Unexpected complication of intralesional injection of recombinant human epidermal growth factor: diabetic foot osteomyelitis.

Dear Editors, A 66-year-old patient with type 2 diabetes mellitus of 13 years duration was referred to the Undersea and Hyperbaric department because of a swollen infected big toe that occurred during the course of intralesional parenteral epidermal growth factor (IP-EGF) treatment. The patient had a chronic non-healing plantar ulcer over the metatarsal head of the first toe for almost 5 years (Figure 1). He was scheduled to receive IP-EGF three times a week for 4weeks, but experienced complication following the third application. The treatment was stopped and the patient was referred for consultation. The patient had hypertension, congestive heart failure and chronic renal failure. On examination his peripheral pulses were impalpable and he had severe loss of foot sensation. The big toe was significantly swollen with increased temperature and marked hyperaemia (Figure 2). An X-ray showed osteomyelitis of the metatarsal head and phalanges of the hallux (Figure 3). The patient was hospitalised and received parenteral piperacillin–tazobactam treatment 4.5mg/kg three times a day for 3weeks. IP-EGF is a lyophilised formulation comprising human recombinant (rH-EGF). It has been introduced as a relatively safe drug with promising outcomes in the treatment of diabetic foot ulcers (1–3). The major concern regarding intralesional wound injections, however, is that they may have the potential to drive the superficial infection, as in our case, to deeper tissues. Alternate treatment opportunities other than intralesional approaches may be a rational approach to prevent such complications. In case of an absolute indication, changing the needle