foot ulcer development by 6% (OR 0.94, 95% CI 0.88 to 0.99). Better scores on two HLQ domains reduced the odds of foot ulcer (actively managing my health (OR 0.23, 95% CI 0.08 to 0.65) and understanding health information well enough to know what to do (OR 0.39, 95% CI 0.19 to 0.78). This was independent of baseline risk for foot disease. CONCLUSIONS/INTERPRETATION: These data provide novel evidence that health literacy is an important clinical risk factor for index foot ulceration. This is an area of potential focus for research and development of educational programs or policy aimed at reducing development of incident foot ulceration.

Patient Perspectives on the Burden and Prevention of Diabetes-Related Foot Disease.

PURPOSE: The purpose of the study was to understand patient perspectives about the impact and prevention of diabetes-related foot disease (DFD). METHODS: An online survey was distributed to patients with a history of DFD during 2020. The survey was designed alongside clinical specialists and DFD patients and utilized the health belief model. It asked about the impact of DFD on health, perceptions on preventive strategies, perceived need for additional support, and patient preferences for telehealth in DFD management. Quantitative data were summarized descriptively and compared between groups. Open-text responses were analyzed using conceptual content analysis. RESULTS: Of 80 participants with a history of DFD, foot ulcers were the complication most often experienced, with over two-thirds having been admitted to hospital for a DFD-related issue and over one-third having a DFD-related amputation. Participants had ranging perceptions on the effect of DFD on health, from minimal to crippling. Those with previous severe DFD complications leading to hospital admission found a lack of mobility and independence the consequences of most concern. Using offloading footwear was perceived as very important for preventing DFD complications, although the use of offloading footwear was low, with participants citing issues relating to cost, comfort, appearance, and access to footwear as barriers to better adherence. Perceptions on telehealth were mixed, with many participants not having access to or being comfortable with the use of digital technologies. CONCLUSIONS: Patients with DFD require additional supports for effective prevention, including offloading footwear.

Fragile Feet and Trivial Trauma: Communicating the Etiology of Diabetic Foot Ulcers to Patients.

People at risk for diabetic foot ulcer (DFU) often misunderstand why foot ulcers develop and what self-care strategies may help prevent them. The etiology of DFU is complex and difficult to communicate to patients, which may hinder effective self-care. Thus, we propose a simplified model of DFU etiology and prevention to aid communication with patients. The Fragile Feet & Trivial Trauma model focuses on two broad sets of risk factors: predisposing and precipitating. Predisposing risk factors (eg, neuropathy, angiopathy, and foot deformity) are usually lifelong and result in "fragile feet." Precipitating risk factors are usually different forms of everyday trauma (eg, mechanical, thermal, and chemical) and can be summarized as "trivial trauma." We suggest that the clinician consider discussing this model with their patient in three steps: 1) explain how a patient's specific predisposing risk factors result in fragile feet for the rest of life, 2) explain how specific risk factors in a patient's environment can be the trivial trauma that triggers development of a DFU, and 3) discuss and agree on with the patient measures to reduce the fragility of the feet (eg, vascular surgery) and prevent trivial trauma (eg, wear therapeutic footwear). By this, the model supports the communication of two essential messages: that patients may have a lifelong risk of ulceration but that there are health-care interventions and self-care practices that can reduce these risks. The Fragile Feet & Trivial Trauma model is a promising tool for aiding communication of foot ulcer etiology to patients. Future studies should investigate whether using the model results in improved patient understanding and self-care and, in turn, contributes to lower ulceration rates.

Conservative Surgery for Diabetic Foot Osteomyelitis is not Associated With Longer Survival Time Without Recurrence of Foot Ulcer When Compared With Amputation.

Conservative surgery of diabetic foot osteomyelitis (DFO) in which bone infection is removed without amputation could minimize the biomechanical changes associated with foot surgery. We hypothesize that patients who undergo conservative surgery will have a longer survival time without recurrence of foot ulcers and further amputations than those who undergo any type of amputation to treat DFO. We assessed a retrospective cohort of 108 patients who underwent surgery for DFO from January 2011 to December 2012. Patients were followed-up until May 2020. Reulceration and reamputation-free survival times were plotted using the Kaplan-Meier method and were calculated from the date of first surgery to recurrence, new amputation, or end of the study. A stratified log rank was used to study differences among groups. Cumulative survival without recurrences at 1, 5, and 8 years was 95%, 36%, and 29%, respectively, in patients who underwent conservative surgery and 95%, 43%, and 30%, respectively, in those undergoing amputation. Cumulative survival without a new amputation at 1, 5, and 8 years was 100%, 80%, and 80%, respectively, in patients who underwent conservative surgery and 98%, 82%, and 69%, respectively, in those undergoing amputation. No differences were found regarding either recurrence (log rank, P = .98) or new amputations (log rank, P = .64). In conclusion, conservative surgery is as safe as amputation to arrest bone infection in the feet of patients with diabetes. Conservative surgery was not associated with a lower rate of recurrence and new amputations than those patients who underwent amputations.

Distal symmetrical polyneuropathy is present in all individuals with diabetes and foot ulcers - and does not associate with healing time.

We estimated the occurrence of diabetic neuropathy using six different diagnostic modalities in individuals with newly diagnosed diabetic foot ulcers (DFUs) and assessed the association with DFU healing time. All individuals with DFU had distal symmetrical polyneuropathy. Presence of neuropathy did not associate with ulcer healing time (p ≥ 0.12).

Routine bacterial culture of proximal bone specimens during minor amputation in patients with diabetes-related foot infections has little clinical utility in predicting re-operation or ulcer healing.

BACKGROUND: Trans-phalangeal and trans-metatarsal amputation, collectively termed 'minor amputations' are important procedures for managing infections of diabetes-related foot ulcers (DFU). Following minor amputation, international guidelines recommend a prolonged course of antibiotics if residual infected bone on intra-operative bone samples are identified, but the quality of the evidence underpinning these guidelines is low. In this study, we examined the concordance of microbiological results from proximal bone cultures compared to results from superficial wound swabs in relation to patient outcomes; with the aim of determining the utility of routinely obtaining marginal bone specimens. METHODS: Data was retrospectively collected on 144 individuals who underwent minor amputations for infected DFU at a large Australian tertiary hospital. Concordance was identified for patients with both superficial wound swabs and intra-operative bone samples available. Patient outcomes were monitored up to 6 months post-amputation. The primary outcome was complete healing at 6 months; and secondary outcome measures included further surgery and death. Mann Whitney U testing was performed for bivariate analyses of continuous variables, Chi-Squared testing used for categorical variables and a logistic regression was performed with healing as the dependent variable. RESULTS: A moderate-high degree of concordance was observed between microbiological samples, with 38/111 (35%) of patients having discordant wound swab and bone sample microbiology. Discordant results were not associated with adverse outcomes (67.2% with concordant results achieved complete healing compared with 68.6% patients with discordant results; P = 0.89). Revascularisation during admission (0.37 [0.13-0.96], P = 0.04) and amputation of the 5th ray (0.45 [0.21-0.94], P = 0.03) were independent risk factors for non-healing. CONCLUSION: There was a moderate-high degree of concordance between superficial wound swab results and intra-operative bone sample microbiology in this patient cohort. Discordance was not associated with adverse outcomes. These results suggest there is little clinical utility in routinely collecting proximal bone as an adjunct to routine wound swabs for culture during minor amputation for an infected DFU.

Prevalence and incidence of mental health issues amongst adults with diabetes at risk of foot complications in the European Union: a systematic review protocol.

OBJECTIVE: The objective of this systematic review is to evaluate and synthesize the evidence to establish the prevalence and incidence of mental health issues in people at risk of diabetic foot ulceration living within the European Union. INTRODUCTION: Due to the large health and financial burden of diabetic foot ulceration, prevention is a key focus for clinicians and researchers. Current foot ulcer prevention strategies are directed at the assessment and management of physical pathologies and risk factors for diabetic foot ulceration. Psychological burden and risk factors are often overlooked. This review will determine the prevalence and incidence of mental health issues among adults with diabetes mellitus who are at risk of foot ulceration. The review will focus on European Union countries. INCLUSION CRITERIA: Studies considered for inclusion will report on adults with a formal diagnosis of either type 1 or type 2 diabetes mellitus, who are at risk of foot ulceration and mental health issues. Studies will have been completed in the European Union. METHODS: A search of MEDLINE, CINAHL, AMED, Embase, Cochrane CENTRAL, and PsycINFO will be conducted for studies published in or translatable into English. Unpublished and gray literature will be searched. Studies will be selected against the review inclusion/exclusion criteria, and selected studies will be critically appraised, with data extraction and synthesis completed using the relevant JBI systematic review tools. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021260815.

Australian guideline on prevention of foot ulceration: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease.

BACKGROUND: There are no current Australian guidelines on the prevention of diabetes-related foot ulceration (DFU). A national expert panel aimed to systematically identify and adapt suitable international guidelines to the Australian context to create new Australian evidence-based guidelines on prevention of first-ever and/or recurrent DFU. These guidelines will include for the first-time considerations for rural and remote, and Aboriginal and Torres Strait Islander peoples. METHODS: The National Health and Medical Research Council procedures were followed to adapt suitable international guidelines on DFU prevention to the Australian health context. This included a search of public databases after which the International Working Group on the Diabetic Foot (IWGDF) prevention guideline was deemed the most appropriate for adaptation. The 16 IWGDF prevention recommendations were assessed using the ADAPTE and GRADE systems to decide if they should be adopted, adapted or excluded for the new Australian guideline. The quality of evidence and strength of recommendation ratings were re-evaluated with reference to the Australian context. This guideline underwent public consultation, further revision, and approval by national peak bodies. RESULTS: Of the 16 original IWGDF prevention recommendations, nine were adopted, six were adapted and one was excluded. It is recommended that all people at increased risk of DFU are assessed at intervals corresponding to the IWGDF risk ratings. For those at increased risk, structured education about appropriate foot protection, inspection, footwear, weight-bearing activities, and foot self-care is recommended. Prescription of orthotic interventions and/or medical grade footwear, providing integrated foot care, and self-monitoring of foot skin temperatures (contingent on validated, user-friendly and affordable systems becoming available in Australia) may also assist in preventing DFU. If the above recommended non-surgical treatment fails, the use of various surgical interventions for the prevention of DFU can be considered. CONCLUSIONS: This new Australian evidence-based guideline on prevention of DFU, endorsed by 10 national peak bodies, provides specific recommendations for relevant health professionals and consumers in the Australian context to prevent DFU. Following these recommendations should achieve better DFU prevention outcomes in Australia.

Debridement of Diabetic Foot Ulcers.

Diabetic foot ulcerations have devastating complications, including amputations, poor quality of life, and life-threatening infections. Diabetic wounds can be protracted, take significant time to heal, and can recur after healing. They are costly consuming health care resources. These consequences have serious public health and clinical implications. Debridement is often used as a standard of care. Debridement consists of both nonmechanical (autolytic, enzymatic) and mechanical methods (sharp/surgical, wet to dry debridement, aqueous high-pressure lavage, ultrasound, and biosurgery/maggot debridement therapy). It is used to remove nonviable tissue, to facilitate wound healing, and help prevent these serious outcomes. What are the various forms and rationale behind debridement? This article comprehensively reviews cutting-edge methods and the science behind debridement and diabetic foot ulcers.

Comorbidities associated with non- healing of plantar ulcers in leprosy patients.

BACKGROUND: Non-healing plantar ulcers are one of the significant causes of disability in leprosy patients. Plantar ulcers often take months or years to heal, affecting the patient's quality of life. Presence of comorbid conditions in these patients can delay wound healing. The study aimed to evaluate the role of associated comorbid conditions as risk factors in ulcer healing. METHODOLOGY/PRINCIPAL FINDINGS: A total of 66 leprosy patients with plantar ulcers registered at LEPRA Society-Blue Peter Public Health and Research Center (BPHRC), Hyderabad, India from June 2018 to June 2019 were studied. Comprehensive clinical assessment was done, including screening for comorbid conditions and treated as per the recommended guidelines. About two-thirds of the participants were aged 50 and above, of which more than half were illiterates, and 93.5% were living below the poverty line. Majority of ulcers were seen on the forefoot; with the head of meta-tarsal bone 27 (41.6%) as the commonest site, followed by calcaneum 23 (38.3%) and great toe 10 (16.6%). Mean ulcer depth was 0.61 (0.57) cm, the area was 5.24 (6.73) cm2 and ulcer volume was 4.72 (14.33) cm3. Ulcer dimensions were significantly associated with low body mass index, hypertension and smoking. CONCLUSIONS/SIGNIFICANCE: Identifying the risk factors delaying wound healing and detailed assessment of ulcers are of profound importance to predict the outcome of plantar ulcers in leprosy patients. The study findings indicate the need for better policies by the leprosy control program for the comprehensive management of plantar ulcers.

Abordaje multiprofesional del paciente con úlcera de pie diabético y presencia de osteomielitis. Casos clínicos / Multidisciplinary approach of the patient with diabetic foot ulcer and presence of osteomyelitis. Clinical cases

La osteomielitis del pie diabético puede presentar al clínico grandes desafíos diagnósticos y terapéuticos. La infección en pacientes con úlceras de pie diabético ocasiona una gran morbimortalidad. Las tasas de mortalidad, sobre todo cardiovascular, tras una úlcera y la amputación son muy elevadas, casi un 60% de las personas fallecen en el transcurso de 5 años tras una amputación y casi un 40% en el caso de las úlceras. El objetivo del artículo es describir el procedimiento con el que se aborda la osteomielitis en pacientes con úlceras de pie diabético a través de un equipo multiprofesional. METODOLOGÍA: A través de dos casos clínicos, se expone el planteamiento quirúrgico y médico para el abordaje de la osteomielitis. RESULTADOS: La resolución tanto de la osteomielitis como de la cicatrización de la úlcera se apoya tanto en la especialización de los profesionales a nivel clínico como en garantizar la continuidad asistencial en los niveles de atención existentes, evitando la variabilidad y garantizando la prestación de los recursos necesarios de manera eficiente. CONCLUSIONES: El abordaje quirúrgico o médico de la osteomielitis precisa de un equipo cualificado que pueda plantear ambas estrategias de atención, consiguiendo la resolución del caso

Osteomyelitis of the diabetic foot can present the clinician with great diagnostic and therapeutic challenges. Infection in patients with diabetic foot ulcers causes great morbidity and mortality. Mortality rates, especially cardiovascular, after an ulcer and amputation are very high, almost 60% of people die within 5 years after amputation and almost 40% in the case of ulcers. The objective of the article is to describe the procedure with which osteomyelitis is approached in patients with diabetic foot ulcers through a multiprofessional team. METHODOLOGY: Through two clinical cases, the surgical and medical approach for the osteomyelitis approach is exposed. RESULTS: The resolution of both osteomyelitis and ulcer healing relies both on the specialization of professionals at a clinical level, and on ensuring continuity of care at existing levels of care, avoiding variability and guaranteeing the provision of Necessary resources efficiently. CONCLUSIONS: The surgical or medical approach of osteomyelitis requires a qualified team that can propose both strategies of care, obtaining the resolution of the case

Acupuncture as adjuvant therapy for diabetic foot: A protocol for systematic review.

BACKGROUND: Diabetic foot (DF) problems are common throughout the world, about one-fourth of them develop a foot ulcer and serious cases would suffer from amputation, which seriously affects the patient's work and life. Previous studies indicated that acupuncture as adjuvant therapy would be effective in treating DF. However, these studies have no consistent results. Therefore, the aim of our study was to explore the efficacy and safety of acupuncture as adjuvant therapy for DF. METHODS: The randomized controlled trials associated with acupuncture therapy (or as adjuvant therapy) for DF will be included. We will search 6 electronic databases relevant to health sciences, including PubMed, Embase, the Cochrane Library, the Chinese databases Sino-Med, CNKI, and WANFANG database. All searches were from databases inception to March 30, 2019. The primary outcomes are the total curative effective rate, and the hemodynamic parameter and adverse events will be deemed as secondary outcomes. The Stata15.1 software and Review Manager (RevMan 5.3; Cochrane Collaboration, Copenhagen, Denmark) will be used for analysis, to assess the bias risk, subgroup analysis, and data synthesis. RESULTS: In this systematic review and meta-analysis, we will synthesize the studies to assess the safety and efficacy of acupuncture as adjuvant therapy for DF. CONCLUSION: The summary of our study will clarify whether acupuncture as adjuvant therapy could be an efficient method for DF.

Leg Amputations Among Texans Remote From Experienced Surgical Care.

BACKGROUND: Surgical outcomes may differ between low-volume and experienced hospitals. We sought to identify characteristics of remote patients-those living more than 50 miles from an experienced center-who underwent leg amputations for peripheral artery disease (PAD) and foot complications at low-volume and experienced hospitals and identify regions of Texas where such patients live. MATERIALS AND METHODS: Publicly available Texas hospitalization data from 2004 through 2009 were used to identify patients with PAD who underwent leg amputation for foot complications, including foot ulcers, foot infections, and gangrene. Geocoding was used to further identify a subset of remote patients and to estimate distances from zip code of residence to hospital in which care was received. RESULTS: Among all leg amputations, 850 (18.6%) were performed on patients classified as remote, and 3723 (81.4%) were performed on patients classified as nonremote. Compared with nonremote patients, remote patients were more often categorized as white and more frequently received Medicare and/or Medicaid. Of the subset of remote patients, those at low-volume hospitals were older, were less often categorized as Hispanic, more often had Medicaid coverage, were also more frequently admitted through the emergency department, and often had a foot infection compared with those at experienced centers. Geospatial analysis identified five concentrated geographic areas of remote patients who live more than 50 miles from an experienced center. CONCLUSIONS: These findings suggest travel distance may at least influence, if not constrain, the choice of hospital for patients with PAD and foot complications. Efforts to decrease leg amputations among remote patients should be focused on five specific geographic areas of Texas.

Micronutrient Status in Diabetic Patients with Foot Ulcers.

Objective: To explore the prevalence of micronutrient deficiencies in patients with diabetic foot ulcers and correlate this with foot disease severity and other clinical factors. Approach: Prospective cohort study of diabetic patients with foot ulcers seen in multidisciplinary foot clinics across Adelaide or admitted to the Vascular Surgery Unit at the Royal Adelaide Hospital between February 2017 and September 2018. A total of 131 patients were included in the study. Plasma serum levels of vitamins A, C, D, and E, copper, zinc, and ferritin were measured. Demographic and clinical data, including BMI, smoking status, duration of diabetes, HbA1c, and WIfI score, were obtained. Results: The most prevalent nutritional deficiency found was vitamin D affecting 55.7% of patients. Suboptimal levels of vitamin C affected 73% of patients, comprising marginal levels in 22.2% and deficient levels in 50.8%. Zinc deficiency, vitamin A deficiency, and low ferritin levels were present in 26.9%, 10.9%, and 5.9% of patients, respectively. There was no correlation between BMI, grip strength, duration of diabetes, HbA1c, or smoking status with micronutrient deficiency. Increased severity of diabetic foot disease was associated with lower vitamin C levels (p = 0.02). Innovation: This study has demonstrated that the deficiency of micronutrients, especially vitamin D, vitamin C, zinc, and vitamin A, is common in diabetic patients with foot ulcers. Conclusions: The prevalence of micronutrient deficiency is high in a diabetic population with foot ulcers/wounds. Special concerns regarding the high prevalence of vitamin C and zinc deficiency, given their roles in wound healing. Although further research needs to be performed to determine the clinical implications of our findings, micronutrient deficiency should be considered in diabetic patients with foot wounds.

Tratamento da úlcera plantar devido à hanseníase / Treatment of leprosy-induced plantar ulcers

Introdução: A úlcera plantar por hanseníase é uma lesão no pé resultante da falta de sensibilidade plantar. O objetivo é descrever o tratamento realizado em portadores de úlceras plantares por hanseníase. Métodos: Estudo de prontuários de portadores de úlcera plantar atendidos no Hospital Sarah em Brasília, de 2006 a 2016, quanto ao sexo, idade, etiologia, localização e tratamento. Resultados: Foram atendidos 27 pacientes, 17(62,96%) homens e 10 (37,04%) mulheres, procedentes de Goiás e DF, na faixa etária de 41 a 60 anos (40,74%). Todos necessitaram de um ou mais procedimentos cirúrgicos. Conclusão: Observou-se maior frequência no sexo masculino, grau avançado, localizadas no primeiro artelho. Todos necessitaram de procedimentos cirúrgicos e não cirúrgicos, evoluindo com cicatrização completa da ferida, amputação transtibial em um caso e de artelhos em sete casos, e 90% dos casos apresentaram recorrência da úlcera após um ano.

Introduction: Leprosy-induced plantar ulcers result from a lack of plantar sensitivity. Objective: This study aimed to describe the treatment provided to patients with leprosy-induced plantar ulcers. Methods: We retrospectively reviewed the medical records of patients with plantar ulcers treated at Sarah Hospital in Brasilia from 2006 to 2016 and collected information about sex, age, etiology, location, and treatment. Results: A total of 27 patients (17 [62.96%] men, 10 [37.04%] women; 40.74% were aged 41­60 years) were treated from Goiás and the Federal District. All required ≥1 surgical procedure. Conclusion: A higher frequency of advanced grade was observed in men, primarily on the first toe. All needed surgical and non-surgical procedures and achieved complete wound healing. Transtibial amputation was required in 1 case and toe amputation in 7 cases; 90% patients developed ulcer recurrence after 1 year.

Corynebacterium diphtheriae bloodstream infection: the role of antitoxin.

A 65-year-old male patient presented with fever, fast atrial fibrillation and frank haematuria on return to Ireland from travel in East Africa. He had a systolic murmur leading to a clinical suspicion of endocarditis. He had no specific clinical features of diphtheria. Blood cultures were taken and empiric therapy commenced with benzylpenicillin, vancomycin and gentamicin. Corynebacterium diphtheriae was detected on blood culture. The isolate was submitted to a reference laboratory for evaluation of toxigenicity. While initially there was concern regarding the possibility of myocarditis, a clinical decision was made not to administer diphtheria antitoxin in the absence of clinical features of respiratory diphtheria, in the presence of invasive infection and with presumptive previous immunisation. There is no specific guidance on the role of antitoxin in this setting. The issue is not generally addressed in previous reports of C. diphtheriae blood stream infection.