Introduction
E.D, a 38-year-old Caucasian female, presents with a complaint of pain, itching, inflammation, and yellow discoloration of her right great toe. She first noticed moderate itching after taking a shower at the gym, but did not pay much attention to it. Over the course of two weeks, the itching became intense and she applied Benadryl cream for relief, with only partial success. She continued going to the gym and observed that the itching worsened, and her toe nail started to change color. Additionally, the toe became swollen, painful, and turned completely yellow two weeks ago. She tried using Lotrimin AF cream, but it did not alleviate her symptoms. She denies associated symptoms of fever and chills.
Medical History
E.D has a history of type 2 Diabetes Mellitus and is currently taking Metformin 500mg PO BID. She is a college graduate, married, and has no children. She consumes one glass of red wine every night with dinner. She is a former smoker, having quit six years ago. Her father has a history of type 2 Diabetes Mellitus and Tinea Pedis, while her mother has a history of atopic dermatitis and hypertension.
Physical Examination
Constitutional: Negative for fever and chills.
Respiratory: No shortness of breath or orthopnea.
Cardiovascular: Regular rhythm observed.
Skin: The right great toe is swollen, itchy, painful, and discolored.
Psychiatric: No anxiety or depression.
Height: 5 feet 5 inches.
Weight: 140 pounds.
BMI: 31, indicating obesity.
Blood Pressure: 130/70.
Temperature: 98.0 degrees Fahrenheit.
Pulse: 88 beats per minute.
Respiratory Rate: 22 breaths per minute, non-labored.
Head: Normocephalic/Atraumatic, bilateral cataracts present. Pupils are equal, round, and reactive to light. Extraocular movements are intact. No tooth loss observed, with no redness of the gums.
Neck: Supple, no palpable masses, no lymphadenopathy, and no thyroid enlargement.
Chest: No crackles, clear lungs bilaterally. Equal breath sounds, symmetrical respiration, and no signs of respiratory distress.
Cardiovascular: Normal S1 with S2 during expiration. Pulses are 2+ in upper extremities. 1+ pitting edema in ankles bilaterally.
Abdomen: No distention, nontender. Bowel sounds present in all four quadrants. No organomegaly observed. Normal contour with no palpable masses.
Renal: No costovertebral angle tenderness bilaterally. Genitourinary examination deferred.
Musculoskeletal: Slow but steady gait observed, with no kyphosis. Right great toe shows yellow-brown discoloration in the proximal nail plate. Marked periungual inflammation and dryness, but no pus or neurological deficits.
Psychiatric: Normal affect observed, and the patient is cooperative.
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.
Thyroid-stimulating hormone (TSH): 3.7 mIU/L.
Glucose: 98 mg/dL.
Differential Diagnosis
Based on the patient’s history and physical examination findings, the differential diagnosis includes proximal subungual onychomycosis, irritant contact dermatitis, lichen planus, and nail psoriasis.
Proximal subungual onychomycosis is a fungal infection that affects the nail plate, nail bed, and proximal nail fold. It is commonly caused by dermatophytes and can lead to discoloration, thickening, and deformity of the nail. It typically occurs in immunocompromised individuals, such as those with diabetes, and can be diagnosed through fungal cultures or microscopy.
Irritant contact dermatitis is a non-allergic skin reaction caused by direct contact with an irritating substance. Symptoms include itching, redness, and swelling of the affected area. In this case, it could be caused by exposure to chemicals or moisture at the gym.
Lichen planus is an inflammatory skin condition that can affect the nails, skin, hair, and mucous membranes. It presents as itchy, flat-topped, purplish lesions and can cause nail abnormalities such as pitting, ridges, and thinning. The exact cause is unknown, but it is thought to be an autoimmune disorder.
Nail psoriasis is a chronic autoimmune disease that affects the nails, skin, and joints. It can cause pitting, crumbling, and discoloration of the nails. In this case, the patient’s history of psoriasis and nail changes suggest the possibility of nail psoriasis.
Further evaluation, such as fungal cultures, histopathology, or rheumatological tests, may be needed to confirm the diagnosis. Treatment options will depend on the underlying cause and may include antifungal medications, topical corticosteroids, or systemic therapy. Close monitoring of the patient’s blood glucose levels and education on foot care will also be important due to her history of diabetes.
