What is the diagnosis and treatment for a patient with chills, a swollen right leg and toes, and elevated blood pressure?

Acute Limb Ischemia with Possible Infection

This patient requires immediate vascular surgery consultation and CT angiography to rule out acute limb ischemia, while simultaneously evaluating for diabetic foot infection or cellulitis. The combination of chills, swollen leg and toes suggests either acute arterial occlusion with systemic inflammatory response or severe soft tissue infection—both are limb-threatening emergencies requiring intervention within 4-6 hours. 1, 2

Immediate Clinical Assessment (Within Minutes)

Check pedal pulses immediately to distinguish between acute limb ischemia (absent pulses) and infection/venous pathology (pulses present). 2

• Assess for the "6 P's" of acute limb ischemia: Pain, Pallor, Pulselessness, Poikilothermia (coldness), Paresthesias, and Paralysis 2
• Evaluate for signs of infection: erythema, warmth, induration, pain/tenderness, or purulent drainage 3
• Do not wait for imaging if pulses are absent or diminished—contact vascular surgery immediately as the salvage window is approximately 4-6 hours 1, 2
• Classify limb viability using Rutherford criteria: the presence of motor weakness or sensory loss beyond the toes indicates immediately threatened (Class IIb) or irreversible (Class III) ischemia requiring urgent intervention 1

Diagnostic Pathway Based on Pulse Examination

If Pulses Are Absent or Significantly Diminished:

This is acute limb ischemia until proven otherwise. 1, 2

• Start systemic anticoagulation (heparin) immediately to prevent thrombus propagation 1, 2
• Order CT angiography emergently to define anatomy and plan revascularization—this is the preferred initial test providing excellent anatomical detail including below-knee arteries 1
• Do not elevate the affected limb above heart level (worsens perfusion) 2
• Vascular surgery consultation should occur before or simultaneously with imaging, not after 1, 2

If Pulses Are Present:

Focus shifts to infection evaluation, but maintain high suspicion for early ischemia. 3

• Diagnose infection by presence of at least two signs of inflammation (redness, warmth, induration, pain/tenderness) or purulent secretions 3
• Classify infection severity: mild (superficial with minimal cellulitis), moderate (deeper or more extensive), or severe (systemic signs like chills/fever) 3
• Chills suggest moderate-to-severe infection requiring urgent surgical consultation for possible deep-space infection or abscess 3
• Probe any visible wound with sterile metal probe—if bone is palpable, osteomyelitis is likely present 3
• Plain radiographs suffice for initial osteomyelitis screening 3

Critical Management Considerations

For Diabetic Patients (High-Risk Population):

• Seek urgent surgical consultation for clinical evidence of life- or limb-threatening infection, even if fever or leukocytosis is absent 3
• A plantar wound with dorsal erythema or fluctuance suggests infection through fascial compartments, requiring surgical intervention 3
• Consider Charcot neuro-osteoarthropathy in diabetic patients with neuropathy and hot swollen foot, though this can coexist with infection 3

Blood Pressure Management:

• Elevated BP in this acute setting does not require emergency reduction unless >220/120 mmHg or there is evidence of acute end-organ damage 3
• Do not aggressively lower BP in suspected limb ischemia—maintaining perfusion pressure is critical for limb salvage 3
• If BP reduction is needed, use oral agents with gradual titration rather than IV agents unless true hypertensive emergency exists 3

Common Pitfalls to Avoid

• Never delay vascular consultation while awaiting imaging if clinical suspicion for acute limb ischemia is high 2
• Do not apply compression therapy to a cold leg with suspected arterial insufficiency 2
• Absence of fever or leukocytosis should not dissuade from considering surgical exploration of deep foot infection 3
• Do not assume venous insufficiency or cellulitis without confirming intact pulses—acute arterial occlusion can initially present with swelling and erythema 1, 2

Anticoagulation Warning

If warfarin-induced skin necrosis is suspected (purple/mottled toes occurring 3-10 weeks after warfarin initiation), discontinue warfarin immediately and consider heparin anticoagulation, as this can progress to gangrene requiring amputation. 4

Disposition

• Absent pulses or motor weakness: Immediate hospital admission, vascular surgery, emergent revascularization 1, 2
• Present pulses with severe infection signs (chills, systemic symptoms): Hospital admission, IV antibiotics, surgical evaluation for debridement 3
• Present pulses with mild-moderate infection: May manage outpatient with close follow-up if no deep-space involvement, but low threshold for admission 3