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Background
In the UK, dogs are the most common source of animal bites in humans leading to over 200000 minor injuries and emergency unit attendances annually. 1 This figure has steadily increased in the last decade. 2 All bites that breach the dermis have the potential to cause significant infection. Immunocompromised individuals, particularly those on steroid therapy, patients with diabetes and splenectomy patients are at risk of developing more severe infections, 3 which may lead to irreparable tissue damage and loss of function.
Patients with diabetic peripheral neuropathy (DPN) are a particularly vulnerable subgroup, as injury is more likely to go unnoticed or ignored. Consequently, these patients may have delayed presentations and are therefore at an increased risk of developing complications secondary to infection. We report an unusual and interesting case of a male who, on two separate occasions whilst asleep and unaware, had several of his toes mutilated by his pet dog. Due to the severity of his injuries and a history of poor wounding healing potential, he ultimately required amputation of the affected digits. We present this case in order to highlight the potential perils of pet ownership in the context of DPN and the importance of prompt medical and/or surgical treatment, and we review the relevant literature.
Case presentation
We present the case of a 59-year-old male who was admitted to hospital with a dog bite to his right hallux. His medical history includes insulin-dependent diabetes mellitus, with associated peripheral neuropathy, polymyalgia rheumatica, steroid-induced osteoporosis, lung fibrosis and hypertension. His regular medications include prednisolone, mycophenolate, alendronic acid, perindopril, Calcichew, Lantus and NovoRapid insulin. He has no known drug allergies. His is an ex-smoker who lives alone and drinks 50-100 units of alcohol per week and is otherwise independent and self-caring. He had recently purchased Staffordshire bull terrier puppy.
Three months previously, the patient had tripped while walking and sustained undisplaced fractures of the bases of the third, fourth and fifth right metatarsals ( figure 1 ). The fractures were managed conservatively with a plaster cast. Unfortunately, he developed a friction wound due to the cast, which he was not initially aware of due to his peripheral neuropathy. The cast was removed to reveal an infected ulcer 3×1.5cm over the medial aspect of...