White nails in AIDS/ARC due to Trichophyton rubrum infection

Superficial fungal infections in renal transplant recipients

BACKGROUND

Renal transplant recipients (RTRs) are predisposed to fungal infections because of long-term graft-preserving immunosuppressive therapy.

METHODS

We prospectively enrolled 223 consecutive adult RTRs. Patients were transplanted at 1 of 2 transplant centers in Poland. The group consisted of 97 women (43%) and 126 men (57%). The control group consisted of 100 patients (39 women and 61 men) randomly selected from the outpatient dermatology clinic and from hospital personnel. All RTRs and the control group were screened for the presence of superficial fungal infections. All patients were examined by the same dermatologist. The oral mucosa and the entire body surface were fully examined. Mucosal swabs were obtained from all patients in both the examined and control groups. Skin scrapings and swabs were obtained from any clinically suspicious lesions. Nail clippings were collected in the case of any nail changes.

RESULTS

Superficial fungal infections have been detected in 133 RTRs (60%)and 27 controls (27%; P = .00001). One hundred eight RTRs (62%) developed superficial fungal infections in the first year after transplantation (P < .008). The most common site for superficial fungal infections in the RTRs group was the oral cavity. Candida albicans was the most frequently isolated species in the oral cavity.

CONCLUSIONS

Superficial fungal infections in RTRs are statistically more common among RTRs than in the general population. Whether the drug was used separately or administrated under immunosuppressive combinations had no influence on the occurrence of fungal infections. The final results showed no correlation between patient age and the occurrence of fungal infections. Dermatologists who care for transplant patients should be aware of the clinical course of fungal species in RTRs compared with the general population.

Superficial white onychomycosis—A syndrome with different fungal causes and paths of infection

Superficial white onychomycosis (SWO) is a clinical term used to describe onychomycosis in which the invasion of the nail plate occurs from the dorsal surface. However, recent observations indicate that the clinical appearances may vary to include infection in patches or in a striate patter. This report shows that, in some cases, it may be combined with either distal and lateral subungual onychomycosis or proximal white subungual onychomycosis. Invasion of the dorsal nail surface, but originating from the proximal nail fold, is another route of infection in SWO. A new classification of this condition is proposed with 4 main variants. Although based on clinical features, often other factors such as immunosuppression or invading organism (eg, Trichophyton rubrum or Fusarium species) appear to play a role in the development of a particular pattern of infection. This is an observational study carried out by trained and experienced clinicians. The main clinical implication is that in combined forms, or where the infection emerges from beneath the proximal nailfold, systemic rather than topical antifungal therapy is advised.

Cutaneous Infections Associated with HIV/AIDS

With diminished and dysregulated cell-mediated immunity, HIV-infected individuals are susceptible to a myriad of skin infections. These infections include the conditions encountered in immunocompetent patients, as well as infections seen almost exclusively in the setting of HIV infection. The HIV/AIDS pandemic has made some previously rare infections more prominent. Although antiretroviral therapy has been helpful in relieving the burden of cutaneous infections in HIV-infected patients, it does not prevent all opportunistic infections in the skin and also has created new dilemmas.

Superficial white onychomycosis revisited

BACKGROUND

Superficial white onychomycosis (SWO) is a distinct pattern of fungal nail invasion, which is usually treated with topical antifungals.

OBJECTIVE

This paper presents a case of SWO with deep penetration and records other similar cases.

METHODS

The clues to deep invasion of the nail plate are twofold: an inability to clear the discoloration by scraping the nail and a clinical involvement of the nail plate in the proximal nailfold area. Histology of the nail keratin will confirm deep penetration beyond the superficial layers of the nail plate.

RESULTS

In the light of this finding the authors propose a further subdivision of SWO to reflect previously unrecognized variants with therapeutic implications into: (i) the classical SWO type; (ii) the dual invasion of the nail plate, superficial and ventral; and (iii) the pseudo-SWO with deep fungal invasion of the nail plate.

CONCLUSIONS

This subdivision of SWO allows the clinician to treat the patient appropriately using topical antifungals when the disease is restricted to the dorsum of the nail. Systemic drugs either in isolation or in combination with topical treatment are mandatory when deep penetration or ventral fungal invasion are observed.

Epidemiology and prevalence of onychomycosis in HIV-positive individuals

BACKGROUND

Patients who are human immunodeficiency virus (HIV) positive are predisposed to the development of infections including tinea pedis and onychomycosis. While smaller studies have been reported, there has been no large study evaluating the prevalence of onychomycosis in HIV-positive individuals, or comparing the development of onychomycosis in a typical temperate area with that in a typical tropical area.

METHODS

HIV-positive individuals were evaluated at five clinics: four in Ontario, Canada and one in Sao Paulo, Brazil. The subjects were asked questions to determine the epidemiology of onychomycosis in HIV-positive individuals. The feet were examined and nail material was obtained for mycologic examination to determine the causative organism of onychomycosis.

RESULTS

A total of 500 subjects were examined (415 men and 85 women; age (mean +/- SE), 39 +/- 0.4 years; 400 Canadian, 100 Brazilian). The racial origins of the Canadian patients were: Caucasian, 83.8%; Asian, 4.3%; African-American, 8.1%; Hispanic, 3.3%; American Indian, 0.3%. The Brazilian origins were: Caucasian, 68.7%; African, 18.1%; mixed race, 13.3%. Abnormal appearing nails and mycologic evidence of onychomycosis were present in 200 (40.0%) and 116 (23.2%), respectively, of 500 subjects. The prevalence of onychomycosis in the Canadian and Brazilian samples was 24.0% (96 of 400) and 20.0% (20 of 100), respectively. The projected prevalence of onychomycosis in HIV-positive individuals in Canada was 19.9% (95% CI: 16.0-23.9%) after taking into account the age and sex distribution of HIV-positive individuals in the population. When nails appeared clinically abnormal, the prevalence of onychomycosis was 50.5% (Canada, 51.3%; Brazil, 45.5%). For comparison, published data indicate that the prevalence of onychomycosis in immunocompetent individuals living in Canada is 6.9%. The clinical presentation of onychomycosis for the whole sample (n=500) was: distal and lateral subungual onychomycosis (DLSO), 20.0%; white superficial onychomycosis (WSO), 3.6%; proximal subungual onychomycosis (PSO), 1.8% (Canadian and Brazilian samples: DLSO 21.2% vs. 15.0%, WSO 3.3% vs. 5.0%, and PSO 1.5% vs. 3.0%). The distribution of the causative fungal organisms was: dermatophytes: Candida species: nondermatophyte molds, 73:2:2 (Canadian and Brazilian samples: dermatophytes 95.5% vs. 90.9%, Candida species 3.0% vs. 0%, and nondermatophyte molds 1.5% vs. 9.0%). The use of protease inhibitors, reverse transcriptase inhibitors, or oral antifungal agents did not make a significant difference in the prevalence of onychomycosis for both the Canadian and Brazilian groups. Patients with onychomycosis were aware of their abnormal appearing nails (chi2(1)=69.7, P<0.001), embarrassed by the appearance of their nails (chi2(1)=29.7, P<0.001), and took measures to hide their nails from other individuals. A higher proportion of individuals with onychomycosis experienced discomfort compared with those without the disease (chi2(1)=9.0, P=0.003). Also, individuals who experienced pain in the nail unit were more likely to have onychomycosis (risk odds ratio (ROR), 2.2; 95% CI: 1.0-4.7, P=0.05).

CONCLUSIONS

The prevalence of onychomycosis in HIV-positive individuals in the sample of 500 patients was 23.2%. In the Canadian (n=400) and Brazilian (n=100) samples, the corresponding figures were 24% and 20%, respectively, with the predominant causative organisms being dermatophytes. The projected prevalence of onychomycosis in HIV-positive Canadians is 19.9%. Predisposing factors include a CD4 count of approximately 370, a positive family history of onychomycosis, a history of tinea pedis, and walking barefoot around pools. Onychomycosis can be symptomatic, a source of embarrassment, and a potential cause of morbidity.

Ciclopirox nail lacquer solution 8% in the 21st century

Ciclopirox nail lacquer solution 8% has been shown to be effective in the treatment of dermatophyte onychomycosis of mild to moderate severity Other studies report the effectiveness of ciclopirox nail lacquer in onychomycosis caused by Candida sp and nondermatophyte molds. Ciclopirox nail lacquer may also be valuable in the treatment of early cases of reinfection/relapse. Ciclopirox nail lacquer solution 8% may be an important adjunct to oral antifungal therapy in certain presentations that might be poorly responsive to oral antifungal therapy alone (eg, lateral onychomycosis, longitudinal spike, dermatophytoma, and extensive onycholysis). In some cases, surgical therapies may need to be considered in addition to, or in preference to, topical nail lacquer treatment. The use of ciclopirox nail lacquer solution 8% as an adjunct to oral antifungal therapy may widen the spectrum of activity of the combination because of the broad spectrum of coverage provided by the lacquer. The use of combination therapy may be synergistic in terms of efficacy, enabling a reduction in the duration and cumulative dosage of oral therapy. This could result in a decrease in the frequency and severity of systemic adverse effects associated with the oral antimycotics and the need to be vigilant about drug interactions. Studies need to be conducted to determine the place of combination oral and topical lacquer therapy in the management of onychomycosis.

Onychomycosis in the elderly

Onychomycosis is found more frequently in the elderly, and in more males than females. Onychomycosis of the toes is usually caused by dermatophytes, most commonly Trichophyton rubrum and T. mentagrophytes. The most common clinical presentations are distal and lateral subungual onychomycosis (which usually affects the great/first toe) and white superficial onychomycosis (which generally involves the third/fourth toes). Only about 50% of all abnormal-appearing nails are due to onychomycosis. In the remainder, trauma to the nail, psoriasis and conditions such as lichen planus should be considered in the differential diagnosis. Therefore, the clinical impression of onychomycosis should be confirmed by mycological examination, whenever possible. The management of onychomycosis may include no therapy, palliative treatment with mechanical or chemical debridement, topical antifungal therapy, oral antifungal agents or a combination of treatment modalities. In the US, the only new oral agents approved for treatment of onychomycosis are terbinafine and itraconazole. Fluconazole is approved for onychomycosis in some other countries. Ciclopirox nail lacquer has recently been approved in the US for the treatment of onychomycosis. In some other countries topical agents such as amorolfine are also used. Griseofulvin and ketoconazole are no longer preferred for the treatment of onychomycosis. The new oral antifungal agents are effective and well tolerated in the elderly. Patient selection should be based on the history (including systems review and medication record), examination and baseline monitoring, if indicated. Laboratory monitoring during therapy for onychomycosis varies among physicians. A combination of removal of the diseased nail plate or local measures and oral antifungal therapy may be optimal in certain instances, e.g. when lateral onychomycosis or dermatophytoma are present. For dermatophyte toe onychomycosis the recommended duration of therapy with terbinafine is 250 mg/day for 12 weeks. For itraconazole (pulse) the regimen is 200 mg twice daily for 1 week on, 3 weeks off, repeated for 3 consecutive pulses and with fluconazole the regimen is 150 to 300 mg once weekly given for a usual range of 6 to 12 months or until the nail plate has grown out. In some instances, if extra therapy is required, one suggestion is that 4 weeks of terbinafine or an extra pulse of itraconazole are given between months 6 and 9 from the start of therapy. Once cure has been achieved, it is important to counsel patients on the strategies of reducing recurrence of disease.

Clinical and mycological features of dermatophytosis in renal transplant recipients

Dermatophytosis was detected in 42% of 100 renal transplant recipients screened, of whom 17% had the infection for more than 1 year. Tinea cruris and tinea corporis were the common clinical types observed. Tinea unguium presented as proximal subungual white onychomycosis (PSWO) in 3% of patients. The lesions in the majority were non-inflammatory, scaly and without central clearance. The commonest isolate was Trichophyton rubrum.

A new classification of onychomycosis

This new classification of onychomycosis is a development of previous schemes and depends on the recognition of different clinical patterns of nail plate involvement associated with fungal infection as well as histopathology. The main types are distal and lateral subungual onychomycosis, superficial onychomycosis, proximal subungual onychomycosis, endonyx onychomycosis and total dystrophic onychomycosis. In addition, patients may show different combinations of these patterns. The identification of clinical patterns of disease may be useful in defining differences in clinical behaviour, treatment response and associated disease.

Onychomycosis in Rome, Italy

This report presents the results of a study conducted between 1985 and 1994 on onychomycosis observed in the city of Rome. Six thousand six hundred and eighty eight patients were examined during this period. Among them 1,762 (26.3%) were affected by fungal nail infections. Because the etiologic agents could not be isolated in 105 cases (6%), the results refer to 1,657 subjects (24.8% of the total), presenting with positive microscopic and cultural examinations. Thirty eight patients (2.3%) had onychomycosis of both their hands and feet. From an etiological point of view, 59.1% of the nail infections were caused by yeasts, 23.2% were infected with dermatophytes and 17.6% by non-dermatophytic fungi. The etiology of onychomycosis of the hands differed from that of the feet. Yeasts were primarily responsible for onychomycosis of the hands (86.2%), while dermatophytes caused tinea unguium peduum (48%). Fungal fingernail infections by Candida spp. were the most common (50.3%), followed by those of the feet by dermatophytes (20%). Candida albicans was responsible for 70.6% of the hand infections but for only 15.9% of those of the feet. Trichophyton rubrum and T mentagrophytes were the most common dermatophytes, mainly causing toenail infections (23.4% and 21%, respectively), while Aspergillus spp., Scopulariopsis brevicaulis, Acremonium spp. and Aspergillus niger were the most common non-dermatophytes observed. With regard to sex, the fungal nail infections were more widespread in women (72.1%) and in subjects of both sexes over the age of 50.

Widespread dermatophytosis due to Microsporum (Trichophyton) gallinae in a patient with AIDS--a case report from Spain

We report the case of a 25-year-old, HIV-positive patient (group IV, A, C2 clinical stage) with a widespread dermatophyte infection. He was a male gypsy with a known history of intravenous drug abuse. After an episode of cerebral toxoplasmosis for which he was treated with systemic steroids (because of cerebral oedema) he developed, over 16 days, a remarkably extensive ringworm of the trunk due to an unusual zoophilic dermatophyte, Microsporum (Trichophyton) gallinae. Human infection with this dermatophyte species is unusual: there are as few as seven proven reported cases, all of whom had localized lesions. This is the first widespread and severe case reported in man and also the first reported from Spain.

Dermatitis of the face, yellow toe nail changes, hairy leukoplakia and oral candidiasis are clinical indicators of progression to AIDS/opportunistic infection in patients with HIV infection

In a prospective longitudinal study of 89 men with HIV infection and persistent generalized lymphadenopathy (PGL) we tried to find clinical signs predictive of development to AIDS/opportunistic infection (OI). The mean observation time was 47 months. 27 patients (30%) developed AIDS/OI after a mean of 37 months. The estimated median time from diagnosis of PGL to AIDS/OI was 68 months. Four clinical signs of progression towards AIDS/OI were identified: dermatitis of the face, yellow toe nail changes, hairy leukoplakia and oral candidiasis. One or more of these signs were recorded in 25/27 (93%) of the patients before the development of AIDS/OI. The estimated median time from registration of each sign to AIDS/OI was: dermatitis of the face, 29 months; yellow toe nail changes, 21 months; hairy leukoplakia, 18 months; and oral candidiasis, 10 months. The estimated median time from herpes zoster to AIDS was only slightly shorter than the estimated time from diagnosis of PGL to AIDS/OI.