Abstract
Paronychia is an inflammation usually involving the lateral and proximal nail folds. It may be acute (lasting six weeks or less) or chronic (lasting longer than six weeks). There are multiple predisposing factors such as trauma, ingrown nail, peripheral arterial disease (PAD), and diabetes mellitus (DM). Acute paronychia is typically caused by bacteria such as Staphylococcus aureus, Streptococcus pyogenes, and Pseudomonas aeruginosaas well as other serotypes of Gram-negative bacteria. The treatment usually consists of local measures such as hot compresses, broad spectrum topical antibiotics, and oral antibiotics like Penicillin derivatives including Amoxicillin or cephalosporins like Cephalexin. Nonhealing of paronychia is frequently encountered by patients with predisposing factors such as PAD and DM1.
Introduction
PAD is due to atherosclerosis which causes the accumulation of lipids and fibrous material. This accumulation ends up deposited in the layers of the arterial wall, leading to a narrowing of the affected artery. The process of atherosclerosis may affect any artery in the body including aorta, coronary, cerebral, renal, etc. The symptoms of atherosclerosis depend on the site of involvement. PAD results in diminished blood supply to the tissue of the lower extremities leading to symptoms of claudication, the presence or absence of which depends on the degree of involvement and the patient’s activity level2.
PAD may affect macro – and microcirculation. The main arteries involved in macrocirculation are anterior and posterior tibial, peroneal artery, and dorsalis pedis. Non-pulsatile arterioles within the skin capillary bed are a part of microcirculation. Patients with PAD may be symptomatic or asymptomatic. Claudication is a typical symptom consisting of lower extremity pain with exertion that subsides or improves with rest. In addition to a detailed physical examination, including visual inspection of the lower extremity and palpation to detect the peripheral pulses, additional non-invasive testing can be performed. Resting Ankle Brachial Index (ABI) is calculated by dividing the ankle pressure by the systolic brachial pressure. ABI below 0.9 is abnormal and suggestive of PAD. A normal or elevated ABI is sometimes misleading in patients with diabetes. A falsely elevated ABI can be due to calcification in the arterial wall. Toe Brachial Index (TBI) can be used in diabetic patients that may have a falsely elevated ABI because the smaller arteries in toes are less likely to become calcified. TBI is systolic blood pressure of the hallux divided by the systolic brachial pressure, this test is less commonly used3. Several imaging modalities using contrast material are also being used for better anatomic visualization of the peripheral arterial microcirculation.
Several clinical entities constitute significant risk factors for development of PAD. They include a history of smoking, hypertension, dyslipidemia, and diabetes mellitus. DM is a significant independent risk factor for future development of PAD4.
Case Report
An 82-year-old man presented to his cardiologist with a paronychia of the left hallux of at least two-three weeks duration following a minor trauma of the toe. Co-morbidities include congestive heart failure, chronic atrial defibrillation, DM type 2, PAD, and sixty pack-year history of cigarette smoking and having quit smoking five years ago. His medications include Furosemide for congestive heart failure, Warfarin for chronic atrial defibrillation, Glipizide for DM type 2, Cilostazol for PAD, and Amlodipine for hypertension. Routine laboratory testing revealed HbA1Cof 9.9 indicating poor diabetic control, Beta natriuretic peptide (BNP) level of 859 consistent with cardiac decompensation and BUN/Creatinine levels of 68 and 2.8 respectively, consistent with chronic kidney disease and pre-renal azotemia. The arterial ultrasound and ABI were consistent with PAD and diffuse plaque formation. ABI was 0.86 right leg and 0.56 left leg, suggestive of moderate PAD on the right leg and severe PAD of the left leg.
Patient was referred to a podiatric physician who instructed the patient to use warm compresses. He was prescribed Gentamicin ointment and oral Amoxicillin/clavulanic acid, and local excision and drainage of pus. After two-three weeks nonhealing was noted and the podiatric physician decided to proceed with a complete nail avulsion. Local and oral antibiotics were continued for a few weeks. The inflammatory process continued and nonhealing was further noted.
It was felt that unless blood flow to the left foot improved, patient may face amputation of the hallux. He was referred to a vascular surgeon and underwent CO2angiography revealing significant disease of the distal arterial system of the left leg/foot. Subsequently patient underwent angiography/angioplasty and stent deployment. Currently, post-procedure dorsalis pedis and tibialis posterior pulses are palpable and detectable by doppler. The left hallux appears less ischemic. Edema and erythema appear remarkably reduced. The amount of pus is also significantly reduced.
Figure 1. Nonhealing of the left hallux after a complete nail avulsion was performed.
Conclusion
This patient presented with a nonhealing paronychia of the left hallux, following alleged minor trauma. Nonhealing was noted as a result of significant PAD documented by remarkably reduced ABI bilaterally and especially on the left side. Patient failed conservative treatment consisting of local measures such as warm compresses, antibiotic ointment, and oral antibiotics. The patient eventually underwent a complete nail avulsion. He had multiple risk factors for the development of PAD including smoking, hypertension, and diabetes mellitus. After successful revascularization, the healing process has begun and the patient is exhibiting ongoing improvement. It appears the need for amputation has been averted.
References
1. Beth Goldstein, MD, Adam Goldstein. MD, Antonella Tosti, MD Paronychia. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on January 2, 2019.)
2. Jeffrey Berger, MD, Mark Davies, MD. Overview of lower extremity peripheral artery disease. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on January 2, 2019.)
3. Kazu Suzuki, DPM, Osami Kawarada, MD. Keys to diagnosing peripheral arterial disease. Podiatry Today. 2012; 27(7):84-92.
4. Jeffrey Berger, MD, Jonathan Newman., MD. Overview of peripheral artery disease in patients with diabetes mellitus. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on January 2, 2019.)