Clinical presentation of onychomycosis in hiv/aids: a review of 280 mexican cases

Retrospective Analysis of Onychomycosis Risk Factors Using the 2003-2014 National Inpatient Sample

INTRODUCTION

Onychomycosis, a fungal nail infection, is associated with significant morbidity and negative impact on quality of life. Therefore, understanding associated risk factors may inform onychomycosis screening guidelines.

OBJECTIVES

This retrospective study investigated common demographic and comorbidity risk factors among hospitalized patients using the National Inpatient Sample.

METHODS

The 2003-2014 National Inpatient Sample (NIS) database was used to identify onychomycosis cases and age and sex matched controls in a 1:2 ratio. Chi-square tests and T-tests for independent samples were utilized to compare categorical and continuous patient factors. Demographic and comorbidity variables significant (P < 0.05) on univariate analysis were analyzed via a multivariate regression model with Bonferroni correction (P < 0.0029).

RESULTS

119,662 onychomycosis cases and 239,324 controls were identified. Compared to controls, onychomycosis patients frequently were White (69.0% versus 68.0%; P < 0.001), Black (17.9% versus 5.8%; P < 0.0001), and insured by Medicare or Medicaid (80.1% versus 71.1%; P < 0.0001). Patients had greater hospital stays (9.69 versus 5.39 days; P < 0.0001) and costs ($39,925 versus $36,720; P < 0.001) compared to controls. On multivariate analysis, onychomycosis was commonly associated with tinea pedis (odds ratio [OR]: 111.993; P < 0.0001), human immunodeficiency virus (OR: 4.372; P < 0.001), venous insufficiency (OR: 6.916; P < 0.0001), and psoriasis (OR: 3.668; P < 0.001).

CONCLUSIONS

Onychomycosis patients had longer hospital stays and greater costs compared to controls. Black patients were disproportionately represented among cases compared to controls. Onychomycosis was associated with tinea pedis, venous insufficiency, human immunodeficiency virus, psoriasis, obesity (body mass index [BMI] ≥ 30 kg/m2), peripheral vascular disease, and diabetes with chronic complications, suggesting that inpatients with onychomycosis should be screened for these conditions.

Nail Changes in People Living with Human Immunodeficiency Virus: Observational and Cross-Sectional Study in a Third-Level Hospital

Introduction

Nail changes in people living with human immunodeficiency virus (HIV) have been scarcely reported. The aim of this study was to establish the frequency and characteristics of nail alterations observed in adults with HIV infection in a third-level hospital in Mexico.

Method

Observational and cross-sectional study carried out in 205 patients receiving care at the HIV/AIDS Clinic of the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ) in Mexico City. We performed a nail and iconographic assessment of both hands and toenails. We collected information of demographic and clinical variables, as well as drugs use, and antiretroviral treatment used by the participants through a questionnaire and from medical records. We performed direct cytological examinations and nail mycological cultures in participants with symptoms of onychomycosis.

Results

The participants were predominantly male patients (91.2%), with a mean age of 41 (range 21-78) years, under antiretroviral therapy (91.2%), with a suppressed viral load (78.5%) and mean CD4+ lymphocyte count of 379.5 (range 20-1,162) cells/μL. Fitzpatrick's IV phototype was prevailing in the studied population (70%). Nail changes were documented in 72.2% of the patients; being pigmentary changes (37.1%) and trauma (30.7%) the most frequent. Onychomycosis was observed in 26.3%; with total dystrophic onychomycosis as the most frequent clinical variant (68.5%). We obtained fungal isolates in 59.3% of participants and Candida parapsilosis was the most frequent of these (37.5%).

Conclusions

We observed a high prevalence of nail changes with very diverse etiology, as well as a variety of nondermatophytic yeasts and molds isolates associated with cases with onychomycosis. These findings reinforce and confirm the need for routine nail examination and stress the importance of medical personnel working with people living with HIV to have broad knowledge of nail pathology.

Nail dermatophytoma in HIV-infected patients in Cali, Colombia

INTRODUCTION

A dermatophytoma is a mass of hyphae that is observed at direct examination, it responds poorly to treatment with antifungal drugs, some authors have proposed that it is actually a biofilm. This pathology is underdiagnosed, and its true incidence is unknown.

OBJECTIVES

This study presents the clinical findings of dermatophytoma in HIV/AIDS patients from Colombia presenting onychomycosis.

MATERIAL AND METHODS

A transversal observational descriptive study was carried out in a third level university hospital. One hundred thirty HIV positive patients diagnosed using ELISA and Western Blot that presented nail lesions on their hands and/or feet compatible with onychomycosis were included. Samples taken from affected nails were observed in direct examination with KOH and seeded onto Sabouraud agar, mycosel agar and dextrose-potato agar. Molds were identified based on macroscopic and microscopic characteristics.

RESULTS

Six (4.6%) individuals presented dermatophytoma. Average age was 43 years (range 33-50); nails more commonly affected (5/6) were on the toes, principally the hallux. Clinical manifestations included a yellow or white, rounded or linear dense area on the nail. Superficial white onychomycosis was present in 83.3% of the patients. Fungal cultures were obtained in only 5 patients; Trichophyton mentagrophytes complex was found in 2 individuals while T. rubrum, T. tonsurans and Epidermophyton floccosum were in the other 3. Average cell count for CD4⁺T lymphocytes was 86.8 cells/mm³ (range 9-282).

CONCLUSIONS

This is the first report in Colombia of dermatophytoma in HIV/AIDS patients, most of them had a CD4+ T lymphocytes count less than 200 cells/mm3. Several clinical forms of onychomycosis were observed, the most frequent was the white superficial onychomycosis.

Liquid chromatography-tandem mass spectrometry is effective for analysis of ergosterol in fungal-infected nails

BACKGROUND

Identification of onychomycosis is mainly based on clinical diagnosis with auxiliary diagnostic methods such as potassium hydroxide (KOH) microscopy, periodic acid-Schiff staining or fungal culture. However, each method is limited by its sensitivity and specificity.

AIM

To develop a new test method using the common fungal end product, ergosterol, and investigate if it can be used as a new diagnostic tool.

METHODS

We collected consecutive data from 20 participants with nail problems. Following clinical diagnosis, samples were taken for KOH microscopy and for mass spectrometry (MS) to check for the presence of ergosterol.

RESULTS

Of the 20 cases collected, 7 were positive for fungal infection by MS. Four of these were already suspected to have onychomycosis, whereas one of the remaining three subjects was presumed to have dry nail and the other two to have onycholysis. The MS test seemed to be better at detecting combinations of nail conditions. Conversely, of the five patients clinically diagnosed as having onychomycosis, four had a positive MS result, whereas the fifth had negative results on both KOH and MS. Two other participants had a positive KOH test and were also found to have positive MS results.

CONCLUSION

Detection of the presence of ergosterol by MS seems to be a useful tool for confirming onychomycosis. However, further studies are needed to verify the sensitivity and specificity of this MS method.

Global perspectives for the management of onychomycosis

Onychomycosis is a fungal nail infection caused by dermatophytes, nondermatophyte molds, and yeasts. This difficult-to-treat chronic infection has a tendency to relapse despite treatment. This paper aims to offer a global perspective on onychomycosis management from expert physicians from around the world. Overall, the majority of experts surveyed used systemic, topical, and combination treatments approved in their countries and monitored patients based on the product insert or government recommendations. Although the basics of treating onychomycosis were similar between countries, slight differences in onychomycosis management between countries were found. These differences were mainly due to different approaches to adjunctive therapy, rating the severity of disease and use of prophylaxis treatment. A global perspective on the treatment of onychomycosis provides a framework of success for the committed clinician with appreciation of how onychomycosis is managed worldwide.

Subclinical Onychomycosis: Not Present in HIV-Positive Population?

Background

Onychomycosis is one of the most common nail diseases and constitutes up to 50% of all nail conditions. It is a chronic fungal nail infection common in the HIV-infected population. Few studies have found fungal organisms in the nail without clinical evidence, and thus, termed subclinical onychomycosis.

Objectives

We analyzed the nails of the HIV population in our hospital, searching for subclinical onychomycosis.

Method

A distal nail clipping was stained with PAS and observed by a trained dermatopathologist.

Results

All of our samples (n = 48) turned out to be negative for fungal structures.

Conclusions

The epidemiology of onychomycosis is changing, treatment options are much better now, and diagnosis and infection detection are being done earlier. Therefore, we will continue to further study this disease in other patient populations so that we can compare our results and see whether the incidence of onychomycosis in the HIV population is now similar to that in those without HIV infection of the same age.

Evaluation of improvement of onychomycosis in HIV-infected patients after initiation of combined antiretroviral therapy without antifungal treatment

Onychomycosis in HIV-infected patients has a prevalence of 20-44% and is more frequently seen with CD4(+) T cell counts ≤450 cel μl(-1). There are case reports of improvement in onychomycosis after initiation of combined antiretroviral therapy (cART), but there are no prospective studies that prove the existence and frequency of this phenomenon. The aim of this study was to evaluate if HIV-infected patients with onychomycosis who begin cART improve and/or cure without antifungal treatment. We included HIV-infected patients with onychomycosis who had not started cART and nor received antifungal therapy during 6 months prior to the study. We evaluated affected the nails with the Onychomycosis Severity Index (OSI); nail scrapings were collected and direct microscopy with potassium hydroxide (KOH) as well as mycological culture were performed. We repeated these procedures at 3 and 6 months to assess changes. CD4 T cell counts and HIV viral load were obtained. A total of 16 patients were included, with male gender predominance (68.7%); distal and lateral subungual onychomycosis (DLSO) was the most common form (31.3%). Trichophyton rubrum was the most frequently isolated microorganism. OSI decreased 21.5% at 3 months and 40% at 6 months after initiation of antiretrovirals (P = 0.05). We found a non-significant tendency towards improvement with higher CD4(+) T cell counts and with viral loads <100 000 copies ml(-1). This could be due to the increase in CD4(+) T cells, decreased percentage of Treg (CD4(+)CD25(+)) among CD4(+) Tcells and/or a decreased viral load; further studies are necessary to prove these hypothesis.

Management of Onychomycosis in Canada in 2014

Background

Onychomycosis has several clinical presentations and is caused by various infectious organisms.

Objective

To provide guidance for selection of appropriate treatment.

Methods

The literature on onychomycosis management was reviewed to generate an evidence-based decision tree.

Results and Conclusion

Several options are available: terbinafine, itraconazole, fluconazole, ciclopirox 8% nail lacquer, efinaconazole 10% nail solution, and laser therapy. Further studies on lasers are needed before use can be recommended. Nondermatophyte molds or mixed infection can be managed with terbinafine or itraconazole with or without topicals. Itraconazole, fluconazole, and efinaconazole can be used for Candida infection. For dermatophytes, topicals can be considered for mild to moderate onychomycosis. For moderate to severe cases, any oral monotherapy can be used; however, we suggest terbinafine if there is a possibility of a drug interaction. These recommendations can be applied for all ages, immune function, or metabolic status, but proper monitoring and contraindications should be taken into consideration.

Tavaborole for the treatment of onychomycosis

INTRODUCTION

Onychomycosis causes approximately one-half of all nail disorders and its prevalence has been steadily increasing. It is difficult to treat, partly due to the subungual location and the inability of both oral and topical antifungals to reach the site of infection. Published cure rates with oral drugs are < 50% and even lower with topical drugs. Pathogenic factors include the diversity of fungal organisms and the difficulty of drugs penetrating the nail plate. Tavaborole is a broad-spectrum oxaborole antifungal agent with low molecular weight, permitting optimal nail plate penetration. In vitro and ex vivo studies have demonstrated the superior nail-penetrating properties of tavaborole compared to existing topical antifungal medications approved for the treatment of onychomycosis.

AREAS COVERED

The clinical characteristics and prevalence of onychomycosis, currently available treatments, and the chemistry, safety and pharmacokinetic properties of tavaborole for the treatment of onychomycosis.

EXPERT OPINION

Tavaborole is a novel, topical antifungal pharmaceutical agent pending FDA approval for the treatment of toenail onychomycosis due to dermatophytes. Efficacy has been demonstrated by a clinical development program including in vitro data and two large Phase III trials that enrolled ∼ 1200 patients. When approved, tavaborole topical solution, 5% may become a safe and effective option for the treatment of onychomycosis.

A preformulation strategy for the selection of penetration enhancers for a transungual formulation

Onychomycosis is associated with the cutaneous fungal infection of the nail and the nail folds (skin surrounding the nail). It is therefore important to target drug delivery into the nail folds along with nail plate and the nail bed. Systematic and strategic selection of the penetration enhancers specific for the skin and the nail is discussed. Twelve penetration enhancers were screened for their ability to improve solubility, in vitro nail penetration, in vitro skin permeation, and in vitro skin penetration of the antifungal drug ciclopirox olamine. In contrast to transdermal drug delivery, the main selection criteria for skin penetration enhancer in topical drug delivery were increased drug accumulation in the epidermis and minimal permeation across the skin. Thiourea improved the solubility and nail penetration of ciclopirox olamine. It also showed enhancement in the transungual diffusion of the drug. Propylene glycol showed a 12-fold increase in solubility and 3-fold increase in epidermal accumulation of ciclopirox olamine, while minimizing the transdermal movement of the drug. Thiourea was the selected nail permeation enhancer and propylene glycol was the selected skin penetration enhancer of ciclopirox olamine. A combination of the selected enhancers was also explored for its effect on drug delivery to the nail and nail folds. The enhancer combination reduced the penetration of ciclopirox in the skin and also the permeation through the nail. The proposed preformulation strategy helps to select appropriate enhancers for optimum topical delivery and paves way towards an efficient topical formulation for passive transungual drug delivery.

[Onychomycosis: multicentre epidemiological, clinical and mycological study]

BACKGROUND

Onychomycosis accounts for up to 50% of all nail disorders. They can be caused by: yeasts, dermatophytes and non-dermatophyte moulds.

OBJECTIVES AND METHODS

A multicentre study designed to determine the prevalence, mycological test results, aetiological agents, and clinical presentation of onychomycosis was carried out. All fingernail and toenail samples taken during a one year period at 9 diagnostic centres were included.

RESULTS

A total of 5,961 samples were analysed, of which 82.3% were from toenails and 17.7% from fingernails. The mean age of the patients was 49.7 years, and 66% were females. Direct microscopic examination was positive in 61% of the samples. In adults, 61.2% of toenails were positive using potassium hydroxide (KOH), and 43.7% were positive in cultures. The prevailing aetiological agents belong to the dermatophyte group (82.8%), and distal subungual was the most common clinical form. In fingernails, direct examination showed 59.8% positive samples, and cultures were positive in 52.9%. The prevailing agents were yeasts belonging to Candida species, and onycholysis was the most common lesion.

CONCLUSIONS

Direct mycological examinations were positive in 61%, a higher value than that found in other series. Dermatophytes were prevalent in toenails of both sexes, and in finger nails yeast were prevalent in females, and dermatophytes in males. Non-dermatophyte moulds corresponded to 4.8% of toenail and 2.05% of fingernails isolates.