Infection of finger caused by Morganella morganii leading to digital amputation: A case report.

RATIONALE: Digital infection is a common disease in clinic, featured by pain and swelling of digits. As far as we know, no article has reported a case of digital infected by Morganella morganii. PATIENT CONCERNS: A 58-year-old Chinese female complains about whitlow with pain and swelling for 2 weeks. She has a history of diabetes for 10 years. She received incision and drainage before coming to our hospital and preoperative X-ray of left ring finger presented no bone eroded. DIAGNOSIS: She is diagnosed with infection of ring finger caused by M morganii in our hospital.
INTERVENTIONS: We perform aggressive operative debridement and drainage firstly. Meanwhile, we provide tissue samples for diagnosis and the result indicates M morganii infection. Then, she is treated with anti-infection therapy and regulation of diabetes. However, 1 week after first surgery, her condition deteriorate presenting bone erosion in distal phalanx of ring finger from X-ray. Considering severity of illness, we decide to perform digital amputation. OUTCOMES: At 3-month follow-up, the patient has a satisfactory result and X-ray shows no bone eroded. LESSONS: Clinicians should consider M morganii, which is rare in hand infection, as a cause of digital infection. This case reminds us that some whitlow is dangerous, amputation should be considered if necessary.

Introduction

Whitlow is a common digital infection caused by various bacterium. Previous study[ reported that the incidence of whitlow, characterized by serious pain and localized erythema, ranged from 2.5% to 15.9%. In 1983, William first described Morganella morganii, which became an important opportunistic nosocomial pathogen in a surgery unit.[ Singla et al[ reported that M morganii was often ignored in Intensive Care Units where nosocomial infections happen, but M morganii was of clinical significance. As far as we know, no report has described hand infection by M morganii. Here, we show a rare case on digital infection caused by M morganii after whitlow.

Consent

The current study was approved by the patient for publication of this case report and any accompanying images and ethics committee of Affiliated Hospital of Hebei University. Informed written consent was obtained from the patient for publication of this case report and accompanying images.

Case report

A 58-year-old woman, who has a history of diabetes for 10 years, complains about whitlow with pain and swelling in left ring finger for 2 weeks. She was treated with incision and drainage for whitlow in another hospital. Nevertheless, condition turns out to be worse off. Skin inflames in palm and dorsal side of left ring finger and palm, as shown in Figs. 1 and 2. But X-ray presents no abnormal change (Fig. 3). The patient body temperature maintains from 38 to 39°C. The blood indices at first show that white blood cell (WBC): 12.1 × 109/L (normal range from 4 to 10 × 109/L), C-reactive protein (CRP): 21 mg/L (normal range from 0 to 10 mg/L), erythrocyte sedimentation rate (ESR): 45 mm/h (normal range from 0 to 20 mm/h), and blood glucose: 7.3 mmol/L (normal range from 3.9 to 6.1 mmol/L). In order to gain clinical improvement, we decide to conduct operation for the patient. Then, S-type longitudinal incision is made and radical debridement and drainage is performed, as shown in Fig. 4. Tissue samples and purulent secretion are collected for diagnosis and the result indicates M morganii infection, which is sensitive to piperacillin. The patient is diagnosed with M morganii infection in left ring finger. Then, the patient is treated with anti-infection treatment and regulation of diabetes. One week after surgery, the aggravation of the disease is manifested as the aggravation of skin swelling and the X-ray shows osteolysis in distal phalanx of left ring finger in Fig. 5. The patient body temperature maintains from 38 to 39°C. The blood variables show that WBC: 11.9 × 109/L, CRP: 20 mg/L, ESR: 40 mm/h, and blood glucose: 6.9 mmol/L at the second time. Considering the severity of the illness, we decide to perform left ring finger amputation, as shown in Figs. 6 and 7. At 3-month follow-up, pain and swelling in left ring finger relieve and the laboratory tests show that WBC: 7.3 × 109/L, CRP: 7 mg/L, ESR: 9 mm/h, and blood glucose: 6.5 mmol/L. X-ray presents no bone resorption at final follow-up.

Figure 1

Swelling in dorsal side of left palm and ring finger.

Figure 2

Swelling in volar side of left palm and ring finger.

Figure 3

X-ray of left hand presented no abnormal change.

Figure 4

Radical debridement and drainage of left ring finger was performed.

Figure 5

X-ray presented osteolysis in distal phalanx of left ring finger 1 week after debridement and drainage.

Figure 6

Skin festered in left ring finger 1 week after debridement and drainage.

Figure 7

Left ring finger amputation was performed.

Discussion

Whitlow is a common hand infection. Incision and drainage is the main procedure to treat this disease. Patel et al[ presented a rare case of 15-month child with recurrent herpetic whitlow. Wang et al[ showed a case on recurrent whitlow infected by Mycobacterium tuberculosis. X-ray showed that radius, ulna, and carpal were eroded. Finally, forearm amputation and antituberculosis therapy were performed. Here, we show a rare case on digital infection caused by M morganii.

In our case, a 58-year-old woman, who has a history of diabetes for 10 years, complains of pain and swelling in left ring finger for 2 weeks, as shown in Figs. 1 and 2. The patient has high body temperature. After aggressive operative debridement, she is treated with anti-infection therapy and regulation of diabetes. But, a week after surgery, we could see osteolysis in ring finger from X-ray, which is related with M morganii infection from Fig. 5. We perform left ring finger amputation due to serious condition correlated with M morganii infection. Three months after surgery, condition of this patient is good, proving that amputation successfully stopped deterioration of illness.

It is well known that M morganii, belonging to the tribe Proteeae of family Enterobacteriaceae, is considered as a rare cause of infection in human beings.[Morganella morganii was first found by William. Since then, an increasing number of reports have been reported that this bacteria could cause urinary tract infections, skin and soft tissue infection, or even lead to fatal consequences.[ As far as we know, hand infection by M morganii has not been reported ever before, implying no experience as a reference to treat this disease. Previous study[ reported a case that a diabetes mellitus patient suffered from septic arthritis infected by M morganii. Our case shows osteolysis in distal phalanx of left ring finger from X-ray a week after debridement and drainage. To prevent the process of disease, we consider finger amputation as the best plan. Up to now, efficacy of amputation is satisfactory. This method treating this disease has some limitations. First, we need a long follow-up to prove efficacy; second, we lack experience to deal with this rare case and we doubt if amputation is radical; third, we need more cases to assess this treatment.

In conclusion, there is no report on digital infection by M morganii for surgeons to refer to. And we provide a method for surgeons when facing the rare case like this. But we also need further study to observe efficacy in long-term follow-up.

Author contributions

Conceptualization: Yanan Niu.

Methodology: Pei Zhao.

Resources: Wenkui Zheng.

Writing – original draft: Di Li, Wenshan Gao.

Writing – review & editing: Cong Jie Li.