Ask a doctor on the topic of Internal medicine

Chronic nail bed infections - a systemic underlying condition?

January 5, 2016 | 50,00 EUR | answered by Dr. med. Ralf Berg

Dear Sir or Madam,

My story of suffering began a year ago (January 2015) when I developed a nail bed infection on the big toe of my right foot a few weeks after a severe intestinal infection. Several dermatologists examined the infection and attributed the cause to tight footwear (which I definitely wore at that time). For several weeks, unsuccessful attempts were made to treat the problem conservatively with antibiotic courses until I decided to undergo surgical treatment in May 2015, and I considered the issue resolved. At the same time, an infection began to spread at the nail bed of the third toe of the same foot, even though at that time I was not wearing closed shoes, doing sports, or otherwise straining my foot.

At that time, I already noticed that something was definitely wrong with my toes, as the nail bed of some toes (including those of the left foot) was irritated and sensitive. A swab was taken, with the result: candida albicans. Fluconazole for 8 weeks + Travogen healed the infection. In September 2015, another infection occurred on the second toes on both feet. At that time, I only wore open shoes, did strength training, and tried to "protect" my toes. Despite receiving nail care exclusively from a podiatry team since the beginning of my suffering, these infections still occurred.

Suspicious, I began to investigate the issue systemically. Initially, I had the HbA1c 5.0 and fasting glucose = 77 determined, which ruled out the first suspicion (diabetes) by my doctor. HIV = Negative. A comprehensive blood test - see attachment - in early November showed all values within the normal range (exception: slightly elevated iron 171µg/dl, and isolated GPT elevation 70 U/l, which my doctor attributed to the fluconazole treatment). An additional urine culture showed the presence of a germ: 'enterococcus faecalis' - burden of 10^4. This result surprised me greatly, as I have no urological complaints. A repeat of the test confirmed: 'enterococcus faecalis' - burden this time 10^3. In the meantime, the big toe on the left foot as well as the third toe on the left foot became inflamed. Some of the nail bed infections healed on their own after self-treatment with Baneocin, while others persist. I have had swabs taken again today from the inflamed areas. Additionally, I should receive the results of a stool culture conducted in the next few days.

Apart from the nail bed infections on the feet (fingers are all infection-free), I do not have any other symptoms (no fever, no fatigue, no tiredness, no dizziness, no vomiting/diarrhea, no urological problems, etc.).

Therefore, my question(s) to you are: What is wrong with me? What factors may be contributing to nail bed infections occurring with such frequency? Could it be that the asymptomatic bacteriuria of the urine is disrupting my immune system to the extent that the smallest injuries to my toes already result in these infections? What other tests would you recommend?

A little about myself. Male, 29, 180cm/75kg, body fat below 20% - Non-smoker. I exercise 2-3 times a week and avoid excessive alcohol consumption. I have a varied diet and try to avoid sugar as much as possible.

Dr. med. Ralf Berg

Good day,

indeed a very unusual story of suffering.
The approach you have taken so far, as you have described it, was correct. I would have done the same.
It seems clear now that 1. You do not have a general immune deficiency.
For further assurance, if not already done, I would recommend the following:
1. An electrophoresis test (provides information on the presence of enough globulins and proteins in the blood, and possibly whether there are anomalies in their distribution (gamma globulopathy) or chronic inflammations.
2. A total IgE test to rule out or get an indication if an allergic reaction may be playing a role.

2. It is not a local mechanical problem (ingrown nail, etc.), so it cannot be approached surgically.

3. It is likely a recurring infection (responds to Baneocin, also disappears from individual toes (more likely ruling out a fungal infection). It is not certain whether the detected bacteria are actually causing the inflammation.
My therapy suggestion: at least 21 days of repeated foot disinfection with the aim of significantly reducing all bacterial strains colonizing the toes and nail folds, and then establishing a new bacterial flora. I have found that in these types of diseases, it is often harmless saprophytic strains of common bacteria (usually Staphylococci or Streptococci) that have acquired a particular virulence and are capable of triggering these infections repeatedly. It is necessary to eliminate or at least reduce them so that other strains can overgrow them. In diagnostics, progress is often limited as these strains are difficult to culture or simply cannot be distinguished from other strains. A nail fungus test was likely already conducted by the dermatologists.
For the recurring bladder infections, my advice would be to secure or dismiss the diagnosis through a one-time catheter urine test. The risk of contamination in a normal mid-stream urine sample is simply too high. I understand this may not be pleasant for a man, but if sterile urine is detected twice, this route can be ruled out. I do not have any specific experiences that would apply to your problem in this regard.

Conclusion: I suspect a virulent bacterial strain. After all that has been done, I suggest trying local external therapy, as thankfully it seems to be only a local problem at the moment.
Twice daily foot disinfection, foot baths, drying with a hairdryer, changing socks daily, and applying a moisturizing cream once at night.

This would be my advice and assessment.

I would be interested in hearing back from you after 3 weeks to see if this has been successful.

Best regards,
Dr. R. C. Berg