Bitten to the Bone: A Case of Anxiety-Induced Osteomyelitis

Onychophagia is a habitual nail-biting disorder, usually associated with mental or emotional diseases. It affects 20-30% of the population in all age groups. Human bites have the potential to become serious injuries due to high virulence in the human oral flora and may often require hospital admission, antibiotics and even debridement in the operating room. Thus, repetitive nail biting has the potential to be limb-threatening if not treated early and appropriately. We present a 49-year-old Spanish-speaking gentleman, with a past medical history of repetitive nail biting secondary to severe anxiety, major depression disorder, bilateral hand neuropathy secondary to diabetes mellitus (DM) type 2 who was initially admitted to the hospital due to cellulitis of the fingers with suspected osteomyelitis in the right hand. Anxiety was being treated by psychiatrist with paroxetine however, given no improvement and prolonged follow-ups, the primary care physician (PCP) added hydroxyzine and scheduled alprazolam in an attempt to minimize symptoms. Despite these efforts, patient continued with nail biting. On initial physical exam, the patient had a lack of fingernails and multiple wounds at various stages of healing across all digits. The distal and middle phalanges of the third right digit showed increased erythema and swelling and band tightening. Patient was started on broad-spectrum antibiotics. Initial radiography of the right hand was concerning for osteomyelitis which was later confirmed with Magnetic Resonance Imaging (MRI). Infectious disease specialist agreed on a course of cefepime, vancomycin and metronidazole. On admission, hand surgeon did not see a need for amputation and patient was treated conservatively. Due to minimal improvement after six days on IV antibiotics, patient underwent fasciotomy of the flexor compartment of the right middle finger after patient rejected hand surgeon's recommendation for amputation. He was discharged to a skilled nursing facility where he was to continue intravenous antibiotics for an additional four weeks. The vulnerable patient population of South Texas is predominately Hispanic, Spanish-speaking and uninsured. It is imperative to treat psychiatric disorders early to prevent complications, however, given the low numbers of psychiatrists in the Rio Grande Valley and even fewer who speak Spanish it is not unusual to find an appointment in more than six months. In this case, we observe how a trivial everyday behavior can lead to limb-threatening complications if not treated early and appropriately.


Introduction
Onychophagia is a habitual nail-biting disorder, usually associated with mental or emotional diseases [1][2][3]. It affects 20-30% of the population in all age groups [3]. Human bites have the potential to become serious injuries due to high virulence in the human oral flora and may often require hospital admission, antibiotics and even debridement in the operating room. Thus, repetitive nail biting has the potential to be limbthreatening if not treated early and appropriately. Here, we present the case of a gentleman with limbthreatening osteomyelitis due to chronic nail biting secondary to severe anxiety.

Case Presentation
Patient is a 49-year-old gentleman with a past medical history of severe refractory anxiety treated with hydroxyzine and scheduled alprazolam, after failing multiple other treatments with multiple psychiatry 1 2 2 3 4
How to cite this article providers, who was admitted to the hospital due to cellulitis of the right third digit. He had already failed outpatient treatment with amoxicillin-clavulanate for cellulitis of the right third digit.
On the initial physical exam, the patient had a lack of fingernails and multiple wounds at various stages of healing across all digits (Figure 1 and 2). The distal and middle phalanges of the 3rd right digit showed increased erythema and swelling with band tightening. Surprisingly, initial labs were unremarkable (Tables  1-3        Hand surgery did not see a need for amputation initially though patient did require fasciotomy of the flexor compartment of the right middle finger on day 6 of admission due to slow recovery. Hand surgery however was not convinced patient would make meaningful recovery and advocated for amputation of finger, but patient decided to continue non operative treatment.
Patient continued to have marked improvement and was ultimately discharged to a skilled nursing facility with a PICC line where he was to continue intravenous antibiotics for 4 more weeks. In regard to his psychiatry follow ups, patient had an upcoming psychiatry appointment the week of discharge and reported concerns of close follow up due to prolonged appointments.

Discussion
Onychophagia begins at childhood and usually tend to stop biting nails overtime. The prevalence is likely underestimated due to reluctance in seeking medical care, it can range from 3% -46.9% among different population groups, with medical students being the highest affected [4]. Etiology of onychophagia is currently unknown, genetic and environmental contributions are associated with its onset and severity.
Numerous studies including twin studies [5] have shown a partial genetic component of the onychophagia [5,6].
Diagnosis of Onychophagia is made with clinical history and physical examination. Complications include Acute paronychia and later osteomyelitis. Onychophagia can also predispose to herpetic whitlow and can facilitate the spread of subungual warts [7,8]. Oral and dental complications such as prevalence of Methicillin-resistant Staphyloccus Epidermidis oral colonization [9], higher carriage of Enterobacteriaceae [10,11]. Nail biting can also be associated with Temporomandibular Joint Syndrome, therefore warrants the need for prompt treatment.
Treatment options are non-pharmacologic and pharmacologic, non-pharmacological include aversive therapies, competitive stimuli, object manipulation, habit reversal and using bitter tasting lacquer [12] . Pharmacological therapy include Selective seratonin reuptake inhibitors, N-acetyl cysteine (NAC) [13], tricyclic antidepressants, dopamine agonists and lithium. Treatment of complications is based on severity and center-specific antibiotic guidelines.
Onychophagia may lead to significant psychosocial problems. Since onychophagia is a challenging disorder to treat, a multi-disciplinary approach involving psychiatrists, internists, dermatologists and dentists may be required. In the Rio Grande valley, located in the southernmost tip of Texas, the prevalance of anxiety and depression increases while the population of physicians struggles to keep up. An estimated 10% of psychiatrist are expected to retire within the next couple of years and the consequences of will have an even bigger impact in the RGV [14][15][16][17].

Conclusions
The vulnerable patient population of South Texas is predominately Hispanic, Spanish-speaking and uninsured. It is imperative to treat psychiatric disorders early to prevent complications, however, given the few numbers of psychiatrist in the Rio Grande Valley and even fewer who speak Spanish it is not unusual find an appointment in more than 6 months out. The patient population of the RGV deserve easier access to mental health including Spanish speaking providers. In this case, we observe the limb-threatening complications a simple "bad habit" can lead to if not treated early and appropriately.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.