A 4-year Old Girl With an Acutely Inflamed Toe

CASE A 4-year old girl presented with an antalgic gait involving her right foot. She was afebrile and otherwise completely well. There was no history of trauma or bite injury. She lived in Edmonton, AB, and was previously healthy with no travel outside of Canada in the preceding year and no history of exposure to tuberculosis. Plain radiographs suggested a Salter Harris II fracture of the proximal phalanx of the right third toe. She was managed with tape immobilization. Over the following 8 days, her symptoms progressed with increased pain and redness over the right third toe, so she presented to an emergency department. Her temperature was 36.6°C, heart rate was 69 beats/minute, respiratory rate was 20 breaths/minute and oxygen saturation was 97% in ambient air. Physical examination now revealed erythema and redness over the toe. White blood cell count was 10 × 109/L, erythrocyte sedimentation rate was 10 mm/h and C-reactive protein was 3.6 mg/L (all within the normal range). A repeat plain radiograph revealed an aggressive lytic lesion at the base of her right third proximal phalanx, suggestive of acute infection (Fig. 1). She was referred to the pediatric infectious disease clinic, and a diagnosis of presumptive osteomyelitis was made. She was emperically treated with oral cephalexin as an outpatient for the most likely pathogens, including methicillin-susceptible Staphylococcus aureus and group A streptococcus. However, over the subsequent 3 days, she had worsening pain and swelling with abscess formation over the third proximal phalanx and extending to the third metatarsal (Fig. 2). She was hospitalized, and the abscess was debrided in the operating room. The Gram stain revealed 3+ polymorphonuclear cells while bacterial culture showed no growth. There was inadequate specimen for pathologic examination.FIGURE 1: Plain radiograph of right third toe on day 8 of symptoms.FIGURE 2: Photograph of right third toe on day 11 of illness course.Following improvement in her pain, the patient was discharged on intravenous cefazolin therapy through a peripherally inserted central catheter. Despite compliance with this therapy, she returned to the orthopedic clinic 14 days later with persistent erythema, increased pain and swelling and purulent drainage at the same location. She remained systemically well and afebrile. Multiple tests of her peripheral white blood cell and C-reactive protein were normal. A second incision and drainage was performed in the operating room, and additional studies revealed the diagnosis.

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