Defeating the Odds: Onychocryptosis, an Underestimated Cause of Morbidity

Onychocryptosis or ingrown toenail is a common disorder that involves the great toe. In general OC is considered a benign pathology. The symptoms and complications originate after the nail curls in and digs into the cuticle and the soft tissues of the toe. As such, toe pain is the most common clinical manifestation resulting in missed work as well as limited activities in sports. Complications of onychocryptosis like osteomyelitis are extremely rare but has been reported in presence of risk factors such diabetes mellitus, vascular insufficiency, immunosuppression and distorted anatomy. A healthy young individual presenting to the emergency department with fever of unknown origin secondary to bilateral OC defeats all the odds and outlines the importance of a thorough history taking and physical exam. It also demonstrates that what most consider a benign pathology can also be associated to severe complications.We report a case of a healthy young male who presented to a primary care clinic with low grade fever of unknown origin. He was evaluated for third time in six weeks due to recurrent abnormal temperature, fatigue, night sweats, progressive weakness and anorexia. His HIV test was negative and his preliminary work up was non-diagnostic. He was referred to the emergency department in order to be hospitalized and undergo a cardiac ultrasound and other diagnostic tests to investigate the etiology of his fever of unknown origin. The physical exam in the emergency department revealed bilateral onychocryptosis with significant tenderness, erythema and cloudy fluid drainage. The patient claimed that his feet were never examined even though he had complained of painful ingrown toenails. Radiographs of compromised toes showed bone cortex erosion suspicious for osteomyelitis. The patient was hospitalized with intravenous antibiotics. The diagnosis was confirmed with MRI and the patient was discharged home afebrile 4 days later.

Keywords: Osteomyelitis; Onychocryptosis.