https://doi.org/10.1177/1534734619879030 The International Journal of Lower Extremity Wounds 1–6 © The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1534734619879030 journals.sagepub.com/home/ijl Case Report Introduction Diabetic foot represents one of the most serious and prevail- ing complications of diabetes mellitus (DM), 1 and infection is a preponderant factor in minor and major amputation of the lower limbs. 2 Infected diabetic ulcers are often polymi- crobial, and in the vast majority aerobic and anaerobic bac- teria are implicated. 1,3,4 Albeit rare, fungi may also be the responsible agent, namely in deep tissue infection that is refractory to antibacterial therapy and appropriate foot care. 5-7 Fusarium spp. is a human opportunistic pathogen that has been gaining emerging importance. 5,8,9 Case Report A 65-year-old man was referred to our unit for recurrence of infected diabetic foot ulcer. The patient had a diagnosis of non-insulin-dependent, reasonably controlled, type 2 DM, for 16 years. His neuroischemic diabetic foot had previ- ously led to the amputation of the third left toe. His history was also remarkable for severe peripheral artery disease previously unamenable to revascularization, ischemic heart disease submitted to coronary artery bypass surgery, dyslip- idemia, and essential arterial hypertension. In addition, the patient had ulcerative proctitis chronically treated with oral prednisolone (20 mg daily). Physical examination revealed a deep ulcer of the dorsal aspect of the forefoot, localized at the base of the fourth left and second left toes, with necrotic base and borders, and pro- gressed to wet gangrene. Onychodystrophy of the toes was present. The patient was apyretic and hemodynamically sta- ble. Analytically, a slightly raised C-reactive protein of 37.6 mg/L was noted, with absent leukocytosis. A diagnosis of diabetic foot with moderate infection was made (perfusion, extent, depth, infection, and sensation: PEDIS Classification System, Grade 3). Lack of improvement with oral antibiotics following microbial analysis led to hospitalization. Amputation of the second and fourth left toes was per- formed, together with extensive debridement of the dor- sal region. This approach resulted in a 4 × 3-cm deep 879030IJL XX X 10.1177/1534734619879030The International Journal of Lower Extremity WoundsJoão et al case-report 2019 1 Department of Dermatology and Venereology, Centro Hospitalar Universitário de Lisboa Central 2 Pathology Department, Centro Hospitalar Universitário de Lisboa Central 3 Diabetic Foot Unit, General Surgery Department, Centro Hospitalar Universitário de Lisboa Central Corresponding Author: Ana Luísa João, Dermatovenereology Department, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Alameda Santo António dos Capuchos, Lisboa 1169-050, Portugal. Email: luisajoao92@gmail.com Fusarium spp.—An Emerging Pathogen in Chronic Diabetic Ulcer: Case Report and Review of the Literature Ana Luísa João, MD 1 , André Lencastre, MD 1 , Eduardo Dutra, MD 2 , Tomás Pessoa e Costa, MD 1 , Ana Formiga, MD 3 , and José Neves, MD 3 Abstract The genus Fusarium is ubiquitous in the environment and has been emerging as an opportunistic human pathogen. We report the case of a 65-year-old man with a history of neuroischemic, otherwise unamenable to revascularization, diabetic foot, who was admitted due to an infected deep foot ulcer. Despite conventional antibiotic and wound care treatment, no improvement was initially observed. A reappraisal of the diagnosis, with microbiological and histological analyses, documented infection of the foot ulcer with Fusarium oxysporum. Clinical improvement was noted under prolonged oral voriconazole therapy. The present case broadens the differential diagnosis of diabetic foot infection. Subcutaneous fusariosis should be considered in recalcitrant infected diabetic ulcers, as early diagnosis and management may help prevent amputation and life-threatening disease. Keywords diabetic foot ulcer, wound infection, Fusarium