We present a case of 38-year-old woman who presented to our Dermatology OPD with complaints of palmoplantar thickening and scaling. During her childhood, she had noticed slight scaling localized to bilateral palms and soles which then progressed to become brownish honeycomb transgradient hyperkeratosis over a period of around ten years (Figure ; Figure ). It was associated with pain, tightening, and winter aggravation. She also had generalized dryness of the skin. However, she did not receive any treatment, and at the age of twenty-five years, she gradually developed a constriction band around the fifth toe which gradually tightened leading to pseudoainhum with amputation at the level of the proximal interphalangeal joint (Figure ). Her hearing, vision, hair, and nails were normal. Among her two children, the elder son is eleven years old and is also affected and the younger daughter is unaffected till this date. Considering the presence of transgradient honeycomb keratoderma with generalized ichthyosis and pseudoainhum in the absence of deafness, a diagnosis of Camisa syndrome was made.
A 12-year-old Cameroonian male adolescent with an uneventful past medical, family and psychosocial histories was referred to the orthopedic department of the National Social Insurance Hospital in Yaoundé, Cameroon for a surgical site infection of a left big toenail leading to a dry gangrene of the affected toe following surgical treatment for an ingrown toenail 36 h before his current hospital presentation.\nThe patient had been suffering from an ingrown nail of the hallux of the left foot for several months. The pain was aggravated by wearing closed shoes and was unremitting to usual analgesics such as paracetamol and diclofenac. Persistent pain caused by the ingrown nail prompted the consult of a general practitioner who proposed a surgical treatment for the patient. His preoperative workups included a complete blood count, prothrombine time, partial thromboplastine time, fasting blood glucose and HIV tests which were all normal. The surgical procedure was performed under local anesthesia containing lidocaine 2% and epinephrine. Intravenous Amoxicilline 1 g and metronidazole 500 mg were administered 30 min before the onset of the surgical procedure. An annular digital block was tied round the necrosed toe. Local anesthesia was infiltrated at the postero-lateral aspect and base of the affected toe. The FROST surgical technique was performed by the general practitioner. The technique entailed an “L-shaped” soft tissue dissection to expose and excise the root of the nail and any abnormal soft tissue associated with it []. There was no intraoperative complication and the patient was discharged home an hour later with an antibiotic regimen consisting of oral amoxicilline 1 g/8 h and metronidazole 500 mg/8 h. The patient returned a day after the operation, with complains of severe pain of the operated toe. He was administered paracetamol and codeine and the wound was dressed (Fig. ). Findings during the dressing were; a very tender amputated toe stump with a black plaque covering 40% of the medial side of the left big toe. A wet dressing of the toe was done using normal saline and the patient was sent back home. On the second postoperative day the persistence of pain and the enlargement of the black plaque into necrosis of the entire toe motivated the referral of the patient to the orthopedic surgical department of the National Social Insurance Hospital in Yaoundé, Cameroon.\nWe received the patient in severe pain rated 8/10 using the visual analogue scale. He was overweight with a body mass index (BMI) of 28.89 kg/m2 all his vital signs were normal. Local examination of the affected toe showed a necrosed (black in colour) and dried left big toe with a loss of sensation (Fig. ). The left big toe also portrayed signs of inflammation such as being swollen, hot and very tender. All distal pulsations were present and of good volume. There were no swollen lymph nodes on examination of both lower limbs. In view of these findings, we made the diagnosis of dry gangrene of the left big toe. After informing the patient’s family members about the pathology and obtaining consent from his parents, we planned a surgical debridement of the necrosed toe. Another laboratory panel performed before the debridement showed C-reactive proteins (CRP) at 96 mg, hemoglobin at 15 g/dl and leucocytosis at 12,000/mm3. Surgical debridement of the necrosed toe was done under a combined saphenous and popliteal nerve block using ropivacaine. Intraoperative findings were necrotic tissues of the entire left big toe (Fig. ). After explanation of the findings to the parents and obtaining a second parental consent, we opted for total amputation of the left big toe rather than surgical debridement. No intraoperative complication occurred. Postoperatively, his treatment consisted of oral ofloxacin 200 mg/12 h, paracetamol 1 g/6 h and tramadol 50 mg/8 h. He was discharged home the same day of the surgery, precisely 11 h after the surgery when the sensitive and motor block induced by the peripheral nerve blocks had waned. Walking physiotherapy sessions were done from the fifth postoperative day to quickly rehabilitate the patient. We equally recommended psychological support by a psychologist due to the trauma associated with the amputated toe. His follow-up was uneventful at 6 months following the ambulatory surgical amputation of his left big toe.