Onychomycosis secondary to onychomadesis: an underdiagnosed manifestation

Onychomycosis is a rare nail disorder in early childhood, while onychomadesis is a periodic idiopathic, non-inflammatory disease that affects the nail matrix and is common in children especially in those who suffer from viral infections. In this study, we investigated recent cases of onychomycosis subsequent to periods of onychomadesis in children. Sixteen young children (six males, 10 females) with a mean age of 36.5 months were diagnosed with onychomadesis, and 13 of the patients had a history of viral infection prior to nail changes. Direct microscopy of nail scaling was positive in 11 cases (68.8%), and culture was positive in the same number of cases. Four Candida species were isolated: Candida glabrata was the most frequent, found in eight cases (72.7%), while C. albicans, C. parapsilosis and C. tropicalis, each were encountered in a single case. All children were treated successfully with or without topical bifonazole therapy.

Onychomadesis after hand-foot-and-mouth disease outbreak in northern Greece: case series and brief review of the literature

BACKGROUND

Nail abnormalities in childhood are generally uncommon. Recently, onychomadesis was described as a late complication of hand-foot-and-mouth disease (HFMD). Onychomadesis outbreaks following HFMD have been reported in many countries worldwide.

AIM

To present a case series of onychomadesis in children, following HFMD outbreak in Northern Greece, and review literature data.

METHODS

Children with evident onychomadesis attending the outpatient clinic between November 2012 and January 2013 were included in the study. A questionnaire including demographic personal and family history information of the children was completed by the parents. Patients were clinically examined, and their pediatric and dermatological records were studied to confirm precedent HFMD. Direct microscopic examination and cultures for fungi were performed. Exposure of participants to coxsackievirus, based on serology testing during infection, was also recorded.

RESULTS

Sixty-eight children with onychomadesis were included. The mean number of affected nails was 8.82. Fingernails were more often involved. Previous clinical diagnosis of HFMD was confirmed in 67/68 cases. The mean time from HFMD diagnosis to onychomadesis development was 39.6 days (range: 28-56 days, STD: 7.33). Direct microscopic examination, as well as cultures for fungal species, was negative for the whole sample size. All the nail changes were transient with spontaneous regrowth after 1-4 months.

CONCLUSION

Our data indicate that onychomadesis outbreak in the region of Thessaloniki during fall-winter 2012-13 was highly related to the outbreak of HFMD. Our study reinforces existing evidence for the association between onychomadesis and HFMD.

Enterovirus co-infections and onychomadesis after hand, foot, and mouth disease, Spain, 2008

Mixed infection of enteroviruses may explain the rare complication of nail shedding.

Onychomadesis after HFMD

Hand, foot, and mouth disease (HFMD), a common disease caused by enteroviruses (EVs), usually affects children. Clustered and sporadic HFMD cases, followed by onychomadesis (nail shedding), occurred during summer and fall 2008 in Valencia, Spain. Fecal samples from onychomadesis patients, who did or did not have previous HFMD, and from healthy children exposed to onychomadesis patients tested positive for EV. The complete viral protein 1 capsid gene sequence was obtained for typing and phylogenetic analysis. Two EV serotypes, coxsackievirus A10 and coxsackievirus B1 (CVB1), were mainly detected as a monoinfection or co-infection in a childcare center where an onychomadesis outbreak occurred. On the basis of our results, and detection of CVB1 in 2 other contemporary onychomadesis outbreaks in childcare centers in Spain, we propose that mixed infection of an EV serotype that causes HFMD, plus the serotype CVB1, could explain the emergence after HFMD of onychomadesis, a rare and late complication.

Onychomadesis outbreak in Valencia, Spain associated with hand, foot, and mouth disease caused by enteroviruses

This report evaluates the June 2008 onychomadesis outbreak in Valencia, Spain. The study sample consisted of 221 onychomadesis cases and 77 nonaffected individuals who lived close to those affected. We collected data on dietary variables, hygiene products, and individual pathological histories. Feces and blood specimens were collected from 44 cases and 24 controls to evaluate exposure to infectious agents. Pathological background data revealed a high frequency (61%) of hand, foot, and mouth disease among the onychomadesis cases. Coxsackievirus A10 was the most commonly detected enterovirus in both case and control groups (49%). Other enteroviruses such as coxsackieviruses A5, A6, A16, B1, and B3; echoviruses 3, 4, and 9; and enterovirus 71 were present in low frequencies in the case and control groups (3-9%). The 2008 onychomadesis outbreak in the metropolitan area of Valencia was associated with an outbreak of hand, foot, and mouth disease primarily caused by coxsackievirus A10.

Onychomadesis after a hand, foot, and mouth disease outbreak in Spain, 2009

Few reports exist regarding the association between onychomadesis and an enterovirus infection presenting clinically as hand, foot, and mouth disease (HFMD). In February 2009, an outbreak of HFMD occurred in a Spanish nursery school, followed by onychomadesis 36-69 days later. Twelve of 17 children with HFMD developed nail shedding; enterovirus was detected in stool samples from eight (47%) of the 17. However, in only three of the children could an enterovirus serotype coxsackievirus B1 be identified. The epidemiological results of this study confirm onychomadesis as a complication in HFMD. In future outbreaks, molecular characterization of enterovirus from appropriate clinical samples should be studied.

Coxsackievirus A6 and hand, foot, and mouth disease, Finland

During fall 2008, an outbreak of hand, foot, and mouth disease (HFMD) with onychomadesis (nail shedding) as a common feature occurred in Finland. We identified an unusual enterovirus type, coxsackievirus A6 (CVA6), as the causative agent. CVA6 infections may be emerging as a new and major cause of epidemic HFMD.

[Post viral onychomadesis outbreak in Valladolid]

INTRODUCTION

An onychomadesis outbreak associated with hand-foot-mouth disease (HFMD) was notified in winter 2008 in Valencia, Spain, with more than 200 people affected, the majority children. Even though this association has already described, this was the first outbreak known in the world. Sixteen cases of post-viral onychomadesis post viral in Valladolid are presented

MATERIAL AND METHODS

Between November 2008 and February 2009, 15 children aged between 18 months and 3 years, and one mother, presented with onychomadesis in Primary Care Centres in Valladolid.

RESULTS

HFMD was diagnosed in a single month in 11 patients who attended two nurseries. The others attended others nurseries of Valladolid area. Nine children (60%) had the clinical diagnosis of HFMD 3 to 12 weeks before (mean: 6 weeks), six with fever. The nail changes were usually temporary with spontaneous normal re-growth in 1 to 4 months.

CONCLUSIONS

The clinical and epidemiological characteristics of this report were similar to the Valencia outbreak: age, geographic clustering, acral eruption prior, etc. Perhaps the diagnosis is underestimated due to ignorance of the disease and the long interval between the acute viral process and nail shedding.