Necrotizing soft tissue infection of the fingertips secondary to paronychia in a leukemic child: a case report and warning

Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy, for which chemotherapy remains the cornerstone of treatment. Skin toxicity is a frequent adverse reaction to chemotherapy; however, progression from paronychia to necrotizing soft tissue infection of the fingertips is uncommon. This report describes the case of a 7-year-old child with ALL who developed paronychia following combination chemotherapy with vincristine and daunorubicin. The infection progressed to involve multiple fingertips as necrotizing soft tissue infection, a course facilitated by the patient's underlying severe neutropenia. Raoultella ornithinolytica was identified on blood culture. A structured, multistep nursing protocol was implemented, including local disinfection, ethacridine lactate compresses, topical application of recombinant human epidermal growth factor solution and mupirocin ointment, and local oxygen insufflation. This regimen resulted in significant improvement of the lesions. Within 7 days, pain subsided, edema reduced by more than 50%, and joint mobility was largely restored, with complete clinical resolution achieved within 14 days. This case highlights the importance of early recognition of chemotherapy-induced skin toxicity and the value of standardized stepwise wound management in improving functional outcomes. It provides a practical reference for managing this rare yet severe cutaneous adverse reaction in children and underscores the critical role of specialized nursing in supportive oncology care.

1 Introduction

Acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy, accounting for approximately 23% of all cancer diagnoses in patients under 15 years of age (1, 2). The management of pediatric ALL typically involves a multimodal strategy integrating chemotherapy, radiotherapy, and in selected cases, surgery. Systemic pharmacotherapy forms the cornerstone of treatment and primarily includes cytotoxic agents, corticosteroids (hormonal therapy), and molecularly targeted drugs, all aimed at inhibiting malignant cell proliferation (3). These drugs serve as indispensable components across all phases of therapy, including induction, consolidation, and maintenance.

However, antineoplastic agents are associated with a spectrum of adverse events (AEs). Nail toxicity is a well-documented cutaneous adverse effect associated with both conventional chemotherapeutic agents and novel targeted therapies (4). This susceptibility arises from the continuously proliferating nail matrix cells, which are highly vulnerable to chemotherapeutic damage. Clinical manifestations may involve three anatomical regions: the nail matrix (presenting as Beau's lines, onychomadesis, or melanonychia), the nail bed (resulting in onycholysis, subungual hemorrhage, or hematoma), and the proximal nail fold (including paronychia or periungual pyogenic granuloma) (5, 6). Nail growth is faster in children and adolescents, proceeding at an estimated rate of 0.12 mm/day (7, 8). Numerous chemotherapeutic agents and regimens have been demonstrated to induce nail changes, including taxoids, cyclophosphamide, doxorubicin/daunorubicin, 5-fluorouracil, and vincristine (9–12). Although not typically life-threatening, chemotherapy-induced nail changes can cause substantial cosmetic concerns, pain, and functional impairments, thereby adversely affecting quality of life and limiting daily and self-care activities (4, 13). Therefore, early and proactive management of these changes is necessary to preserve patient function and quality of life.

In this study, we report a case of a 7-year-old child with ALL who developed paronychia following combination chemotherapy with vincristine and daunorubicin. The condition progressed rapidly to necrotizing soft tissue infection. A structured wound care protocol was implemented, leading to a favorable clinical outcome. This case offers valuable insights into the evidence-based management of chemotherapy-induced paronychia complicated by necrotizing soft tissue infection and may help guide the optimization of clinical strategies for this complication among pediatric oncology patients.

2 Patient presentation

A 7-year-old girl with no significant family history of hematological disorders, although with a documented digit-sucking habit, presented to our hospital with arthralgia and joint swelling lasting over one month, skin petechiae for three days, and abnormal blood test results for 3 h. The clinical timeline and laboratory data of the entire case are summarized in Figure 1 and Table 1. Initial laboratory findings revealed thrombocytopenia (platelet count: 12 × 10⁹/L) and neutropenia (absolute neutrophil count: 0.79 × 10⁹/L), prompting hospitalization with a provisional diagnosis of immune thrombocytopenic purpura. Bone marrow aspiration cytology on day 3 confirmed acute leukemia, and subsequent immunophenotyping established a definitive diagnosis of B-cell acute lymphoblastic leukemia (B-ALL). According to the Chinese Children's Cancer Group 2020 protocol (CCCG-ALL-2020), the patient was classified into the intermediate-/high-risk group and received the corresponding remission induction chemotherapy. The specific regimen consisted of the following: an initial 4-day intravenous course of dexamethasone (6 mg/m², q8h); from day 5 onward, daily oral prednisone (60 mg/m², q8h) combined with dexamethasone (8 mg/m², q8h), plus single intravenous doses of vincristine (1.5 mg/m²) and daunorubicin (25 mg/m²) on day 5 and on day 6, and a single intramuscular injection of pegaspargase (2,000 U/m²) along with triple intrathecal therapy (methotrexate 12.5 mg, cytarabine 35 mg, and dexamethasone 5.0 mg) for central nervous system leukemia prophylaxis. Transfusion support was provided in accordance with institutional guidelines to maintain platelets >20 × 10⁹/L and hemoglobin >80 g/L.

Figure 1

Figure 1. A clinical timeline of the pediatric patient.

Table 1

Table 1. The laboratory characteristic of the pediatric patient in the entire case.

During chemotherapy, the patient exhibited involuntary finger-picking behavior. She developed febrile episodes on days 10 and 19, with peak temperatures of 39.0 °C and 39.4 °C, respectively. On day 21, yellow purulent discharge appeared around the nails of the right hand, accompanied by tenderness but with preserved finger joint mobility. A diagnosis of paronychia was made, and topical ethacridine lactate solution was applied three times daily. By day 23, the patient had been diagnosed with sepsis following blood cultures identification of Raoultella ornithinolytica. On day 27, identification of the fingertips deteriorated, manifesting as ulceration, epidermal desquamation, and erythema. An orthopedic consultation and X-ray were performed, which revealed no evidence of bony abnormalities. Mupirocin ointment was added to the treatment regimen for enhanced infection control. By day 29, the patient had experienced a rapid worsening of the fingertip lesions, which progressed to dark purple discoloration accompanied by severe pain, indicating progression to necrotizing soft tissue infection. The evolution of digital clinical manifestations is summarized in Table 2. The clinical presentation was distinguished from purpura fulminans and ecthyma gangrenosum based on the observed features and supporting laboratory indicators (Table 1). A general surgery consultation was subsequently obtained. Given the absence of signs indicating deep tissue involvement, management proceeded with close observation. Subsequent pain and swelling led to flexion contractures of the fingers, severely impairing activities of daily living (Figure 2).

Table 2

Table 2. Temporal progression and management of necrotizing fingertip infection.

Figure 2

Figure 2. A clinical photograph taken during examination showing a necrotic lesion on the right fingertip. Informed consent for the publication of clinical images was obtained from the patient's parents.

Following the diagnosis of necrotizing soft tissue infection, the child was administered intravenous meropenem (15 mg/kg, q8h). Concurrently, a series of targeted and systematic nursing interventions were initiated. The nursing protocol included the following: (1) systematic daily pharmacotherapeutic monitoring for potential adverse drug reactions such as rash, pruritus, and drug-induced fever; (2) patient and caregiver education to avoid hand contact with objects and refrain from scratching skin lesions; (3) a structured wound care protocol administered six times daily (two times each in the morning, afternoon, and evening) during the initial 4-day period. Each wound care session comprised the following: firstly, a 20-min application of 75% ethanol followed by 15–20-min compresses with ethacridine lactate solution compresses; then, topical administration of recombinant human epidermal growth factor solution (Jinyinte®) and mupirocin ointment (Bactroban®) to violaceous edematous areas; and finally, 10–20 min of local oxygen insufflation to enhance drug absorption. Supplemental lidocaine hydrochloride gel was applied as needed (maximum twice daily) for relief of paroxysmal pain, with oral acetaminophen reserved for breakthrough pain. The analgesic gel was discontinued on day 5 following pain resolution, while the core four-step care cycle was maintained. After 7 days of targeted care, violaceous edema had regressed by more than 50% with significant pain reduction. Partial functional recovery of finger extension was achieved, accompanied by a marked improvement in range of motion (Figure 3A). With continued application of the four-step core care, the violaceous edema and the associated inflammation were eliminated completely within 14 days (Figure 3B).

Figure 3

Figure 3. Findings from clinical photography demonstrating the progression of wound healing following 1 week (A) and 2 weeks (B) of comprehensive nursing intervention. Informed consent for the publication of clinical images was obtained from the patient's parents.

3 Discussion

Hematologic malignancies, which originate from the hematopoietic system, are highly prevalent in the pediatric population and pose a significant threat to both the physical and the psychological wellbeing of affected children (14). In China, the peak incidence of childhood cancer occurs between 1 and 4 years of age, with leukemia representing 32.89% and constituting the most common malignancy (15). Acute lymphoblastic leukemia (ALL) is the most frequent subtype of pediatric leukemia, accounting for approximately 70% of childhood leukemia cases and approximately 25% of all malignancies in children under 15 years of age. The annual incidence of ALL in China is 3–4 cases per 100,000 children, a rate roughly three times higher than that observed in adults (15).

The primary treatment modalities for pediatric ALL include chemotherapy, hematopoietic stem cell transplantation, targeted immunotherapy, and chimeric antigen receptor T-cell immunotherapy (CAR-T). Chemotherapy remains the foundational first-line approach (16, 17). In China, commonly used chemotherapeutic protocols include the CCLG-ALL 2018 and CCCG-ALL-2015/2020 regimens. At the international level, protocols from the Children's Oncology Group (COG) and the Berlin–Frankfurt–Munster (BFM) study group are widely adopted (18–21). Notably, the CCCG-ALL-2015/2020 regimen employs refined disease classification and minimal residual disease (MRD) monitoring to guide risk stratification and treatment planning, achieving a 5-year overall survival (OS) rate exceeding 95% in children with ALL (22). In clinical practice, the selection and adjustment of chemotherapy regimens are based on a comprehensive assessment of factors including leukemia subtype, genetic profile, individual drug metabolism, and treatment response. This personalized strategy aims to maximize therapeutic efficacy while minimizing toxicity (23). Treatment typically follows a multiphase structure. The induction phase, designed to achieve complete remission, frequently combines agents such as vincristine, prednisone, daunorubicin, and L-asparaginase to rapidly reduce the leukemic burden. This is followed by a consolidation phase, which often utilizes high-dose methotrexate and cytarabine. Subsequently, maintenance therapy administered for 2–3 years and usually consisting of low-dose methotrexate and 6-mercaptopurine is critical for preventing relapse (24–31).

The limitations of chemotherapy arise principally from the considerable toxicity of its agents. These drugs can produce a range of adverse effects that may disrupt treatment and, in severe cases, necessitate its interruption. Cutaneous toxicity is among the frequently observed adverse reactions, and nail toxicity represents a particularly notable manifestation (31–33). Investigation of chemotherapy-related nail changes is hindered by several confounding factors: first, the use of multiple agent regimens complicates the identification of a single causative drug; second, frequent modifications in therapy for progressing or refractory disease may lead to cumulative damage to the growing nails; and third, opportunistic infections occurring during chemotherapy, radiotherapy, or combined surgical treatment can also impair nail development (4). In the present case, the development of paronychia in the child was likely related to the concomitant administration of vincristine and daunorubicin.

The subsequent rapid deterioration of the condition was likely precipitated by the child's unconscious picking behavior, which breached the skin barrier and facilitated bacterial entry. Against a background of severe neutropenia, the infection became uncontrolled and progressed swiftly, culminating in abscess formation. The resulting increase in local tissue pressure further compressed the microvasculature, leading to tissue ischemia and necrosis that clinically manifested as dark purple edema of the fingertips. The diagnosis of necrotizing soft tissue infection in this case was primarily clinical, based on the rapidly progressive tissue edema, evolution from cyanosis to dark purple discoloration, severe pain, and systemic signs of infection in a neutropenic host. This clinical impression was supported by a LRINEC score ≥6 points (34, 35). The presentation was distinguished from purpura fulminans by normal coagulation parameters and the absence of disseminated intravascular coagulation (Table 1) (36). The coagulation profile, characterized by persistently elevated D-dimer and a single episode of raised fibrinogen, was primarily attributable to inflammatory and coagulant activation secondary to systemic sepsis. Furthermore, the clinical picture differed markedly from ecthyma gangrenosum, which typically presents as painless macules or punched-out ulcers with a central eschar (37). This patient exhibited painful, diffuse swelling and cyanosis of the fingertips that progressed rapidly to necrosis, a presentation consistent with necrotizing infection in the setting of severe neutropenia and bacteremia. In this immunocompromised pediatric case, a chemotherapy-induced paronychia rapidly progressed to sepsis and necrotizing infection following minor local trauma. Severe complication aligns with the pathophysiological framework reviewed by Słonimska et al., wherein chemotherapeutic agents systemically impair tissue repair through multiple pathways, including the suppression of cellular proliferation, reduction of growth factor synthesis, compromise of immune responses, and disruption of angiogenesis (38). Consequently, even minor inflammatory lesions become highly susceptible to progression into extensive tissue necrosis, underscoring that such complications represent a systemic failure of wound healing. This underscores that clinical management must integrate early anti-infective therapy, meticulous wound care, and systemic support, alongside investigating targeted strategies to promote tissue repair.

Raoultella species, belonging to the Enterobacteriaceae family, are gram-negative, aerobic, opportunistic pathogens commonly encountered in immunocompromised hosts, including cancer patients. Typical clinical presentations include biliary tract infections, pneumonia, and bacteremia (39–41). In contrast to adults, pediatric infections are primarily bloodstream-derived (42). Epidemiological data indicate that Raoultella ornithinolytica predominantly infects children over 3 years of age and newborns, with no significant gender predilection. Underlying conditions in older children frequently involve malignancies or immune disorders, a finding consistent with a report by Seng et al., in which approximately half of 112 pediatric cases had tumor- or immune-related diseases (43). R. ornithinolytica exhibits intrinsic resistance to ampicillin mediated by β-lactamase production. Current therapeutic evidence supports the use of cephalosporins, carbapenems, quinolones, and aminoglycosides as effective options (44–46). Although timely antibiotic intervention generally yields favorable outcomes, fatal cases have been reported (43). In the present case, blood culture confirmed the presence of R. ornithinolytica bacteremia. Meropenem, a carbapenem antibiotic that acts via irreversible inhibition of bacterial cell wall synthesis and is a cornerstone agent for infections caused by ESBL-producing Gram-negative bacilli, was selected for treatment (47). Treatment was administered for 10 days, resulting in resolution of fever and a reduction in inflammatory markers within 72 h.

The structured wound care protocol was designed based on institutional experience and supporting evidence from the literature. Ethacridine lactate compresses were chosen for their broad antiseptic action and low tissue toxicity, qualities that make them suitable for managing exudative, erosive, and contaminated wounds, including venous ulcers (48, 49). They are often used in debridement and dressing of various traumas, exudations, erosive infectious wounds, and skin lesions such as venous ulcers (50). Topical recombinant human epidermal growth factor (rh-EGF) was incorporated to promote re-epithelialization in necrotic tissue (51, 52). Mupirocin ointment was selected for its targeted activity against primary skin pathogens while preserving commensal flora, thereby supporting the skin's natural barrier function in both primary and secondary infections (53). The protocol also aimed to optimize the local wound environment. Lactate, in the presence of oxygen, stimulates fibroblast proliferation and angiogenesis (54). Since optimal epithelial regeneration occurs at oxygen concentrations between 10% and 50%, the regimen was designed to support this range (55–57). The potential adjunctive role of hyperbaric oxygen therapy in enhancing fibroblast function and keratinocyte differentiation was also considered within this physiological framework (58).

Systematic nursing care plays a crucial role in managing pediatric ALL patients who develop chemotherapy-induced paronychia that progress to necrotizing soft tissue infection. At present, no standardized, uniformly effective nursing protocol exists for this complication. In providing targeted care and pharmacovigilance, nursing staff should emphasize proactive communication with the patient and family, delivering psychological support and disease-specific health education. Fostering a positive and optimistic outlook toward treatment is essential to promote both psychological and physiological recovery. In the case of the patient in this study, the implementation of a structured wound-care protocol was associated with marked clinical improvement.

4 Conclusion

In conclusion, we report the successful management of a pediatric patient with ALL in whom chemotherapy-induced paronychia progressed rapidly to necrotizing soft tissue infection of the fingertips. The nursing team was instrumental in promptly implementing a structured, multistep wound care protocol. The protocol effectively controlled the infection, promoted tissue regeneration, and helped restore function despite the patient's profoundly immunocompromised state due to severe neutropenia. This case highlights the importance of early warning, systematic assessment, and standardized stepwise wound management in severe chemotherapy-related skin toxicity to improve clinical outcomes. Our experience provides valuable insights into managing rare, but critical adverse drug reactions in pediatric oncology nursing underscore the essential role of specialized nursing in supportive cancer care.

Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material, and further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving humans were approved by the Dalian Women and Children's Medical Center (Group) Medical Ethics Committee. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants' legal guardians/next of kin. Written informed consent was obtained from the individual(s), and minor(s)' legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.

Author contributions

NL: Data curation, Formal analysis, Investigation, Resources, Writing – original draft. ZZ: Data curation, Formal analysis, Visualization, Writing – original draft. YL: Data curation, Formal analysis, Writing – original draft. HW: Formal analysis, Methodology, Writing – original draft. YZ: Data curation, Investigation, Writing – original draft. FC: Conceptualization, Project administration, Supervision, Writing – review & editing.

Funding

The author(s) declared that financial support was not received for this work and/or its publication.

Acknowledgments

We thank the patient and staff associated with the clinical study discussed here.

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

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