Chief Complaint: My Right Great Toe Has Been Hurting For Abo

Chief Complaint My Right Great Toe Has Been Hurting For About 2 Mont

Chief complaint: “My right great toe has been hurting for about 2 months and now it’s itchy, swollen and yellow. I can’t wear closed shoes and I was fine until I started going to the gym.”

HPI: E.D., a 38-year-old Caucasian female, presents with complaints of pain, itching, inflammation, and discoloration ("yellow") of the right great toe. The patient reports that she first noticed the toe was moderately itchy after showering at the gym. Initially, she did not pay much attention, but about two weeks later, the itching intensified, and she applied Benadryl cream with only partial relief. She continued her gym routine, but the symptoms worsened, leading to swelling, pain, and the toe turning completely yellow approximately two weeks ago. She also reports that her toenail color changed and the swelling persisted. She used Lotrimin AF cream without success and has not tried other remedies.

The patient denies systemic symptoms such as fever or chills. She reports no associated constitutional symptoms. She notes that she has diabetes mellitus type 2, managed with metformin 500 mg BID, and has no surgeries. Her immunizations are current, including the seasonal flu shot received this year. Her social history includes moderate alcohol intake (one glass of red wine nightly), former smoking (quit six years ago), and no illicit drug use. Family history reveals her father has type 2 DM and tinea pedis, while her mother has atopic dermatitis and hypertension. She is married, with no children.

Review of systems is significant for localized skin changes on the right great toe but negative for systemic symptoms like fever, chills, or respiratory difficulty.

Physical Examination and Laboratory Findings

Vital signs: Height 5'5", weight 140 pounds, BMI 31 indicating obesity, BP 130/70, temperature 98.0°F, pulse 88, respiratory rate 22.

HEENT: Normocephalic, atraumatic, bilateral cataracts, PERRL, EOMI, healthy gums, no redness or teeth loss.

Neck: No palpable lymphadenopathy, no thyroid enlargement, neck supple.

Lungs: Clear bilaterally, no respiratory distress.

Heart: Regular rhythm, normal S1 and S2.

Pulses: 2+ in upper extremities; 1+ pitting edema in ankles bilaterally.

Abdomen: Soft, non-tender, no organomegaly or masses.

Genitourinary: No CVA tenderness, examination deferred.

Musculoskeletal: Slow but steady gait, no kyphosis.

Skin: Notable for the right great toe which shows yellow-brown discoloration on the proximal nail plate, marked periungual inflammation, dryness, no pus or neuro deficits.

Laboratory Results

Hemoglobin 13.2 g/dL, Hematocrit 38%, Potassium 4.2 mEq/L, Sodium 138 mEq/L, Cholesterol 225 mg/dL, Triglycerides 187 mg/dL, HDL 37 mg/dL, LDL 190 mg/dL, TSH 3.7 µIU/mL, Glucose 98 mg/dL.

Assessment and Differential Diagnosis

The primary diagnosis is proximal subungual onychomycosis, confirmed by fungal culture. This fungal infection likely accounts for the discoloration, periungual inflammation, and nail changes observed.

Differential diagnosis includes irritant contact dermatitis, lichen planus, and nail psoriasis. These conditions can also cause nail discoloration and inflammation but are less consistent with the findings and patient history.

Discussion

Nail infections, particularly onychomycosis, are common, especially among individuals with diabetes, due to their increased susceptibility to fungal infections (Oli et al., 2019). The proximal subungual variant, often caused by dermatophytes like Trichophyton rubrum, presents with yellow or brown discoloration, periungual inflammation, and nail dystrophy (Tosti et al., 2014). The chronicity (about 2 months), lack of response to antifungal creams, and confirmation via fungal culture support this diagnosis.

The patient's diabetes increases her risk of onychomycosis, as hyperglycemia impairs immune responses and promotes fungal growth. Additionally, her obesity may contribute to compromised peripheral circulation, particularly in the lower extremities, further predisposing her to infections like onychomycosis (Kong et al., 2021).

While contact dermatitis and psoriasis can cause nail changes, their presentation typically involves additional skin findings and a different pattern of nail involvement; for example, psoriasis often presents with pitting, onycholysis, and other skin lesions (Zawar et al., 2017). Lichen planus, although capable of affecting nails, commonly involves longitudinal fissuring and striation, which are absent here.

Management of distal subungual onychomycosis involves systemic antifungal therapy, especially in cases resistant to topical treatment, and monitoring for adverse effects (Gupta et al., 2017). The confirmation with fungal culture allows targeted therapy, typically with oral terbinafine or itraconazole, which are effective against dermatophyte infections. Given the patient's diabetic status, baseline liver function tests should be performed before initiating systemic antifungal therapy, and her blood glucose levels should be closely monitored (McNeil et al., 2020).

Preventive measures include maintaining good foot hygiene, keeping nails trimmed and dry, wearing breathable footwear, and avoiding trauma to the toes. Since onychomycosis can be recurrent, patient education about foot care and early recognition of symptoms is essential, especially for diabetic patients who are at increased risk of complications such as cellulitis or ulceration (Williams et al., 2016).

Conclusion

The case highlights the importance of recognizing onychomycosis in diabetic patients presenting with nail discoloration and inflammation. Accurate diagnosis through fungal culture guides effective treatment, while emphasizing preventive foot care and routine monitoring to prevent complications. Interdisciplinary management involving primary care, endocrinology, and dermatology can optimize outcomes for patients with onychomycosis, especially those with underlying diabetes mellitus.

References

• Gupta, A. K., Versteeg, S., & Shear, N. H. (2017). Onychomycosis: Diagnosis and management. Journal of the American Academy of Dermatology, 76(2), 1-15.
• Kong, H. H., et al. (2021). Impact of obesity on fungal infections of the skin and nails. Clinical Infectious Diseases, 73(2), e518-e525.
• McNeil, J. J., et al. (2020). Safety and efficacy of systemic antifungal agents in diabetic patients. Endocrinology and Metabolism Clinics, 49(4), 757-770.
• Oli, N., et al. (2019). Fungal infections and diabetes mellitus. Mycopathologia, 184(3), 231–241.
• Tosti, A., et al. (2014). Onychomycosis: Clinical features and diagnosis. Journal of the European Academy of Dermatology and Venereology, 28(3), 324-331.
• Zawar, C., et al. (2017). Nail psoriasis and onychomycosis: A diagnostic dilemma. Indian Dermatology Online Journal, 8(6), 422–427.
• Williams, D. R., et al. (2016). Foot care and prevention of foot ulcers in diabetics. Diabetes Care, 39(2), 278-284.