Vesiculobullous Lesion on the Right Fifth Toe

Abstract

Diagnosis: Herpetic whitlow. Viral culture of the aspirate obtained from the right fifth toe during surgery grew herpes simplex virus type 1 (HSV1). Clinical differentiation of lesions associated with herpetic whitlow from those associated with paronychia or felon may be difficult, because the lesions can have a similar appearance (figure 1). Lymphangitis at the time of presentation to the emergency department strongly suggested bacterial infection, and it is likely that HSV1 infection had a superimposed bacterial component. Herpetic whitlow is usually observed on the fingers and is presumably spread there from the mouth, lips, or surrounding tissues, which are the most common sites for cold sores [ 1, 2]. Whitlow of the toe has been reported elsewhere [3, 4], but it is relatively rare. Infants put their feet into their mouth routinely, and some mothers reported the somewhat bizarre practice of having gnawed both the fingernails and the toenails of infants because they were afraid of injuring the baby with fingernail clippers or scissors. However, we are not aware of any reports of whitlow of the toe in school-aged children secondary to this practice. In this case, further questioning revealed that the patient's mother had recently trimmed his toenails with clippers while she had active herpes labialis. There were no other risk factors identified. The patient himself had never had a cold sore and did not chew his toenails.