Recurrent Pus Filled Nail Bed

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Hello all
I would appreciate some advice on a patient please go easy on me!
Brief Medical History: Type II diabetic, poorly controlled with insulin. Atrial Fibrillation, history or 2-3 MIs.
Pedal pulses biphasic, no neuropathy.

Both 1st toe nails have lifted, and the nail beds initially appeared granulating and healing well. As soon as part of one heals however, there develops a pocket of thick white pus on the nail bed. Lance it, debride it, nice granulating base, heals well, but another pocket of fluid appears else where.
This is an ongoing problem and I don?t know the cause! Repeating Swabs always negative.

On xray there is a loss of clarity to the tip of the left distal phalanx raising the possibility of osteomyelitis. This was reviewed by consultants and they had no concern.
There is also a small exostosis but this is away from the nail bed and is unlikely to be the cause.

This patient seems to heal well but for some reason there is recurrent ?blistering? with this thick white fluid (sort of thing you might see with a gouty joint ? but no hx of gout anywhere)

Any thoughts on what might be causing this?

Many Thanks in advance

 

My first guess would be osteomyelitis due to the osteolysis of the distal phalanx, no matter what your consultants say. An MRI scan would demonstrate this more clearly than a plain film radiograph. The patient might heal fastest with a surgery to excise the distal half of the distal phalanx since this is probably where the exudate is coming from.