Candida keratitis in a patient with candidiasis of the fingernails

PURPOSE

To report a case of Candida keratitis following penetrating keratoplasty in a patient with Candidiasis of the fingernails.

CASE REPORT

An 80 year-old male presented with recurrent Candida keratitis following penetrating keratoplasty. Patient was found to have evidence of Candidiasis of the fingernails.

COMMENT

Candidiasis of the fingernails have led to recurrent fungal keratitis following penetrating keratoplasty. Cultures grew Candida albicans. Preoperative recognition, prompt and appropriate therapy of foci of infection may prevent Candida keratitis following penetrating keratoplasty.

The definition of Trichophyton rubrum syndrome

Although chronic widespread dermatophyte infection is reported widely in the literature, neither a uniform nomenclature, nor even a clear definition of this syndrome have been established so far. Thus, we suggest Trichophyton rubrum syndrome (TRS) for denomination and define the following obligatory clinical and mycological criteria for TRS. (A) Skin lesions at the following four sites: (1) feet, often involving soles; (2) hands, often involving palms; (3) nails; and (4) at least one lesion in another location than (1) (2) or (3), except for groins. (B) Positive microscopic analyses of potassium hydroxide preparations of skin scrapings in all four locations. (C) Identification of Trichophyton rubrum by cell culture at three of the four locations at least. For diagnosis of TRS the criteria (A) and (B) and (C) have to be fulfilled. This standardization is a prerequisite for further investigations of underlying mechanisms of this disease. The typical clinical pattern of TRS is illustrated by the presentation of two paradigmatic cases.

Outbreak of sternal surgical site infections due to Pseudomonas aeruginosa traced to a scrub nurse with onychomycosis

From 19 February 1999 through 31 October 1999, 16 (8.6%) of 185 patients who underwent median sternotomy developed infections with Pseudomonas aeruginosa. Seven patients had mediastinitis, 5 had deep sternal wound infection, 2 had superficial sternal wound infection, 1 had prosthetic valve endocarditis, and 1 had sepsis. Pulsed-field gel electrophoresis confirmed that all 13 isolates that were available for typing were the same strain. Cultures of hand specimens identified 1 nurse from whom the same strain of P. aeruginosa was repeatedly isolated; the nurse had been in contact with all 16 infected patients. Investigation revealed that the nurse had severe onycholysis and onychomycosis of the right thumbnail. Cultures of samples of this nail's subungual region and of multiple cosmetic products from the nurse's home yielded the identical P. aeruginosa strain. This outbreak of surgical site infections due to P. aeruginosa was caused by wound contamination from the thumbnail of this nurse, despite her appropriate use of latex surgical gloves.

Extracts from "Clinical evidence": Athlete's foot and fungally infected toenails

Definition Athlete's foot is a cutaneous fungal infection that causes the skin to itch, flake, and fissure. Nail involvement is characterised by ungual thickening and discoloration.

Isolation of Sporothrix schenckii from the nails of domestic cats (Felis catus)

We report the first isolation of Sporothrix schenckii from the nail surfaces of cats. The fungus grew from nail clippings of three cats associated with three household outbreaks of sporotrichosis involving cats and human beings. The identification of the isolates was based on macroscopic and microscopic morphological characteristics at 25 degrees C and conversion of S. schenckii to the yeast-like form at 37 degrees C.

[How to improve efficacy of onychomycosis treatment?]

Onychomycosis is a public health concern because of its high world wide prevalence, and its potential for spread of fungal elements to others. About one half of all patients presenting to dermatologists' offices for nail disorders have onychomycosis. This kind of infection may impact upon physical, functional, and emotional aspects of life. Onychomycosis can be treated with the new generation of oral antifungals. Efficacy rates for fingernail onychomycosis are high; however, for toenail onychomycosis, efficacy rates may range from 60% to 80%. Relapse rates have been estimated to be 15% to 20% measured at 2 years following therapy initiation. Because many factors may be associated with a suboptimal clinical response, consideration to measures that reflect the most appropriate pharmacologic and supportive regimens must be made in order to meet the challenge of onychomycosis cure. In some situations supplemental therapy consisting of extra antifungal or adjunctive (topical/surgical) therapy may be beneficial.

Incidence of Candida species isolated from human skin and nails: a survey

Distribution of Candida species was investigated by examining 245 samples from skin lesions and nails. The isolates were identified using standard laboratory methods including germ tube test, micromorphology of colonies on rice agar, the commercial kit, saccharide assimilation and fermentation tests. Eight species of Candida were identified: C. albicans accounted for 56.4% of the isolates, C. parapsilosis 29.1, C. tropicalis 7.8, C. pulcherrima 2.9, C. guilliermondii 1.5, C. krusei and C. zeylanoides for 0.9% each, and C. robusta for 0.5%. The factors significantly associated with colonization were prolonged antibiotic therapy, parenteral nutrition, low birth body mass of infants, intubation, duration of stay in hospital, indwelling intravenous catheter, malignancies, diabetes, surgery, and obesity.

[Fungal and bacterial nail infections]

Fungal and bacterial infections are very common causes of nail deformity. The majority of fungal nail infections are caused by dermatophytes. Dermatophytosis result from a human contamination. A dermatophyte is always a pathogenic agent. Very effective drugs are available to treat dermatophyte nail infections. Yeasts of the genus Candida, notably C. albicans are the second most common cause of nail infection. The infections of nails due to Candida and bacteria are related with Candida sp and bacteria which are common commensals of the gastrointestinal tract, vagina or skin. Except C. albicans which is always a pathogen of skin, the other species of Candida and the bacteria could be a commensal of the skin, a colonizer of a dermatological disease or a true pathogen of nail. It is important to consider these different situations. More rarely, environmental moulds, most often known as saprophytic agents, can affect nails. They do not respond to conventional antifungal drugs. So, their diagnosis do not suffer any error. In order to evaluate properly the patient with possible fungal or bacterial infection of nails and also to choice an accurate therapy, the laboratory confirmation is essential. Clinical diagnosis is not sufficient to distinguish an infection of nails from a dermatological disease (psoriasis, traumatism) and to identify the responsible agent.

Mycotic infections. Effective management of conditions involving the skin, hair, and nails

Superficial mycotic infections of the skin, hair, or nails are recurring presentations in the geriatric primary care setting. The most common infections are those caused by dermatophytes. The genus Trichophyton gives rise to most of the tinea dermatophytoses, including tinea capitis, tinea pedis, and tinea unguium (onychomycosis). Part of the diagnostic challenge lies in distinguishing the mycotic lesions from those caused by cutaneous diseases such as psoriasis, eczema, dyshidrosis, and contact dermatitis. Because environmental conditions play a major role in fungal infection onset, clinical management should include patient education about conditions conducive to fungal propagation. Oral agents are the primary mode of treatment for fungal infections of the scalp and nails, whereas topical treatments are frontline agents for other superficial skin conditions.

A case of melanonychia caused by Exophiala dermatitidis

We report a case of a healthy 61-year-old woman with discoloration of the nail on her right big toe. We first treated her with topical steroid and urea under suspected diagnosis of nail eczema, but the lesion remained. In culture, black, shiny, pasty and yeast-like colonies grew repeatedly. Examination of debris from her nail showed dematiaceous spherical cells and hyphal elements. Microscopically, annelloconidia were produced at the apical ends of anellidic conidiogenous cells. This colony grew at 40C. Mitochondrial DNA restriction fragment length polymorphism was analysed in this strain and its restriction pattern confirmed the isolate to be Exophiala dermatitidis. Based on these findings, we diagnosed this nail deformity as fungal melanonychia due to Exophiala dermatitidis. This is the third reported case of this disease.

Epidemiology of dermatomycoses of humans in Central Poland. Part II--Non-dermatophyte infections of nails and periungual walls

This study presents the epidemiology of dermatomycoses and their etiological agents of people living in the Lódź region, Central Poland, over the years 1987-1996. The study comprised a total of 25,737 patients. Positive mycological results were obtained for 14,084 patients (54.7%). The total number of 14,295 of positive mycological results included 6902 (48.3%) isolations of non-dermatophyte fungi. Among these positive results, isolations from subjects with infections of nails and periungual walls amounted to 2034 (29.5%). Candida albicans (59.9%) and Aspergillus sp. (17.3%) were major etiological factors of those infections. The decade in question was marked by a steady growth in incidence of the infections studied, especially over the years 1994-1996.

Epidemiology and in vitro activity of antimycotics against candidal vaginal/skin/nail infections in Singapore

BACKGROUND

Candidal infections of the skin/nails and vagina are very common worldwide. Various in vitro test systems are available to help to determine the antifungal activity of drugs. The minimum inhibitory concentration (MIC) is a standard measure of the in vitro potency of drugs against yeasts.

METHODS

Vaginal smears and skin/nail scrapings of 50 consecutive patients with candidal vaginitis and 46 consecutive patients (28 women, 18 men) with cutaneous/nail candidosis were used in the study. Direct microscopy and culture from vaginal smears and skin scrapings were performed on all patients. The MICs were determined using the broth dilution method.

RESULTS

For vaginal candidosis, the mean age of the patients was 28.2 years (range, 9-49 years). Candida albicans accounted for 58% of the isolates, C. glabrata for 32%, C. tropicalis for 6%, and C. parasilosis for 4%. At the MIC of < or = 4 mg/L, 65-95% of C. albicans, 66-94% of C. glabrata, 33-100% of C. tropicalis, and 0-50% of C. parasilosis were susceptible to the drugs tested (ketoconazole, itraconazole, nystatin, amorolfine, clotrimazole, and miconazole). For cutaneous/nail candidosis, the mean age of the patients was 45 years (range, 19-82 years). C. albicans made up 59% of the isolates, C. parasilosis 20%, C. krusei 13%, C. glabrata 4%, and C. tropicalis 4%. At the MIC of < or = 4 mg/L, 59-96% of C. albicans, 100% of C. glabrata, 83-100% of C. krusei, 89-100% of C. parasilosis, and 100% of C. tropicalis were susceptible to the drugs tested (ketoconazole, itraconazole, nystatin, amorolfine, clotrimazole, and miconazole).

CONCLUSIONS

C. albicans is the most common Candida species causing cutaneous/nail and vaginal candidosis in Singapore. The in vitro antifungal activities of ketoconazole, itraconazole, nystatin, amorolfine, clotrimazole, and miconazole are similar against the various Candida species. C. parasilosis in vaginal candidosis appears to be less susceptible. Here, itraconazole and amorolfine may be more effective.

Long-term post-treatment follow-up of onychomycosis treated with terbinafine: a multicentre trial

Between 1991 and 1993, 32 cases of fingernail mycosis and 20 cases of toenail mycosis caused by dermatophytes were treated with terbinafine. For 8 weeks, 250 mg of terbinafine was given daily for fingernail infections, and for 12 weeks the same dose was given for toenail involvement; the short-term follow-up was 24 and 48 weeks respectively. A long-term follow-up was performed twice, initially at 24 and then at 48 months after the end of the treatment. For fingernail mycosis, the mycological cure rate was 100% at the end of month 24 and 91% at the end of month 48. Mycological cultures gave negative results in toenail infections in 90% after 24 months and in 86% after 48 months. After 24 months, 23 out of 26 patients (88%) with fingernail and 17 out of 20 patients (95%) with toenail mycosis were clinically cured. After 48 months, 20 out of 22 cases (91%) with fingernail and 10 out of 14 cases (71%) with toenail involvement showed a complete cure.

Clinical and diagnostic aspects of dermatophyte onychomycosis

The paper presents mechanisms of the spread of dermatophyte infection in the nail and the associated most frequently encountered clinical features. Particular attention has been paid to advantages for dermatological practice that are based on using some diagnostic traits of dermatophyte onychomycosis, in particular signs of a transverse and spriggy network, typical of the disease.

Dermatologic problems in podiatric sports medicine

The podiatric physician should be keenly aware of various skin conditions and how to deal with them. Dermatologic conditions can be a significant deterrent to the athlete and his or her training schedule.

Onychomycosis caused by Scytalidium dimidiatum

We report a case of onychomycosis caused by Scytalidium dimidiatum (syn., Hendersonula toruloidea) in a patient who did not live in an endemic area. This nondermatophyte mold may produce disease indistinguishable from dermatophyte fungi, but it does not respond to current systemic antimycotic therapy. Distal subungual onychomycosis, lateral onycholysis followed by lateral nail plate invasion, and chronic paronychia are common nail presentations.

The role of yeasts in onychomycosis

Twenty patients with onychomycosis secondary to paronychia or to onycholysis were examined for causative fungal agents. The role of yeasts in these diseases is critically discussed.

Etiology and clinical characteristics of mycotic leukonychia

The purpose of the present paper is to add to our understanding of the prevalence of mycotic leukonychia. Twenty patients with mycotic leukonychia were studied. Leukonychia with atypical characteristics not previously described or with discordant characteristics relative to the ones that were responsible of this infection were found. Direct microscopic examination and cultures showed that Fusarium spp. were the responsible agents in 10% of the cases and that dermatophytes were implicated in the other 90%, where Trichophyton rubrum was the predominant etiologic agent. In this report we describe the clinical characteristics of the nail infections, the probable predisposing causes of the disease and the evolution of the cases.