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A toddler with complicated toenail infection
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A 17-month-old female is referred by her pediatrician for a complicated toe infection. The onset was spontaneous several days earlier.
There was no history of trauma to the toe, which was initially treated like an infected ingrown nail with oral trimethoprim-sulfamethoxazole (Septra, Monarch Pharms). However, it continued to worsen. Upon re-evaluation, herpes was suspected and the patient was started on oral acyclovir and referred to the pediatric infectious disease clinic 24 hours later.
James H. Brien
Her medical history was complicated by maternal fever at delivery. She had cultures taken and treated per protocol with antimicrobials, and after negative cultures at 72 hours, went home with her mother. She has had no significant health problems since. Her family history is positive for her mother having occasional cold sores, but denies any recent outbreaks and no other sick contacts.
Examination revealed a healthy, happy 17-month-old female whose right great toe was somewhat swollen with a dark reddish color, some skin breakdown on the dorsum, and an intact lesion on the plantar surface of the toe. The toe lesion appeared to be an irregular-shaped, fluid-filled, yellowish lesion with several flat macular lesions all around, as well as a few flat, red lesions in the arch of the foot (Figures 1 and 2). Bacterial culture and a herpesvirus PCR of the dorsal toe lesion are pending.
The toe lesion appeared to be an irregular-shaped, fluid-filled, yellowish lesion with several flat macular lesions all around, as well as a few flat, red lesions in the arch of the foot (Figures 1 and 2).
Images: Brien JH
What’s Your Diagnosis?
A. Septra-resistant methicillin- resistant Staphylococcus aureus
B. Pseudomonas aeruginosa
C. Herpes simplex virus
D. Coxsackievirus A16
The patient had a herpetic whitlow (C) of the toe with a positive PCR for herpes simplex type 2. The bacterial culture was negative. After 48 hours of treatment with acyclovir, there was dramatic improvement in the appearance, as shown in Figure 3. The patient was treated with acyclovir for 10 days with complete resolution.
After 48 hours of treatment with acyclovir, there was dramatic improvement in the appearance, as shown in Figure 3..
Certainly, S. aureus and P. aeruginosa can cause infections of the digits, especially paronychia. However, the pattern of vesicles and pustules in this case are characteristic for herpes. P. aeruginosa and other gram-negative bacterial paronychia tend to be more common in those whose hands are frequently in water and those who bite their nails (Figure 4).
When it comes to foot infections, especially puncture wound infections, one should consider Pseudomonas, as children’s shoes (sneakers) are often heavily colonized. Another unusual cause of toe paronychia is shown in a child who presented with scarlet fever (Figure 5) without a sore throat, but a sore toe (Figure 6), which revealed a paronychium with a positive culture for group A strep; another first for me.
P. aeruginosa and other gram-negative bacterial paronychia tend to be more common in those whose hands are frequently in water and those who bite their nails (Figure 4). Another cause of toe paronychia is shown in a child who presented with scarlet fever (Figure 5) without a sore throat.
Another cause of toe paronychia is shown in a child who presented with scarlet fever (Figure 5) without a sore throat, but a sore toe (Figure 6), which revealed a paronychium with a positive culture for group A strep. Coxsackievirus A16 usually causes discrete lesions in the mouth and vesicles about the hands, wrists, ankles and feet (Figure 7).
Coxsackievirus A16 is the cause for most cases of hand-foot-and-mouth disease (HFMD) and usually causes discrete lesions in the mouth and vesicles about the hands, wrists, ankles and feet (Figure 7), which can bear close resemblance to herpetic lesions. However, herpes simplex is more likely to be a bit more inflamed and localized to a specific area as opposed to other sites, as often seen in HFMD.
Columnist comments
We have all seen herpetic whitlows of the fingers, but this is the first whitlow of the toe that I have personally seen. You can use your imagination as to how it got there. I’m not here to judge, but when I presented this case to an audience at a meeting, one person told of a case he had in which the parent admitted sucking on the child’s toe. At any rate, the word “whitlow” has its origins in Middle English, derived from the word whitflawe, which can be further broken down into the Middle Dutch word vijt (abscess) and Middle English, flaue (flaw).
Atypical HFMD syndrome is an emerging disease caused mostly in the United States by coxsackievirus A6 and characterized by more fever and widespread, larger papulovesicular lesions, some with crusting; all of which can be seen in Figure 8.
This also seems like a good time to point out the recognition of atypical HFM syndrome, an emerging disease caused mostly in the United States by coxsackievirus A6 and characterized by more fever and widespread, larger papulovesicular lesions, some with crusting; all of which can be seen in Figure 8. Also, the cases reported tended to be in the winter months, as opposed to other enteroviruses that peak in the summer.
I would like to thank
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James H. Brien, DO, is a member of the Infectious Diseases in Children Editorial Board, and can be reached at jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.