Green nail: Etiology and treatment of chloronychia.

"Green nails" or chloronychia results from an infection mostly caused by Pseudomonas sp. but also from other bacterial or fungal contamination. Its presents as a typical triad: green discoloration of the nail plate with proximal chronic paronychia and disto-lateral onycholysis. In a moist environment, Pseudomonas colonizes onycholysis of any origin (traumatic, inflammatory or tumoral). Nail color varies from pale green to dark green, almost black. Treatment consists in cutting of the detached nail plate, brushing the nail bed with a 2% sodium hypochlorite solution twice daily accompanied by moisture eviction by wearing latex gloves over cotton ones for all daily household tasks.

Extensive pyomyositis secondary to paronychia-related MRSA infection: A case report.

RATIONALE: Pyomyositis is characterized by an insidious and multifactorial inflammatory process, which is often caused by hematogenous pathogen. Predisposing risk factors include immunodeficiency, diabetes, malignancy, or trauma. The spectrum of clinical presentation depends on disease severity, typically presented by fever and hip pain. We hereby present a case with extensive pyomyositis secondary to chronic paronychia infection. PATIENT CONCERNS: A 14-year-old immunocompetent male presented with fever and hip pain. The patient was initially surveyed for common infectious etiologies prior to the presentation of acute limping, which led to image confirmation of extensive pyomyositis. DIAGNOSIS: The patient presented with acute pain in the right hip accompanied by headache, myalgia of the right leg, and intermittent fever for a week. Physical examination disclosed limping gait, limited range of motion marked by restricted right hip flexion and right knee extension, and chronic paronychia with a nail correction brace of the left hallux. Diagnosis of pyomyositis was confirmed by magnetic resonance image. Methicillin-resistant strains of Staphylococcus aureus was isolated from the patient's blood and urine cultures within 2 days of collection. The same strain was also isolated from the pus culture collected via sonography-guided aspiration. INTERVENTIONS: Antibiotics treatment with oxacillin, teicoplanin, daptomycin, and fosfomycin were administered. Sonography-guided aspiration and computed tomography-guided pigtail drainage were arranged, along with nail extraction of his left hallux paronychia prior to discharge. Oral antibiotics fusidic acid was prescribed. Total antibiotics course of treatment was 4 weeks. OUTCOMES: The patient gradually defervesced and was afebrile after drainage. Followed limb doppler sonography showed regression of the abscess at his right lower limb. Gait and range of motion gradually recovered without sequelae. LESSONS: Ambulation and quality of life are greatly affected by the inflammatory process of pyomyositis. Detailed evaluation of predisposing factors should be done, even in immunocompetent individuals. Timely diagnosis is vital to successful treatment.

Fingertip Infections.

The fingertip is the most common site of infections in the hand, which frequently are encountered by surgeons, dermatologists, and emergency and primary providers. Their mismanagement may have serious consequences. This review discusses the unique anatomy of the volar fingertip pulp and perionychium and reviews pathophysiology and treatment of acute and chronic paronychia, including the decision for surgical versus medical management, choice of antibiotics, incisional techniques, and postincisional care. Felons and the evidence regarding their management are reviewed. Several infectious, rheumatologic, and oncologic conditions that may mimic common fingertip infections and about which the managing provider must be aware are presented.

Coagulase-Negative Staphylococcus Skin and Soft Tissue Infections.

Coagulase-negative staphylococcus organisms may be normal flora of human skin, however these bacteria can also be pathogens in skin and soft tissue infections. A summary of skin and soft tissue infections caused by coagulase-negative staphylococcus species is provided in this review. We conducted a search of the PubMed database using the following terms: abscess, auricularis, biofilm, capitis, cellulitis, coagulase, contaminant, cyst, draining, epidermidis, felon, folliculitis, furuncle, haemolyticus, hominis, indolent, infection, lugdunensis, mecA, microbiome, negative, osteomyelitis, paronychia, saprophyticus, skin, simulans, sinus, soft, staphylococcus, systemic, tissue, virulence, virulent, and vulvar. The relevant papers, and their references, generated by the search were reviewed. Skin and soft tissue infections have been observed to be caused by many coagulase-negative staphylococcus organisms: Staphylococcus auricularis, Staphylococcus capitis, Staphylococcus epidermidis, Staphylococcus haemolyticus, Staphylococcus hominis, Staphylococcus lugdunensis, Staphylococcus saprophyticus, and Staphylococcus simulans. Coagulase-negative staphylococcus skin infections predominantly present as abscesses and paronychia. They are most common in elderly patients or those individuals who are immunosuppressed, and tend to be broadly susceptible to antibiotic treatment. In conclusion, albeit less common, coagulase-negative staphylococcus organisms can result in skin and soft tissue infections, particularly in older and/or immunocompromised individuals. A review of the literature found that coagulase-negative staphylococcus organisms are most commonly grown in cultures of abscesses and paronychia. Therefore, coagulase-negative staphylococcal organisms should not always be considered as contaminants or normal flora, but rather as causative pathogens. They are usually susceptible to antibiotics used to treat methicillin-sensitive Staphylococcus aureus.

Fusarium onychomycosis: prevalence, clinical presentations, response to itraconazole and terbinafine pulse therapy, and 1-year follow-up in nine cases.

BACKGROUND: Invasive fusariosis is an infection with Fusarium spp. that primarily affects patients with hematologic malignancies and hematopoietic cell transplant recipients. Wounds, digital ulcers, onychomycosis, and paronychia are the typical cutaneous portals of entry. Early management of mycotic nails in immunocompromised and diabetic hosts is crucial to prevent life-threatening disease. OBJECTIVES: We report nine cases of Fusarium onychomycosis (F. dimerum, n = 5; F. oxysporum, n = 3; Fusarium spp., n = 1) in immunocompetent hosts and their response to itraconazole and terbinafine pulse therapy. METHODS: The patients received either itraconazole 400 mg daily or terbinafine 500 mg daily for 7 d/month; two pulses for fingernails and three pulses for toenails. RESULTS: Of the 68 confirmed cases of onychomycosis, eight (11.7%) were Fusarium spp.; the ninth patient was culture positive but microscopy negative and responded well to itraconazole. Distal subungual onychomycosis was the commonest clinical manifestation (seven of nine), one had proximal subungual onychomycosis, and total onychodystrophy was noted on four patients. Associated paronychia was marked on 66.7% (six of eight) patients. Itraconazole was given to six patients/25 nails and terbinafine to three patients/20 nails. All nine patients completed treatments, but one defaulted at 12 months follow-up. The efficacy parameters were clinical cure (CC) and mycological cure (MC). At month 12 after the start of treatment, the response was itraconazole CC 13 of 25 (52%)/MC four of six (66.6%) and terbinafine CC four of eight (50%)/MC one of two (50%). Recurrence was noted in four of 13 (30.7%) and eight of 13 (61.5%) cured nails in the itraconazole group within 3 and 12 months, respectively. CONCLUSIONS: Fusarium onychomycosis was clinically indistinguishable from other onychomycosis. Both itraconazole and terbinafine pulse therapy were only partially effective on Fusarium onychomycosis. Antifungals that are more effective should be sought.

[Exudative onycholysis and acute bacterial paronychia related to BIBF-1120 and paclitaxel: response to topical therapy]. / Onicólisis exudativa y paroniquia bacteriana aguda en relación con BIBF-1120 y paclitaxel: respuesta a la terapia tópica.

A case of a 50 years-old breast cancer patient treated with weekly paclitaxel and BIBF 1120 is reported herein. At the end of the twelfth cycle of chemotherapy, the patient developed distal onycholysis with intense hyponychium serous exudates, pain and malodor in all her fingernails. It was treated with topical fusidic acid and 1% methylprednisolone aceponate two times daily, with an excellent clinical response from the first three days of treatment. Bacterial paronychia with nail plate loss of the fifth left fingernail was observed a week after the topical therapy was started, with positive cultures for Methicillin susceptible Staphylococcus aureus. There are few reported cases of exudative onycholysis associated with chemotherapy. However, these are especially related to paclitaxel. No recurrences of nail disturbances were observed weeks after the end of chemotherapy. Topical corticosteroids and fusidic acid could be considered as a therapeutic option when exudative onycholysis related to paclitaxel is established

Onicólisis exudativa y paroniquia bacteriana aguda en relación con BIBF-1120 y paclitaxel: respuesta a la terapia tópica / Exudative onycholysis and acute bacterial paronychia related to BIBF-1120 and paclitaxel: response to topical therapy

Se presenta el caso de una paciente de 50 años de edad con cáncer de mama tratada con paclitaxel y BIBF 1120 semanal. La paciente desarrolló al final del duodécimo ciclo de quimioterapia una onicólisis distal, con exudado seroso intenso en el hiponiquio, dolor y mal olor en todas las uñas de las manos. Se trató con ácido fusídico tópico y aceponato de metilprednisolona al 1% dos veces al día, con una excelente respuesta desde los tres primeros días de tratamiento. A la semana de iniciar la terapia tópica, se observó una paroniquia bacteriana con la pérdida de la uña del quinto dedo de la mano izquierda, con cultivos positivos para Staphylococcus aureus sensible a meticilina. Hay pocos casos publicados de onicólisis exudativa asociada a quimioterapia. Sin embargo, están especialmente relacionados con paclitaxel. No se observaron recurrencias de las alteraciones ungueales semanas después de culminar la quimioterapia. Los corticoides tópicos y el ácido fusídico podrían ser considerados como una opción terapéutica cuando la onicólisis exudativa relacionada con paclitaxel esté establecida.

A case of a 50 years-old breast cancer patient treated with weekly paclitaxel and BIBF 1120 is reported herein. At the end of the twelfth cycle of chemotherapy, the patient developed distal onycholysis with intense hyponychium serous exudates, pain and malodor in all her fingernails. It was treated with topical fusidic acid and 1% methylprednisolone aceponate two times daily, with an excellent clinical response from the first three days of treatment. Bacterial paronychia with nail plate loss of the fifth left fingernail was observed a week after the topical therapy was started, with positive cultures for Methicillin susceptible Staphylococcus aureus. There are few reported cases of exudative onycholysis associated with chemotherapy. However, these are especially related to paclitaxel. No recurrences of nail disturbances were observed weeks after the end of chemotherapy. Topical corticosteroids and fusidic acid could be considered as a therapeutic option when exudative onycholysis related to paclitaxel is established.

Atypical chronic sterile paronychia leading to tissue and joint space destruction in a patient with thromboangiitis obliterans.

We report the case of a patient with severe thromboangiitis obliterans (Buerger's disease) and untreated paronychia which eroded into the digital joint space causing acrolysis of digits and significant soft tissue and joint destruction.

Tuberculous dactylitis presenting as paronychia with pseudopterygium and nail dystrophy.

Scrofuloderma is a type of secondary tuberculosis (TB) arising from contiguous involvement of skin by an underlying tuberculous focus in the lymph nodes or bones. It may occasionally be the presenting feature of osteoarticular TB. Tuberculous dactylitis is the involvement of the small tubular bones of the hands and feet, and most cases occur in children younger than 6 years of age. Fingers are more commonly involved than toes, and painless swelling of a digit is the usual presentation. Involvement of the toes is rare, with only a few reported cases. The indolent clinical course leads to a delay in diagnosis, and bone shortening with joint deformity is the usual outcome, especially in tuberculous dactylitis affecting the foot. We report here a case of tuberculous dactylitis of the great toe and scrofuloderma affecting the nail fold presenting as painless paronychia with pseudopterygium and nail dystrophy. Nail involvement led to an early presentation and timely diagnosis and treatment before progression to permanent bone or joint deformity.

Onychomycosis: Diagnosis and management.

Onychomycosis is a common nail ailment associated with significant physical and psychological morbidity. Increased prevalence in the recent years is attributed to enhanced longevity, comorbid conditions such as diabetes, avid sports participation, and emergence of HIV. Dermatophytes are the most commonly implicated etiologic agents, particularly Trichophyton rubrum and Trichophyton mentagrophytes var. interdigitale, followed by Candida species and non dermatophytic molds (NDMs). Several clinical variants have been recognized. Candida onychomycosis affects fingernails more often and is accompanied by paronychia. NDM molds should be suspected in patients with history of trauma and associated periungual inflammation. Diagnosis is primarily based upon KOH examination, culture and histopathological examinations of nail clippings and nail biopsy. Adequate and appropriate sample collection is vital to pinpoint the exact etiological fungus. Various improvisations have been adopted to improve the fungal isolation. Culture is the gold standard, while histopathology is often performed to diagnose and differentiate onychomycosis from other nail disorders such as psoriasis and lichen planus. Though rarely used, DNA-based methods are effective for identifying mixed infections and quantification of fungal load. Various treatment modalities including topical, systemic and surgical have been used.Topically, drugs (ciclopirox and amorolfine nail lacquers) are delivered through specialized transungual drug delivery systems ensuring high concentration and prolonged contact. Commonly used oral therapeutic agents include terbinafine, fluconazole, and itraconazole. Terbinafine and itraconazole are given as continuous as well as intermittent regimes. Continuous terbinafine appears to be the most effective regime for dermatophyte onychomycosis. Despite good therapeutic response to newer modalities, long-term outcome is unsatisfactory due to therapeutic failure, relapse, and reinfection. To combat the poor response, newer strategies such as combination, sequential, and supplementary therapies have been suggested. In the end, treatment of special populations such as diabetic, elderly, and children is outlined.

Hand infections.

Hand infections are commonly seen by orthopedic surgeons as well as emergency room and primary care physicians. Identifying the cause of the infection and initiating prompt and appropriate medical or surgical treatment can prevent substantial morbidity. The most common bacteria implicated in hand infections remain Staphylococcus aureus and Streptococcus species. Methicillin-resistant S aureus infections have become prevalent and represent a difficult problem best treated with empiric antibiotic therapy until the organism can be confirmed. Other organisms can be involved in specific situations that will be reviewed. Types of infections include cellulitis, superficial abscesses, deep abscesses, septic arthritis, and osteomyelitis. In recent years, treatment of these infections has become challenging owing to increased virulence of some organisms and drug resistance. Treatment involves a combination of proper antimicrobial therapy, immobilization, edema control, and adequate surgical therapy. Best practice management requires use of appropriate diagnostic tools, understanding by the surgeon of the unique and complex anatomy of the hand, and proper antibiotic selection in consultation with infectious disease specialists.

Disseminated Fusarium infection originating from paronychia in a neutropenic patient: a case report and review of the literature.

Fusarium is a saprophytic organism that is widely found distributed in soil, subterranean and aerial plants, plant debris, and other organic substrates. It can cause local tissue infections in immunocompetent patients, such as onychomycosis, bone and joint infections, or sinusitis. The incidence of disseminated disease has notably increased since the initial cases of disseminated Fusarium were described, particularly affecting immunocompromised patients with hematologic malignancies. We report a 39-year-old man hospitalized with newly diagnosed acute myelocytic leukemia who developed disseminated Fusarium infection originating from toenail paronychia in the setting of neutropenia. Pathologic diagnosis of Fusarium is difficult because the septate hyphae of Fusarium are difficult to distinguish from Aspergillus, which has a more favorable outcome. Cultures of potential sources of infection as well as tissue cultures are essential in identifying the organism and initiating early aggressive therapy.

Paronychia due to Prevotella bivia that resulted in amputation: fast and correct bacteriological diagnosis is crucial.

Prevotella bivia is mainly associated with endometritis. The case of a patient with paronychia in a thumb due to P. bivia resulting in osteitis and amputation is reported. The species was not acknowledged in the first bacterial culture 2 weeks before surgery.

Subungal abcesses secondary to paclitaxel.

Various cutaneous side effects, including nail changes, have been associated with taxane chemotherapeutic agents, but usually docetaxel has been implicated. We report a patient with acute paronychia due to paclitaxel administered for treatment of breast cancer.

Chronic paronychia, osteomyelitis, and paravertebral abscess in a child with blastomycosis.

Blastomycosis is an unusual fungal infection in children. It is often a chronic infection characterized by granulomatous and suppurative lesions. Clinical manifestations include either pulmonary findings or disseminated disease. Disseminated blastomycosis usually begins with a lung infection that spreads to the skin, bones, and central nervous system. This is a case report of a child with chronic blastomycosis presenting with chronic paronychia, fever, cough, malaise, and back pain. The child underwent surgical drainage of a paravertebral abscess and administration of intravenous amphotericin B. He was discharged in good condition on oral therapy with ketoconazole. The literature on blastomycosis, with particular emphasis on clinical presentations and management, is reviewed. When the history and physical examination suggest a chronic granulomatous or disseminated disease, such as tuberculosis, the physician must include blastomycosis in the differential.