Rosh Review A1.2

Q. A 39-year-old woman presents to the ED complaining of pain and swelling to her distal index finger. On exam, you note her finger as seen in the below image. There is mild tenderness and full range of motion at the distal interphalangeal joint. Which of the following is the most likely diagnosis?

A. Eponychia

B. Felon

C. Herpetic whitlow

D. Paronychia

The lesion seen above is a herpetic whitlow, secondary to herpes simplex infection. This is the most common viral infection of the hand. It is usually caused by direct inoculation of the virus into an open wound or broken skin. It is often reported in adult women who also have genital herpes, children with coexistent herpetic gingivostomatitis, and healthcare workers who are exposed to orotracheal secretions. The infection usually involves a single finger and begins with localized pain, pruritus, and swelling, followed by the appearance of clear vesicles. Systemic symptoms are usually absent. But, secondary bacterial infection of the vesicles can occur. Over two weeks, the vesicles coalesce to form an ulcer, at which time the lesion may be difficult to distinguish from other common finger infections, such as a felon or paronychia. The lesions will resolve spontaneously over 3 to 4 weeks. The lesions should be kept covered. The role of oral acyclovir is not clear in immunocompetent individuals, but should be administered in the immunocompromised and those with recurring infections.

An eponychia (A) is a localized soft tissue infection, similar to a paronychia (D), but occurs under the eponychium aspect of the nail. Both present with a swelling, erythema, and tenderness at the respective nail fold. A felon (B) is an infection of the fingertip pulp. The main difference between this finger infection and others is the fingertip is separated into small closed spaces by vertical septae. Infection can easily spread along these compartments.

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