A 54-year-old female from the Northern region of Cameroon, presented on January 12, 2018 to our primary health care hospital with a 6-month history of a painful circular constriction band at the base of her right fifth toe. There was no history of trauma, ligation or bangles on the toe nor laceration of the toe. Her past history was not notable for any chronic disease such as diabetes, ischaemic heart disease, peripheral vascular disease, skin pathologies, HIV/AIDS and psychiatric disorder. Also, she was a non-smoker. There was no family history of similar skin disease.\nOn examination, she was conscious, oriented, and was not ill-looking. Her blood pressure was 138/74 mmHg, pulse rate 102 beats/minute and regular, respiratory rate 18 breaths/minutes and temperature 36.4 °C. All distal pulses were present and of normal volume. There was no regional lymphadenopathy. On examination of the right foot, the fifth had a circular constrictive band at the base of the proximal inter-phalangeal joint (see Fig. ). A provisional diagnosis of a toe infection was made. She was admitted and administered cefuroxime 1.5 g/12 h intravenously (IV), metronidazole 500 mg/8 h IV, paracetamol 1 g/6 h IV, diclofenac 75 mg/ 12 intramuscularly and wound dressing every 48 h. Her clinical re-assessment 1 week later was notable for progression of the constricting band which made contact with the bone until a stage of near auto-amputation of its distal segment (see Fig. ). The distal aspect of the toe was bulbous and oedematous. The affected toe was very mobile and any attempt to actively or passively mobilize it caused excruciating pain. There was bilateral plantar hyperkeratosis. The rest of her clinical assessment was normal. X-ray of the right foot could not be done because it was not available in our health facility. A laboratory panel requested on her admission revealed complete blood count (CBC): white blood cell count 8,400/mm3, haemoglobin 12.1 g/dl, platelet count of 348,000/mm3; raised C-reactive proteins at 48 mg/l and an erythrocyte sedimentation rate at 46 mm 1st hour and 89 mm 2nd hour. The worsening of her toe’s pathology prompted a quick diagnostic review, thereby advocating for the diagnosis of stage four ainhum with impending auto-amputation based on the history and clinical findings. After proper preoperative workups consisting of a complete blood count, prothrombin time and activated thromboplastin time (which were all normal), the constricting band was excised under local anaesthesia by infiltration of lidocaine 2% at its base, the right fifth toe was disarticulated at right fifth metatarsophalangeal joint and the skin was closed surgically. Histopathological examination of the amputated toe was not accessible. Her postoperative course was uneventful and she was discharged on day seven after wound healing. Follow-up to 1 year was equally uneventful.
A 35-year-old man presented to us with pain and fissuring in his left fifth toe []. The patient noted a groove occurring in the inner aspect of his toe 5 years back, which gradually increased. Similar grooves started appearing in his fourth toe bilaterally since the past 2 years. At the age of 8 years, he had a similar problem affecting the right fifth toe, which gradually led to the loss of the digit as accounted by his father. On examining the father who accompanied him, it was noted that he also had similar but asymptomatic grooving involving the right fourth and fifth toes and left fifth toe []. The grooving was most severe in the fourth toe. The patient presented with hope to control the disease from spreading to all his digits and to prevent any further loss of his digits.\nThe patients were otherwise healthy; all his baseline investigations were done and X-ray of the foot was taken. Antibiotics were given for control of secondary infection and he was advised to prevent trauma to the foot. After control of infection, the patient was referred to plastic surgery for favor of Z plasty procedure. The patient came for regular reviews. On subsequent visits, the patient noted significant reduction in the pain following the procedure with reduction in the progression of the fissuring. The improvement was better for the son than for the father after both underwent Z plasty [Figures and ].