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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!

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

 

M/S, obviously might be helpful. Just because you haven't demonstrated sensory neuropathy doesn't mean it not implicated. Filaments and vibration testing are not fool proof. Say to yourself would this be painful to me and I think it probably would be. (Blisters always hurt me). So look at the fit of the footwear and other situations when trauma could insidiously occur.
Regards
Ros

 

Hiya,

if possible a photo would be great!
I'm assuming that no part of the nail is aggravating the nail bed itself either due to direct pressure or via nail spicule. Have you taken a swab for culturing purposes? Possibly candidal onychomycosis?

Just my thoughts without a visual aid :)

Paul.

 

Many thanks for your replies

@ Ros Kidd. Pt currently in Darco boots. Tried to eliminate dorsal pressures with these. Ofcourse I cant account for the time she isnt in clinic although seems quite compliant.
Can you clarify what M/S is referring to?

@ Quirkyfoot. Swabs for MC+S mostly clear. Occasional Staph infection treated with abx.
Getting photos at the moment is difficult but I will endeavor to load a photo when possible. There is an ongoing information governance issue that is trying to be resolved.
There is no nail present on either nail bed. They came off before I started seeing this lady.

Kevin Kerby did post a reply which now seems to be deleted. Next step is to get another xray to monitor OM. Possible MRI if I can convince someone to authorise it

Thanks again for your input

 

I have no idea why my post was deleted. I didn't do it. Why even bother to post good, clinical responses to queries here on Podiatry Arena if they are going to be deleted??!!:butcher:

 

OK, I'll say it again and see if Podiatry Arena keeps my post up for everyone to view or not this time. The patient has osteolysis of the distal phalanx and a chronically draining nail bed, which just so happens to be right on top of the distal phalanx. The "consultants" have "no concern" about osteomyelitis of the distal phalanx. Why? I don't have a clue.

You need to assume this is osteomyelitis regardless of what the consultants believe or don't believe. Unless you do an MRI or preferably a bone biopsy, you will never know if they have osteomyelitis of the hallux distal phalanx or not. If it is osteomyelitis, the longer you wait, the more likely the patient will need more of their big toe surgically removed than if you actually became more aggressive in your treatment.

Check out Robert Christman's webpage on differential diagnosis of distal phalanx radiographic abnormalities, it's very good. http://footrad.com/NailsOther.html

 

My post also was deleted.
M/S = Microscopy and sensitivities. Often useful to repeat this if you are seeing the pt in a hospital setting.
Getting a more productive history now and my DDx would include OM which needs aggressive antibiotics. Her poor BSL level control needs to be addressed.
Ros