54-year-old patient, medical professional with no reported medical history, who consulted 3 days after the onset of his illness for a scabbed wound on the back of his right foot at the base of the fourth toe.

The chronology of events is as follows:

Three days before his consultation: sensation of itching in his right foot at the base of the fourth toe on the dorsal side during the night of October 4 to 5, 2022. No visible lesions. No treatment received at home.The following day, he presented with moderate pain in his right foot, swelling of the right foot, functional impairment of the right lower limb, generalized tingling sensation throughout the body starting from the back of the right foot, a 1 cm diameter blister on the right foot at the base of the fourth toe on the dorsal side, no treatment received at home (Figure 2 and Figure 3).Two days later, he presented with: increasingly intense pain radiating to the root of the right lower limb, a 4 cm diameter blister on the right foot at the base of the fourth toe on the dorsal side, no treatment received at home (Figure 4).Three days later, he presented with: severe physical weakness, profuse sweating, heart palpitations, tachycardia, chills, shock, anorexia, intense thirst, blurred vision, functional impotence of the right lower limb, edema of the right foot, generalized tingling sensation, intense pain in the right lower limb, and a 5 cm phlyctenoma on the right foot at the base of the fourth toe on the dorsal side (Figure 5). He decided to take one 500 mg tablet of azithromycin and to scrape the phlyctenoma after disinfecting the skin with hydroalcoholic gel solution, which released 5 ml of purulent fluid. He discovered a wound 5 cm in diameter with a base covered with necrotic tissue, sphacelated fascia, and exposed tendon. He dressed the wound with a compress soaked in hydroalcoholic gel and applied a cream made from a combination of clotrimazole, betamethasone, neomycin sulfate, and chlorocresol. Eight hours later, he reopened the dressing and found a blood clot covering the wound.

He was taking the following medication at home: a combination of paracetamol and tramadol, 2 tablets per day; azithromycin, 500 mg tablet, 1 tablet per day; a combination of norfloxacin and metronidazole, 400 mg tablet, 2 tablets per day; and cloxacillin, 500 mg capsule, 3 capsules twice per day (Figure 6).

He takes the following medication at home: Paracetamol/Tramadol combination 2 × 1 tablet per day, Azithromycin 500 mg tablet 1 × 1 tablet per day, Norfloxacin/Metronidazole combination 400 mg tablet 2 × 1 tablet per day, Cloxacillin 500 mg capsule 3 × 2 capsules per day.

A scab-covered wound (Figure 7) is observed during resuscitation and dressing change, which is coated with chlorhexidine.The following day, he consulted at the Boma Regional Hospital, where the following was noted: severe physical weakness; fever of 38˚C; shock with blood pressure of 80/60 mm Hg and a pulse rate of 120 beats per minute; 17 cm edema extending from the toes to the right ankle (Figure 7); erythema on the back of the right foot; heat and intense painful sensitivity in the right foot extending up to the right groin. Vascular examination was unremarkable, with no crepitus on palpation.

Resuscitation was performed and the dressing was changed with chlorhexidine liquid solution, and the treatment started at home was continued for a maximum of 10 days. The patient was discharged from the hospital the day after resuscitation to be followed up on an outpatient basis until the wound had completely healed.

On day 4 after consultation: pain in the lower limb had become mild; tingling sensation; edema of the right foot. The wound had become clean with soft tissue regeneration (Figure 8); treatment remained the same.On day 7 after consultation: appearance of sebaceous gland island in the wound (Figure 9).On day 8 after consultation: appearance of 2 hairs around the sebaceous gland island (Figure 10).On day 12 after the consultation: complete resolution of the edema with the appearance of skin folds and the onset of molting. Only the bandage remained in place (Figure 11 and Figure 12).On day 25 after the consultation: clear desquamation of the skin, the edges meet, leaving a white border between them (Figure 13).On day 57 after stripping: complete fusion of the edges, healing is complete (Figure 14).On day 104, grayish spots were observed on the sole of the affected right foot (Figure 15).After 24 months, skin considered healthy and uniform began to appear, signaling the clinical end of the patient’s wound healing process (Figure 16).

Table 1.Paraclinical tests requested upon admission: laboratory and imaging.

Figure 2.On the morning of the first day after the onset of his illness (October 5, 2022), a vesicle approximately 1 cm in diameter.

Figure 3.On the morning of the second day after the onset of his illness (October 6, 2022), a vesicle developed into a bubble approximately 3 cm in diameter.

Figure 4.Evolution of the 4 cm blister into a phlycten (October 6, 2022).

Figure 5.On the morning of the third day after the onset of his illness (October 7, 2022, at 12:30 p.m.), a phlyctenule measuring 5 cm in diameter before rupturing.

Figure 6.Blister ruptured after 8 hours (October 7, 2022) under a bandage covering a wound 5 cm in diameter covered with a blood clot.

Figure 7.Crust formation one day after phlyctenum removal (October 8, 2022).

Figure 8.On the fifth day after phlyctenum debridement (October 12, 2022), the appearance of subcutaneous tissue, aponeurosis, and muscle.

Figure 9.On the eighth day after phlyctenum debridement (October 15, 2022), an island of sebaceous glands appeared at the distal part of the lesion’s large diameter.

Figure 10.On the 9th day after phlyctenum removal (October 16, 2022), two hairs appeared around the glandular island.

Figure 11.On the 12th day after phlyctenum debridement (October 19, 2022), the skin tissue covering the gland extends centrifugally.

Figure 12.On the third day after phlyctenum removal (October 20, 2022), complete resolution of edema with the appearance of skin folds and the onset of moulting (skin shedding).

Figure 13.On the 26th day after phlyctenum debridement (November 2, 2022), very obvious desquamation, the distal edge of the sebaceous gland skin meets the edge of the wound (of the 4th toe), leaving a white border between the proximal edge of the wound and that of the gland.

Figure 14.On day 57 (December 3, 2022), There was complete fusion of the edges without any demarcation line except for the outline of the large wound, approximately 5 cm in diameter, with apparently healthy skin and good coloration, which had completely healed after 57 days.

Figure 15.On day 104 (January 29, 2023), grayish spots of varying ages appeared on the sole of the right foot, the affected foot.

Figure 16.At 24 months (October 7, 2022-October 7, 2024), the appearance of skin considered healthy could signal the clinical end of the patient’s wound healing process.