Blistering Digital Dactylitis Complicated by Osteomyelitis and Amputation in an HIV-Positive Infant

Abstract

HIV infection is rapidly emerging as a predominant cause of morbidity and mortality in children from developing countries. This probably accounts for the many reports that have emanated from resource-limited settings in the last decade. Reports highlighting bone infections and untoward complications in HIV-infected children are rare. This informed our decision to report the case of a 9-month-old HIV-positive Nigerian girl who presented with blistering dactylitis of the right middle finger. Plain radiograph of the right hand showed amputation of the terminal phalanx and changes consistent with osteomyelitis in the middle phalanx of the third finger. The case is discussed with a view of highlighting this rare complication and the challenges associated with management in a resource-limited setting.

Introduction

Blistering distal dactylitis (BDD) is a localized infection involving the volar part fat of the distal phalanx of the digit. ¹ It has been documented to occur in both immune-competent and immune-compromised individuals. ² The usual causative agent of BDD is group A beta hemolytic streptococcus. Staphylococcus aureus and Staphylococcus epidermidis are less commonly implicated etiologic agents. Complications that may arise from bacterial skin infections include ulcerations, abscesses, osteomyelitis, and septicemia, if prompt and appropriate treatment is not instituted. ^3–5

Infections of the bones are not uncommon in children and they usually present as osteomyelitis or arthritis. ^6,7 Bone infections usually arise from hematogenous spread from other infected organs such as the lungs or urinary tract. They may also occur from spread from infected contiguous structures such as the skin, in cases of cellulites or furunculosis. Previous studies have shown that the incidence of osteomyelitis is not higher among individuals with HIV compared to the general population. ^6–8 Poor management of osteomyelitis can however lead to chronic osteomyelitis or fractures and rarely amputation.

Case Report

A 9-month-old female girl presented with vesicular rashes on the face and chest noted 2 months prior to presentation. The vesicles later broke down leaving ulcers after releasing clear fluids. A month later, a swelling and redness developed in the right middle finger and this slowly increased in size and became vesicular. The vesicles then broke down to leave ulcers which expanded minimally. The mother managed these ulcers at home by topical application of gentian violet. However, when the lesions did not resolve, she brought the child to the hospital. There was no fever or weight loss in the patient.

The patient tested positive to the HIV virus by the polymerase chain reaction test. The child had never been transfused but was exclusively breastfed for 4 months. The mother of the patient is a 27-year-old hair dresser married to a 30-year-old farmer. She tested positive to the HIV virus 4 months prior to the present visit with her daughter. The father however does not know his retroviral status and refused the screening test.

Examination of the infant revealed a chronically ill–looking, underweight infant with a weight of 6.25 kg, which is 69.4% of that expected for age. She was mildly pale and had a low-grade fever recording of 37.6°C. There was significant generalized lymph node enlargement. The skin showed ulcers on the right half of the face and right side of the upper chest wall. There was a swelling of the distal half of the right middle finger which was also erythematous (Figure 1 ). Significant findings on the systemic examination were those of an enlarged liver and spleen, both were displaced 4 cm below the right and left costal margins, respectively. In addition, the liver was firm smooth and not tender.

Figure 1.

Right hand with infected middle finger.

A tentative diagnosis of ecthyma with blistering distal dactylitis of the right middle finger was made and the child was planned for admission. Full blood count examination revealed a packed cell volume of 44% and a total white cell count of 7100/mm ³ , with a neutrophil and lymphocyte differential count of 48% and 52%, respectively. The child tested positive for the HIV virus based on the polymerase chain reaction test and the CD4 count was 2052 cells/mm ³ . Radiograph of the right hand showed a total amputation of the terminal phalanx and osteolytic changes of the middle finger. The radiograph is shown in Figure 2 . Blood culture could not be done because of financial constraints on the part of the patient. However, a swab of the skin lesions yielded a growth of Staphylococcus aureus.

Figure 2.

Terminal phalanx amputation and osteolytic changes in middle phalanx of third finger.

A final diagnosis of osteomyelitis of the right middle phalanx and the spontaneous amputation of the terminal phalanx following BDD in an HIV-positive child was made. Subsequently, the child was referred to the orthopedic surgery unit for review. The surgeons decided to admit the child and placed on antibiotics. They also planned a surgical intervention on the finger. However, the mother declined admission and treatment because of financial constraints and promised to bring back the child for treatment, after obtaining the fathers approval. The mother failed to bring the child for further treatment. She was however seen 3 months later at another health facility in another city by one of the authors (OOA). The reasons given for not following up on the previous treatment of her child was the failure of the father to consent and financial constraint.

Discussion

Immune suppression from diseases such as HIV infection may be a significant predisposition to complications and progression of bacterial skin diseases. ⁵ Thus, it may not be a surprise that osteomyelitis complicated this case of BDD, judging from the fact that this patient presented 2 months after the pyogenic skin digital lesion was noticed. Furthermore, the patient also had advanced HIV as her WHO clinical staging was indicative of stage 3. The above reasons also probably explain the progression of BDD through osteomyelitis and eventual digital amputation.

There are few studies documenting the effect of HIV on the bone in children. ^9,10 The HIV virus is believed to reduce mineral bone density and reduce bone turnover in adults; in addition, individuals with advanced HIV disease may present with impeded bone formation and increase resorption. ¹⁰ Possible explanations for the observed digital amputation therefore may be as a result of the effect of the virus on the bone or a sequelae of the bone destruction following osteomyelitis. Although antiretroviral therapy has also been associated with adverse changes in bone density, metabolism, and body composition, ¹¹ they were not implicated because they were yet to be initiated.

The development of digital amputation post BDD underscores the need to treat infections involving the bones or close to the bones aggressively in HIV positive individuals. Complications such as osteomyelitis and septicemia often leave no sequelae posttreatment, when management is prompt and appropriate. Amputation of a digit, however, leaves an obvious deformity and this may constitute a handicap to the individual later in life. This unusual case also shows a need for further studies on the association between HIV and the bone in children from developing countries. Children from developing countries have a peculiar problem of malnutrition, which is not as common in developed countries.

A number of socioeconomic problems might have contributed to the development of digital amputation and osteomyelitis in this HIV-positive child. Most of the problems are connected with the late presentation of the child by the mother, the poor treatment instituted in the initial phase of BDD, and the need to obtain approval from the father before obtaining quality care for the child by the mother. Financial constraint was an obvious problem here and this could be possibly overcome by making the treatment of HIV and opportunistic infections free in its entirety. Currently, foreign organizations and the federal government of Nigeria provide financial aids to subsidize or make the treatment of HIV free. However, the subsidy in the management of some aspects of people with HIV does not cover treatment of opportunistic infections and some microbiological investigations such as culture and sensitivity of wounds and surgery. Thus, there is a need by the above bodies to improve funding or for other philanthropic organizations to assist in funding of these uncovered aspects of HIV care.

Poor utilization of the health services for the treatment of this HIV-positive child could also be related to the low socioeconomic class of the parents. Parents from the lower socioeconomic class have been found to poorly utilize health services for their children or wards, from previous studies. ^12,13 Formal education on the part of the mother might have influenced the treatment-seeking behavior and caused the mother to present earlier or test her child when she was found to be HIV positive or obtain proper care for the BDD. Financial and legislative empowerment of the mother is expected to enable the mother access quality health care for her children, in cases where the father fails to give an approval for the treatment of a child.

The important lessons that can be learnt from this case report are the following. All infections of the soft tissue overlying the bone or in close proximity to the bone should be treated aggressively and promptly with appropriate antibiotics in order to prevent involvement of the bones and deformity. There is also a need to increase the funding for HIV treatment in developing countries in order to make drugs and investigative materials needed for the treatment and diagnosis of opportunistic infections, respectively, freely available for those who need them. Empowerment of the female gender or potential mothers is also expected to go a long way in accessing quality health care for their children or wards.