When the story doesn’t fit: A case of acral lentiginous melanoma of the big toe

Melanoma is an aggressive but easily preventable cancer. However, it may have a highly atypical presentation which makes early detection more difficult. This case report discusses a 25-year-old patient with a rare case of melanoma developing underneath the nail of the first toe. The case was originally diagnosed as trauma due to its rarity and epidemiological unlikeliness, however through the patient’s persistence for alternative opinions the correct diagnosis was eventually made. However, this led to an amputation as well as more intense, invasive treatment. There were several points on history (duration of the lesion, appearance of the lesion, and lack of healing progress) which when combined with the lesion’s physical appearance should have made such a presentation suspicious for a more malignant cause. This case highlights the importance of early detection in the prognosis and treatment of patients with cancer, the importance of considering all aspects of a history and physical exam, and the importance of listening to and addressing a patient’s concerns. As always, more common diagnoses should be first considered, but when the story does not match up with the presentation, one should move past the horses to consider the zebras