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Herpetic whitlow is a viral infection of the fingers or toes caused by the herpes simplex virus. Herpes simplex virus is a common pathogen that causes infections in any cutaneous or mucocutaneous surface, most commonly gingivostomatitis or genital herpes. However, infection of the digits is also infrequently reported. Herpetic whitlow occurs when the virus infects the distal phalanx of the fingers or toes by means of direct inoculation, causing pain, swelling, erythema, and vesicle formation. The proper diagnosis is important because the condition can mimic various other podiatric abnormalities such as paronychia, bacterial cellulitis, or even embolic disease. Improper diagnosis often leads to unnecessary work-up, antibiotic therapy, or even surgical intervention. This case will help illuminate the clinical presentation of herpetic whitlow in an atypical location, and the patient’s subsequent treatment. We present an atypical case of right hallux herpetic whitlow with delayed diagnosis and associated cellulitis. The patient was admitted after seeing multiple providers for a progressive right hallux infection that presented as a mixture of vesicular lesions and apparent cellulitis. His history was positive for biting his fingernails and toenails, and the lesions were noted to be honeycomb-like, with minimal drainage. The lesions were then deroofed and viral cultures were obtained, which were positive for herpes simplex virus type 1, thus confirming a diagnosis of herpetic whitlow. Although he remained afebrile with negative wound cultures during admission, a secondary bacterial infection could not be excluded because of his nail avulsion and surrounding cellulitis. He was discharged on oral antibiotics, antivirals, and wound care recommendations. Herpetic whitlow should be included in the differential diagnosis of pedal digital lesions that appear as vesicular or cellulitic in the pediatric population.
Antibiotic Stewardship
The Lower-Extremity Physician's Prescription for Effectively Treating Infection
The discovery of antibiotic drugs was one of the most significant medical achievements of the 20th century. The improper use of antibiotic drugs to prevent and treat infections has resulted in the emergence of resistance. Antimicrobic stewardship programs are becoming a mainstay in the fight against multidrug-resistant organisms. Individual clinicians should be encouraged to adopt the principles of antibiotic stewardship when treating lower-extremity infections in their scope of practice. First, a review of the available literature outlining the concept and practice of antibiotic stewardship is offered. Second, a discussion describing how to adopt and apply these principles to the individual clinician's practice as it applies to lower-extremity infections is offered. Finally, specific antimicrobial pharmacologic spectra and antibiogram information are offered.
Background: Fungal foot infection is a common superficial fungal infection and is recognized as an important public health problem. Related to the wearing of occlusive footwear, foot infection is usually caused by dermatophytes and nondermatophyte molds. Previous in vitro studies have demonstrated that zinc oxide nanoparticles (ZnO-NPs) have antimicrobial activity against fungi. This study, therefore, evaluated the ability of socks coated with ZnO-NPs to inhibit fungal growth in an in vitro model mimicking real-life situations.
Methods: Scale from patients with fungal foot infections was equally divided into three groups: control, plain socks, and ZnO-NP socks. The specimens in the control group were routinely fungal cultured, whereas in the plain sock and ZnO-NP sock groups, scale was incubated with plain socks and ZnO-NP socks, respectively, for 24 hours. After incubation, each piece of sock was cultured. The fungal culture results of the three groups were progressively evaluated for 4 weeks.
Results: From 31 specimens, the positive fungal culture results of the control, plain sock, and ZnO-NP sock groups were 100%, 64.5%, and 54.8%, respectively. Specimens incubated with plain socks (P = .001) or with ZnO-NP socks (P < .001) had a significant reduction in the number of positive fungal cultures compared with the control.
Conclusions: Plain socks and ZnO-NP socks significantly inhibited fungal growth relative to the control. The wearing of either plain socks or ZnO-NP socks can prevent fungal foot infection because these socks act as a barrier to the insoles of shoes.
The Diagnosis of Onychomycosis in a Geriatric Population
A Study of 450 Cases in South Florida
An investigative study was performed to determine the diagnosis of onychomycosis in a South Florida geriatric population. In this study, 450 cases of suspected onychomycosis involving men and women 65 years of age and older from a private practice office and two nursing home settings were used. Samples were taken from the hallux toenail and sent to a mycology laboratory for fluorescent potassium hydroxide (KOH) preparation and microscopic examination of a fungal culture. Of the 450 cases studied, 46.4% of the patients had a single fungal organism cultured, 30.4% had a mixed fungal infection cultured, and 23.1% had no fungal growth. Saprophytes were found in 59.9% of the 526 total fungal organisms cultured while dermatophytes were found in only 23.8%. The results of this investigation demonstrate that there may be a shift from isolated dermatophyte infection to mixed saprophyte infections in a geriatric population with onychomycosis. (J Am Podiatr Med Assoc 91(9): 456-464, 2001)
Streptococcus anginosus (SAG) is a known human pathogen and member of the Streptococcus milleri group. SAG is a known bacterial cause of soft-tissue abscesses and bacteremia and is an increasingly prevalent pathogen in infections in patients with cystic fibrosis. We describe a rare case of SAG as an infectious agent in a case of nonclostridial myonecrosis with soft-tissue emphysema. This is the only case found in the literature of SAG cultured as a pure isolate in this type of infection and was associated with a prolonged course of treatment in an otherwise healthy patient.
Stevens-Johnson syndrome and toxic epidermal necrolysis are rare; however, when they occur, they usually present with severe reactions in response to medications and other stimuli. These reactions are characterized by mucocutaneous lesions, which ultimately lead to epidermal death and sloughing. We present a unique case report of Stevens-Johnson syndrome and associated toxic epidermal necrolysis in a 61-year-old man after treatment for a peripherally inserted central catheter infection with trimethoprim-sulfamethoxazole. This case report reviews a rare adverse reaction to a commonly prescribed antibiotic drug used in podiatric medical practice for the management of diabetic foot infections. (J Am Podiatr Med Assoc 100(4): 299–303, 2010)
Most fungal infections primarily occur in immunocompromised patients. We describe a case of osteomyelitis involving the first metatarsal head due to Cryptococcus neoformans in a previously healthy immunocompetent patient. She was treated with surgical debridement combined with antifungal drug therapy for 6 months. At 5-year follow-up, she remained symptom free with full range of motion of the first metatarsophalangeal joint. Fungal osteomyelitis should be considered as a possible cause in osteolytic lesions in the metatarsal bone.
Acute rheumatic fever is a delayed inflammatory disease that follows streptococcal infection of the throat. Poststreptococcal reactive arthritis is a sterile arthritis associated with antecedent streptococcal infection in patients not fulfilling the Jones criteria for acute rheumatic fever. Poststreptococcal reactive arthritis has been reported to have lower-extremity predominance and, therefore, should be included in the differential diagnosis of patients with lower-extremity arthritis. A review of the literature, distinguishing poststreptococcal reactive arthritis from acute rheumatic fever, and treatment options are discussed here. A case report is also presented. (J Am Podiatr Med Assoc 96(4): 362–366, 2006)
Background:
This study investigated the resistance of bacteria isolated from diabetic foot ulcers (DFUs) to antibiotics frequently used in the management of the diabetic foot infections, at a range of pH values (pH 6.5, 7.5, and 8.5) known to exist in DFU wound fluid. This study aimed to determine whether changes (or atypical stasis) in wound fluid pH modulate the antibiotic resistance of DFU isolates, with potential implications in relation to the suppression/eradication of bacterial infections in DFUs.
Methods:
Thirty bacterial isolates were recovered from DFU wound fluid, including Staphylococcus spp, Staphylococcus aureus, Escherichia coli, Streptococcus spp, Pseudomonas spp, and Pseudomonas aeruginosa. The resistances of these isolates to a panel of antibiotics currently used in the treatment of infected or potentially infected DFUs, ie, ciprofloxacin, amoxicillin-clavulanate, doxycycline, and piperacillin-tazobactam, at the previously mentioned pH values were determined by a modification of the Kirby-Bauer assay.
Results:
The resistance of DFU isolates to clinically relevant antibiotics was significantly affected by the pH levels in DFU wound fluid.
Conclusions:
These findings highlight the importance of a more comprehensive understanding of the conditions in DFUs to inform clinical decision making in the selection and application of antibiotics in treating these difficult-to-heal wounds. The scale of the differences in the efficacies of antibiotics at the different pH values examined is likely to be sufficient to suggest reconsideration of the antibiotics of choice in the treatment of DFU infection.
Background: Transmetatarsal amputations are limb salvage surgical procedures that preserve limb length and functional ankle joints. Indications for transmetatarsal amputations include forefoot trauma, infection, and ischemia. Prior research demonstrates patients who undergo transmetatarsal amputations have a lower 2-year mortality rate compared to those who undergo more proximal amputations. The aim of this study was to determine whether primary closure of a transmetatarsal amputation is a superior treatment compared to secondary healing of a transmetatarsal amputation for forefoot abnormality of infection, gangrene, or chronic ulceration.
Methods: A retrospective chart review was performed on patients aged 18 years or older requiring a transmetatarsal amputation because of forefoot abnormality between September of 2011 and December of 2019. Foot and ankle surgeons performed transmetatarsal amputations. Outcome variables measured included healing time of transmetatarsal amputation site, recurrent infection, recurrent gangrene, and the need for revision surgery or higher level amputations.
Results: Of the original 112 patients, 76 met the inclusion criteria; 47 of these had primary closure of transmetatarsal amputation and 29 of these had an open transmetatarsal amputation performed. Primarily closed transmetatarsal amputations resulted in a significantly greater overall healing rate of 78.8% (37 of 47) compared to open transmetatarsal amputations, with a healing rate of 37.9% (11 of 29) (P < .01). Closed transmetatarsal amputations were statistically significantly less likely than open transmetatarsal amputations to have recurrent gangrene, require revision pedal operations, or progress to higher level amputations.
Conclusions: Our research demonstrated that primary closure of transmetatarsal amputations is a superior treatment compared with secondary healing of transmetatarsal amputations in specific cases of infection, dry gangrene, or chronically nonhealing ulcerations.
