Recurrent blistering distal dactylitis due toStaphylococcus aureusin an immunocompetent elderly woman

Abstract

An 86-year-old woman presented with marked blistering of her left index fingertip and ulceration of the left middle fingertip, with a 2-year history of recurrent blistering and ulceration of her fingers bilaterally. She denied any preceding finger trauma, although she reported frequent gardening. She denied systemic symptoms. Her medical history was significant for a 2-year history of atrial fibrillation on carvedilol, amiodarone and apixaban, and she was a lifetime non-smoker. On admission, she had elevated inflammatory markers but unremarkable autoantibodies. Radiograph of the hand revealed diffuse soft tissue fullness and subtle irregularities at the tuft of the index finger, but all other investigations were unremarkable. The lesion was incised and drained, revealing blood-tinged purulent fluid. Wound biopsy revealed spongiosis with neutrophils, consistent with a diagnosis of blistering distal dactylitis.

Blistering Distal Dactylitis: A Narrative Review

“…It is of rare occurrence in adults regardless of their immune status and even more so in the elderly population [5]. However, physicians should be vigilant about this disease no matter the age group [6]. Rare cases of BDD have also been seen in children under 24 months of age [7].…”

“…BDD occurs more commonly in the fingers than in the toes [11,17] with the index and the thumb being the most frequently concerned digits [12]. The predilection for fingers may be partly explained by the theories behind the development of the disease such as the autoinoculation of the fingers due to nose-picking [6], finger sucking (especially in children aged 1 to 3 years old), exploring the mouths of adults, animal bites [14] and anthropophilic transmission [18,19], traumas like abrasions, finger pricks, and burns [5,7], abnormal skin appendages [20], and iatrogenic causes of intravascular inoculation such as forearm injections [21]. BDD may also be caused by undetectable infections of the anus, conjunctiva or the nasopharynx [8].…”

“…Upon closer examination, a blood-tinged or purulent liquid is generally found. As is the norm with superficial infections of the digits, systemic symptoms such as fever, chills, and weight loss are rarely reported [5,6,8,12,22,23]. When systemic symptoms do occur, a concomitant infection must be eliminated [12].…”

“…It mainly includes chemical, thermal or traumatic burns, Herpes Simplex Virus (HSV) infections, Staphylococcal bullous impetigo [4,15] (Figure 2) as well as acral psoriasis, insect bites, dyshidrotic eczema (pompholyx) (Figure 3), allergic contact and irritant dermatitis, foreign body reactions and pustular dermatosis of the hands [8]. Vasculitis, cellulitis, osteomyelitis, peripheral neuropathy (with or without thermal Orthopedics and Rheumatology Open Access Journal (OROAJ) injury), peripheral arterial disease and thromboembolism were also mentioned [6]. While both are caused by the same bacteria, bullous impetigo is very superficial in comparison with BDD [25].…”

“…Cellulitis [6,39] Predisposing factors: trauma, tinea pedis, onychomycoses, lymphatic/ vascular compromise Redness, pain, swelling, heat.…”