Dermatology Online Journal

A review and report of blistering distal dactylitis due to Staphylococcus aureus in two HIV-positive men
Noah Scheinfeld MD JD
Dermatology Online Journal 13 (2): 8

Department of Dermatology, Metropolitan Hospital Center, New York, New York. NSS32@columbia.edu

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Abstract

Blistering distal dactylitis (BDD) is attributed to infection with group A beta-hemolytic Streptococcus or Staphylococcus aureus (SA). Although initially described in children, BDD subsequently has also been reported in adults. It occurs in the immunocompetent and immunocompromised individuals. This report notes two HIV-positive men with BDD, one with bullae and the other with erosions caused by SA, effectively treated with amoxicillin trihydrate/clavulanate potassium. This report highlights the reasoning behind adjusting empiric therapy to account for SA, that BDD can present with erosions, and that the course and presentation of BDD in HIV-positive patients mirrors that of non HIV-positive patients.

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Case 1

A 42-year-old man with acquired immunodeficiency syndrome (AIDS) secondary to human immunodeficiency virus (HIV) with a CD-4 count of ~200 cc³ presented with a 4-day history of two bullae that had evolved into erosions on the dorsal part of two of this fingers on the same hand (Fig. 1). Each finger was cultured and a putative diagnosis of blistering distal dactylitis was made. The patient was given a 10-day course of oral amoxicillin trihydrate/clavulanate potassium. The culture grew out Staphylococcus aureus that was penicillin and amoxicillin trihydrate/clavulanate potassium sensitive. The patient experienced a resolution of the BDD over 2 weeks without scarring.

Figure 1	Figure 2
Figure 1 Erosions of dorsal fingers of patient #1 that were culture positive for Staphylococcus aureus
Figure 2 Purple bullae on the thumb of patient #2 that was culture positive for Staphylococcus aureus

Case 2

A 38-year-old man with acquired immunodeficiency syndrome secondary to human immunodeficiency virus (HIV) with a CD-4 count of ~250 cc³ presented with a 3 day history of a bullae on his thumb that was growing in size (Fig. 2). A putative diagnosis of BDD was made, a culture taken, the bullae was incised and drained, and therapy instituted with oral amoxicillin trihydrate/clavulanate potassium for 14 days. The culture grew out Staphylococcus aureus resistant to penicillin but sensitive to amoxicillin trihydrate/clavulanate potassium. He was examined several times over the ensuing 3 weeks and his bullae resolved with out scarring.

Comment

Blistering distal dactylitis (BDD) results from and was initially described in group A β-hemolytic Streptococcus infections of acral skin [1]. Recent reports link BDD to Staphylococcus aureus [2, 3].

This report of BDD in adults is not novel or singular. Although BDD most commonly occurs and was initially described in children [4, 5], it occurs also in adults [6]. Such adults can be immunocompetent or immunocompromised [7, 8]. Reports in HIV-positive patients with BDD have not been noted in Pubmed previous to this report.

The location where BDD occurs has been well described. Blistering distal dactylitis is an acral infection. Blistering distal dactylitis most classically occurs on the volar fat pads of the fingers. However, it can occur on the proximal phalangeal areas of the fingers and palmar and dorsal areas of the hands [9]. Blistering distal dactylitis can also occur on the feet and toes.

The clinical appearance of BDD has been well described. The bullae are typically tense but evolve into bullae with central erosions and simple erosions often with adherent layers of skin. One or several bullae can manifest when infection resulting in BDD occurs. Multiple bullae may be a predictor that S. aureus is the causative agent [3]. Diagnosis of BDD can be made based on clinical presentation with confirmatory bacterial cultures or Gram stain of interest but not necessarily necessary. Thus, the clinical presentation and diagnosis of the two patients in this case report mirrors presentations and diagnoses in previously reported cases.

The proximate basis and timing for BDD is not certain. Although infection with Gram-positive bacteria is common, BDD is uncommon. Why BDD is uncommon compared to impetigo or cellulitis is not certain. Blistering distal dactylitis can be co-incident with Gram-positive infection or colonization of the nasopharynx or conjunctiva [10[, but such infections or colonizations do not result in BDD.

Commentators have outlined a standard approach for BDD. The bullae of BDD should be incised and drained, the erosions of dried out and treatment with a β-lactam antibiotic instituted. Although a β-lactamase stable antibiotic would seem preferable because SA is commonly resistant to simple (non-synthetic) β-lactam antibiotics, as reports have not noted treatment failures, it is likely that any β-lactam antibiotic will result in effective treatment of BDD. Nevertheless, it would seem prudent that as Staphylococcus aureus commonly exhibits antibiotic resistance, in particular to penicillin, empiric therapy of BDD should be adjusted accordingly, with β-lactamase-stable antibiotics such as amoxicillin trihydrate/clavulanate potassium utilized when BDD is suspected or diagnosed.

In conclusion, BDD is a blistering acral eruption that manifests as bullae that can evolve into erosions in children and adults resulting from infection by Group-A β-hemolytic Streptococcus and Staphylococcus aureus [14, 15, 16, 17, 18]. This report highlights (1) the need to adjust empiric therapy to account for S. aureus, that BDD can present with erosions, and that the course and presentation of BDD in HIV-positive patients mirrors that of non-HIV-positive patients.

References

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