A 25-year-old man instanted with ac...

A 25-year-old man instanted with aching, swollen, scarlet lesions forward the tips of all 10 fingers (Figure 1) following a three-day prodrome of worsening sharp pain in his thumb little fingers, and lips. His temperature was 382[degrees]C (1008[degrees]F) and he was unable to largely extend his fingers because of throbbing pain. Small, cylindrical crusted lesions resembling recently ruptur blisters lined his lips. rigid pustular lesions surrounded by a bright border of erythema and a certain number of superficial desquamation encircled the fingertips (Figure 2) The patient denied any late trauma or other lesions. No adenopathy was appreciated. His white offspring cell count, blood chemistries, and transaminase plains were within normal limits.

[FIGURES 1-2 OMITTED]

Question

Based onward the patient's history, physical examination, and laboratory ordeals which one of the following is the correct diagnosis?

[] A. Pompholyx

[] B Herpes zoster

[] C Herpetic whitlow.

[] D Endocarditis with Osler's nodes.

[] E Paronychia.

Discussion

The answer is C: herpetic whitlow. Herpetic whitlow is in the differential diagnosis of any patient with a fingertip infection. Positive issues from direct fluorescent antibody proofs and viral cultures from the patient's oral and digital lesions confirmed symbol 1 herpes simplex virus (HSV) infection. Further history revealed that the patient regularly bit his nails.

Herpetic whitlow is an HSV infection of the fingers and toes and may show a primary infection or a secondary resort of type 1 or 2 HSV infection. It come abouts primarily in medical personnel and in patients with herpetic stomatitis. Before the advent of universal precautions, herpetic whitlow occurr predominantly in health care professionals inoculated by the agency of infected patients. (1) The virus is transmitted via saliva, sperm cervical fluid, and active lesions, and repeatedly is introduced through direct contact. (2) Following a short incubation period, painful, coalescing vesicles with surrounding erythema expand The vesicle fluid usually is serous yet may appear purulent in patients with secondary infection. Low-grade heat malaise, and regional lymphadenopathy also may fall out (3) Treatment involves inhibition of viral replication with acyclovir (Zovirax), valacyclovir (Valtrex), or famciclovir (Famvir); symptomatic pain relief; and treatment of bacterial superinfection. The course typically lasts a not many weeks, and healing usually is complete

Pompholyx or dyshidrotic eczema, is a nonspecific reaction pattern of unknown etiology that preferentially affects the palms and sides of the fingers. (4) Painful pruritus leads the appearance of bilateral, symmetrical, clear vesicles that progres to bullae. Desquamation, inflammation, and secondary infection frequently follow. Attacks normally subside spontaneously within sum of two units to three weeks.

Herpes zoster infection ends from reactivation of the varicella zoster virus, which lies dormant in the sensory ganglia after primary infection. While its vesicular lesions bear likeness [i]or[/i] resemblance to those of HSV infections, their tonic distinguishing feature is their distribution. (5) Herpes zoster vesicles typically form a dermatomal distribution over the affected nerve, while HSV vesicles form at the distal [i]finale[/i]s of affected nerves.

Osler's nodes are painful, swollen violaceous subcutaneous nodules occurring mainly in the soft part of the fingers and toes. They are undivided of several cutaneous manifestations of bacterial endocarditis, and are caused through septic emboli from acute bacterial endocarditis or small-vessel perivasculitis in subacute bacterial endocarditis. (6)

Paronychia, a localized infection of the perionychium, may be acute or chronic and is characterized by dint of pain, erythema, and swelling of the posterior or lateral nail flocks and subsequent superficial abscess. Acute paronychia commonly ensues from nail biting or trauma and is typically a mixed infection, with Staphylococcus aureus predominating, whereas chronic paronychia likely portray by actions a multifactorial eczematous condition or fungal infection. (7)

REFERENCES

(1) Jone JG Herpetic whitlow: an infectious occupational hazard. J Occup M 1985;27:725-8

(2) Yeung-Yue KA, Brentjen MH to leeward PC, Tyring SK. Herpes simplex viruses 1 and 2 Dermatol Clin 2002;20:249-66

(3) Spruance SL Overall JC Jr Kern ER Krueger GG Pliam V Miller W The natural history of returning herpes simplex labialis: implications for antiviral therapy. N Engl J M 1977;297:69-75

(4) Crosti C Lodi A. Pompholyx: a still unresolv kind of eczema. Dermatology 1993;186:241-2

(5) Chen TM George s Woodruff CA, Hsu S. Clinical manifestations of varicella-zoster virus infection. Dermatol Clin 2002;20:267-82

(6) Fitzpatrick TB Johnson RA, Wolff K Polano MK Suurmond D ed Color atlas and synopsis of clinical dermatology: usual and serious diseases. 3d ed New York: McGraw-Hill, 1997:623.

(7) Rockwell PG Acute and chronic paronychia. Am Fam Physician 2001;63:1113-6