Photo Quiz

A Swollen Thumb

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Am Fam Physician. 2014 Apr 15;89(8):663-664.

A 78-year-old man with a history of diabetes mellitus and hypertension presented with a four-month history of progressively worsening, painless swelling at the base of his left thumbnail. The swelling was accompanied by a serosanguineous discharge at the cuticle. There was no history of trauma to the area. Treatment with levofloxacin (Levaquin), 500 mg, for 10 days was ineffective.

Physical examination revealed hyperpigmented skin just below the cuticle of the left thumb with swelling (see accompanying figure). The base of the nail appeared fleshy with loss of the cuticle and dystrophy of the nail plate.




Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Chronic paronychia.

B. Felon.

C. Herpetic whitlow.

D. Onychomycosis.

E. Subungual hematoma.

Address correspondence to Charles M. Sow, MD, MSCR, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


1. Tully AS, Trayes KP, Studdiford JS. Evaluation of nail abnormalities. Am Fam Physician. 2012;85(8):779–787.

2. Rockwell PG. Acute and chronic paronychia. Am Fam Physician. 2001;63(6):1113–1116.

3. UpToDate. Goldstein BG, Goldstein AO. Paronychia and ingrown toenails. May 10, 2012. (subscription required). Accessed February 15, 2013.

4. Rigopoulos D, Larios G, Gregoriou S, Alevizos A. Acute and chronic paronychia. Am Fam Physician. 2008;77(3):339–346.

5. Tintinalli JE, Stapczynski JS, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw-Hill; 2011.

6. Rakel RE, ed. Textbook of Family Medicine. Philadelphia, Pa.: Saunders-Elsevier; 2007.

Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.

A collection of Photo Quizzes published in AFP is available at

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at To be considered for publication, submissions must meet these guidelines. E-mail submissions to

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