Skier €™s toe: traumatic onycholysis complicated by Pseudomonas chloronychia

 

Nicholas Matheson, Michael Weekes, Sian Coggle

Nicholas Matheson, nicholas.matheson@addenbrookes.nhs.uk

Published 20 August 2009

One of the authors suffered €œblack toe € on a skiing trip.1 Vigorous fore-aft movements of the feet caused the halluces to strike repeatedly the ends of the ski boots resulting in recurrent micro-trauma and, eventually, subungual haematoma formation and onycholysis. Examination 3 months later revealed the nail of the right hallux to have developed a green discolouration accompanied by non-tender paronychia (fig 1). Microscopy and culture of nail cuttings for fungi were negative but a swab from the nail bed grew Pseudomonas aeruginosa.

Figure 1A and B Green discolouration of the nail of the right hallux caused by traumatic onycholysis and secondary infection by Pseudomonas aeruginosa. Residual staining of the contralateral hallux by subungual haematoma reveals the trauma to have occurred approximately 100 days previously (assuming nail growth of 0.5 mm every 10 days).

Green nail syndrome, or chloronychia, is typically associated with nail infections caused by P aeruginosa.2 The same green colouration may be exhibited by colonies of P aeruginosa grown on agar (fig 2) and results from production of the diffusible pigments pyoverdin and pyocyanin.3 Treatment options for Pseudomonas chloronychia include trimming the affected nail and applying topical astringents and antibiotics or, as in this case, systemic treatment with an oral quinolone.


Figure 2 A and B Colonies of Pseudomonas aeruginosa on CLED agar showing the same characteristic green pigmentation.

P aeruginosa is a ubiquitous opportunistic pathogen favouring warm, moist environments. Onycholysis results in disruption of the hyponychium (the region immediately beneath the free edge of the nail), which normally forms a tough, waterproof barrier protecting the nail bed. This allows secondary Pseudomonas infection, which may, therefore, accompany onycholysis of any aetiology €”particularly when the nails are also exposed to moisture. This is the first case report of Pseudomonas chloronychia in a skier, where the combination of repeated micro-trauma, causing onycholysis, and perspiration, causing a moist environment, makes ski boots a particularly conducive milieu.

Footnotes

Competing interests: none.

Patient consent: Patient/guardian consent was obtained for publication.

References

  1. Elling RM. The all-mountain skier: the way to expert skiing. 2nd ed. Camden (ME): Ragged Mountain Press, 2002: 102.
  2. Maes M, Richert B, de la Brassinne M. Le Syndrome des ongles verts ou chloronychie. Rev Med Liege 2002;57(4): 233 €“5. [PubMed ® abstract]
  3. Mandell GL, Bennett JE, Dolin R. Pier GB, Ramphal . Pseudomonas aeruginosa. In: Mandell GL, Bennett JE, Dolin R , eds. Principles and practice of infectious diseases. 6th ed. Philadelphia (PA): Churchill Livingstone, 2004: 2587 €“615.

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