CUTANEOUS LESIONS IN A 4-YEAR-OLD GIRL: CASE PRESENTATION

1. CUTANEOUS LESIONS IN A 4-YEAR-OLD GIRL: CASE PRESENTATION Dunja Delevska PMS-4 New York College of Podiatric Medicine February 2013

2. OUTLINE • Presentation • Initial treatment • Laboratory work-up • Final treatment

3. PRESENTATION 4-year-old girl presents to ED accompanied by grandmother with cc of three-day history of right toe pain Patient was in ED 2 days prior Vesicles incised and drained / D/c on Keflex PMH: asthma exacerbation 1 month ago PSH: denies Meds: none Allergies: NKDA FHx: non contributory SHx: Patient lives in NY home shelter with grandmother

4. PRESENTATION(CONT.) • Erythema, edema and pain on palpation • Multiple serous filled vesicles and bullae • Lateral nail border onychocryptosis  partial hallux nail avulsion • D/c with Clindamycin

5. 2 days later… • No improvement in pain and symptoms • Grandmother reports systemic signs of infection including fever, loss of appetite, and vomiting • Patient’s grandmother is not allowing collection of wound cultures

6. ADMISSION • IV Clindamycin • Application of Clotrimazole cream twice daily

7. 2 days after admission… • No improvement in symptoms and clinical appearance • Clindamycin was discontinued • Zosyn and Bactrim were started

8. 3 days after admission… • No improvement of symptoms and worsening clinical appearance • Aerobic and viral cultures were obtained • Clotrimazole application was replaced with topical Acyclovir (applied five times daily)

9. 5 days after admission… • Clinically the vesicles and bullae began to resolve with epithelialized crusts • Painful edema and erythema resolved • partial nail avulsion is healing uneventfully

10. Laboratory Results • Wound cultures sterile • Viral cultures positive for Herpes Simplex Virus Type 1 • FINAL DIAGNOSIS: Herpetic Whitlow

11. FINAL TREATMENT • Bactrim was discontinued • Seven day course of Zosyn was completed • Topical Acyclovir was continued • Daily oral Acyclovir was initiated

12. 9 days after admission… • Clinical signs and symptoms continue to improve • D/c home with a prescription for oral Acyclovir to be taken daily for five days

13. 1 month follow-up… • Continues to do well with no present reoccurrences

14. SUMMARY • Vesicles on an erythematous base should raise suspicion of potential viral infection • If initial treatment is not yielding satisfactory results • reconsider the diagnosis • change the treatment • When possible, treatment should be guided by wound culture results