Case 5: Paronychia?
Monday, January 24th, 2011One of your more junior staff asks for your help with this young man with very painful lesions of his right thumb and index finger. The junior doctor believed that these were paronychiae and has undertaken several incisions, using Ring blocks for anaesthesia. Only serous fluid was obtained.
1. What is the diagnosis?
Click to see the answerThis is primary infection with herpes simplex, commonly known as herpetic whitlow. This causes exquisitely tender vesicular lesions, usually of one or more fingertips. The majority of infections are with herpes simplex type 1, but a significant minority are due to type two infections (genital herpes type). The virus is thought to penetrate through minor breaks in the skin, particularly of the nail folds.
2. Which patient groups are affected?
Click to see the answerThree groups are principally affected:
a. Young children. This is usually as a result of auto-inoculation from primary herpetic stomatitis.
b. Healthcare workers, who have had contact with oral secretions, without gloves. The infection can be caught from cases of primary herpetic stomatitis, or from recurrent cases (‘cold sores’). Historically it has been a particular hazard for dentists.
c. General public. Most cases which do not fall into the about two categories are due to infection with genital herpes (HSV2).
3. What is the treatment?
Click to see the answer3. The condition is self limiting, but either topical or oral acyclovir, speed recovery. De-roofing vesicles may improve symptoms, but formal incision should be avoided.