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short case history.. 24 yoa caucasian female excellent heath and hygiene. 4 weeks ago went to an urgent care with edematous third left toe, red, painful. they x rayed it gave her keflex 500 mg qid, ibuprofen 800 mg. no follow up x rays negative.. patient to me a week later. evaluate all systems unremarkable no meds no issues of any kind.. skin intact on left foot. no nail issues. Toe red stiff swollen cellulitic in appearance.. change medications to dicloxacillin, lab for cbc sed rate all normal, after three days toe not improved, switch back to keflex slight improvement.. then rx indocin 75 sr qd then after a week it is 80% improved.. patient dc indocin and after three days pain edema increase... patient seen, films again negaitve, and given rx indocin again and labs for sed rate RA factors, hlab, uric acid, others comprising arthritic panel .. so far half of them reported and all normal ... hunch was gout. patient called not improving did not fill rx for indocin until today. Just to see I sprayed toe with ethyl chloride and it reduced to normal size and range of motion. returned to previous state in 5 minutes. no antibiotics now for two weeks. will see in 48 hours response to indocin75sr.. any ideas!?? ran this past a fellow pod ,, he suggested everything I tried.
Infection/gout/arthritis/ ????/ I once in 35 years saw a osteo blood borne etiology looked like this but films negative on this, as is everything else. non drinker vegan. new and only post..............listening

 

Psoriatic arthritis?

 

hi
Is the sensation ok?
a neuroma?

 

not anything like a neuroma.. arthritis of some type my quess.. looks like a red sausage toe.

 

Various causes of sausage toe/dactylitis here, but psoriatic is most common one I've seen

http://www.dermnetnz.org/reactions/dactylitis.html

 

hi
not a bite of any kind?

she could try antihistamines as last resort.

thanks
anthony

 

My immediate thought on that description was Psoriatic arthritis so I concur with Ian's suggestion. I have seen a few cases with just a single digit affected with dactylitis which have been referred to Rheumatology and PA has been confirmed. NB I think I'm right in saying there doesn't have to be associated skin lesions, though there often is.

 

https://www.psoriasis-association.o.../treatments-for-psoriatic-arthritis/diagnosis

 

In the absence of a pic, I`m with Drakard `n Ella; Ps Arthritis, tho` I`d be interested to hear the reported uric acid levels....

 

I'm going PA too.

 

Inflammatory arthritis.

 

If there is swelling plantarly at the metatarsophalangeal joint then you should also rule out an acute plantar plate tear since these can make the whole toe become swollen for over a month or two.

 

Hi
Did you say that a follow up xray had been done?
Just sometimes small fractures are not seen at the acute stage and a follow up will usually show cancellous bone formation if it was a fracture.

Regarding inflammation from PA would this not show elevated inflammatory markers - CRP and ESR levels.

Don't know were you are but MRI may be needed to rule out any nasty stuff

Good luck with the patient
Ed:D

 

Well you're full of surprises "Ed", aren't you?

Your post had me reaching for my Big Boys Book of Rheumatology:D in double-quick time, just to see if I'd missed anything.
Nope. The two common causes for the presentation of a single swollen digit are psoriatic arthropathy (common-ish) and Reiters Syndrome (much less common, and the epidemiological distribition is all wrong for this patient).
Kevin has made a good point though.

So I stand by my PA, with Kevins acute plantar plate tear as a sideline, and a chigger infection as a wide outside possibility.

 

Hi, any history of gastroenteritis or conjunctivitis type pathologies, seen a case of Reiters once, as it was a single digit involved we initially thought infection etc!

Cheers
Barty

 

Ha Ha david just don't drop the book on your toe!

Sometimes we look for diagnosis and chase after problems.
Problem is we have no picture to help.
Has she been off loaded as could try air boot with weekly review?

the differential diagnoses is still acute and kevs planter tear fits this not sure about PA though.
what would be your treatment plan for PA david?
thanks
Ed