Paronychia: A soft tissue infection around a fingernail.

causes

• Acute paronychia

o Acute paronychia usually results from a traumatic event, however minor, that breaks

down the physical barrier between the nail bed and the nail; this disruption allows the

infiltration of infectious organisms.

o Acute paronychia can result from seemingly innocuous conditions, such as hangnails,

or from activities, such as nail biting, finger sucking or artificial nail placement.

o Staphylococcus aureus is the most common infecting organism.

o Organisms, such as Streptococcus and Pseudomonas species, gram-negative bacteria,

and anaerobic bacteria are other causative organisms.

• Chronic paronychia

o Chronic paronychia is primarily caused by the yeast fungus Candida albicans.

o Chronic paronychia most often occurs in persons whose hands are repeatedly exposed

to moist environments or in those who have prolonged and repeated contact with

irritants such as mild acids, mild alkalis, or other chemicals.

o People who are most susceptible include housekeepers, dishwashers, bartenders, and

swimmers.

o Other conditions associated with abnormalities of the nail fold that predispose

individuals to chronic paronychia include psoriasis, mucocutaneous candidiasis, and

drug toxicity.

Clinical Features of Acute Paronychia

• The affected area often appears very tender, erythematous and swollen.

• In more advanced cases, pus may collect under the skin of the lateral fold.

• In severe cases, the infection may track proximally under the skin of the finger.

• The fulminant purulence of the nail bed may generate enough pressure to lift the nail off

the nail bed.

Clinical Features of Chronic Paronychia

• Swollen, erythematous, and tender nail folds without fluctuance are characteristic of

chronic paronychia.

• Eventually, the nail plates become thickened and discoloured, with pronounced transverse

ridges.

• The cuticles and nail folds may separate from the nail plate, forming a space for the

invasion of various microorganisms.

Investigations

• The diagnosis of paronychia is primarily based on the features of the history and on the

physical examination findings.

• Full blood picture: leucocytosis

• Erythrocyte sedimentation rate: raised (this is usually not necessary as the diagnosis is a

clinical one)

Management of Paronychia

• Oral antibiotics with gram-positive coverage against Staphylococcus aureus are usually

administered, such as amoxicillin and clavulanic acid (Augmentin) or cloxacillin.

• Soaking the affected digit in hot (but not burning ) water can also be helpful

• If paronychia does not resolve despite best medical efforts, surgical intervention may be

indicated.

• Also, if an abscess has developed, incision and drainage must be performed.

• The most common surgical technique used is called eponychial marsupialization.

• Give analgesics.

Cellulitis

• Cellulitis: An inflammation of the connective tissue underlying the skin.

Aetiology of Cellulitis

• Cellulitis can be caused by normal flora or by exogenous bacteria and often occur where

the skin has previously been broken, cracks in the skin, insect bite, surgical wound or IV

canulla insertion.

Clinical Features of Cellulitis

• Fever, headache and pain of the affected area.

• Cellulitis is characterized by redness, swelling, warmth and tenderness.

• In advanced cases the cellulitis, red streaks may be seen traversing up the affected area.

Investigations

• Full blood picture: leucocytosis

• Erythrocyte sedimentation rate: raised

• Blood culture

Management

• Combination of IV and oral antibiotics

• Analgesics

• Bed rest and elevation of the limb

Pyomyositis

• Pyomyositis: An acute, subacute, or chronic supurative infection of skeletal muscle.

Aetiology of Pyomyositis

• Pyomyositis is often caused by staphylococcus aureus, but trauma, viral infection, and

malnutrition have been implicated.

• Although most cases of tropical pyomyositis occur in healthy individuals, other

pathogenetic factors include nutritional deficiency, immune deficiency and associated

parasitic infection.

• In the temperate climates, pyomyositis is seen most commonly in patients with diabetes,

HIV infection, and malignancy.

Clinical Features of Pyomyositis

• Fever and malaise are common.

• Muscles are painful, swollen, tender, and indurated.

• Quadriceps muscle is involved most commonly.

• The second most common location is the psoas muscle, followed by the upper

extremities.

• Depending on the site of involvement, it may mimic appendicitis (psoas muscle), or

septic arthritis of the hip (iliacus muscle).

• Findings may be subtle in immunocompromised persons requiring a high index of

suspicion for diagnosis.

Investigations and Management Pyomyositis

Investigations

• Full blood picture: leucocytosis

• Erythrocyte sedimentation rate: raised

• Pus swab for culture and sensitivity

• Blood culture and serology for HIV

Management

• Incision and drainage

• Broad spectrum antibiotics

• Analgesics

• Treat underlying cause

 

References

• Das, S. (2008). Concise Textbook of Surgery (5th ed.). India.

• Fraser L., Moore, P., & Kubba, H. (2008, March). Atypical Mycobacterial Infection of

the Head and Neck in Children: A 5-Year Retrospective Review. Otolaryngology – Head

and Neck Surgery, 138(3):311-4.

• Friedmann A.M. (2008, February). Evaluation and Management of Lymphadenopathy in

Children. Pediatric Review, 29(2):53-60.