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The nondermatophyte molds: Emerging as leading cause of onychomycosis in south-east Rajasthan.

Raghavendra KR, Yadav D, Kumar A, Sharma M, Bhuria J, Chand AE - Indian Dermatol Online J (2015 Mar-Apr)

Bottom Line: Nondermatophytes were isolated in 53 (35.33%), dermatophytes in 28 (18.66%), and yeasts in 15 (10%) of cases.The most commonly isolated species was Aspergillus in 45 (30%) cases.Aspergillus flavus was more commonly isolated compared to Aspergillus niger.

View Article: PubMed Central - PubMed

Affiliation: Department of Skin and VD, Government Medical College, Kota, Rajasthan, India.

ABSTRACT

Background: Onychomycosis is a fungal disease of the nail apparatus caused by both dermatophytic and nondermatophytic strains. Treatment involves long duration antifungal therapy. However, long treatment duration without identifying the causative species may lead to resistance. Confirmation of diagnosis and speciation by culture before administering antifungal therapy is ideal.

Aims: To study the clinical and epidemiological aspects of onychomycosis in Hadoti region (south-east Rajasthan) and identify various mycological strains and predisposing factors causing onychomycosis.

Materials and methods: A prospective study of clinically diagnosed cases of onychomycosis attending the outpatient Department of Dermatology in our institute conducted from June 2012 to May 2013. The clippings were subjected to potassium hydroxide (KOH) examination and culture in the appropriate medium.

Results: A total of 150 cases were enrolled in our study. There were 110 males (73.33%) and 40 females (26.66%) and male to female ratio was 2.75:1. The total dystrophic onychomycosis was the most common presentation seen in the majority of cases (46%) followed by distal lateral subungual onychomycosis in 52 cases (34.6%), mixed onychomycosis in 16 cases (10.66%), superficial white onychomycosis in 11 cases (7.33%), and proximal subungual onychomycosis in 2 cases. None had the endonyx variant. Direct microscopic examination of the nail clipping mounted with 40% KOH demonstrated fungal elements in 83 (55.33%) cases. Rate of isolation of organisms by culture was 64%. Nondermatophytes were isolated in 53 (35.33%), dermatophytes in 28 (18.66%), and yeasts in 15 (10%) of cases. The most commonly isolated species was Aspergillus in 45 (30%) cases. Aspergillus flavus was more commonly isolated compared to Aspergillus niger.

Conclusion: The nondermatophyte molds appear to be more common causative agents of onychomycosis compared to usual dermatophyte species in south-east Rajasthan. Our study re-emphasizes the importance of culture for diagnosis of onychomycosis in every suspected case prior to therapy.

No MeSH data available.


Related in: MedlinePlus

All fingers and toes show total dystrophic variant of onychomycosis
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Figure 1: All fingers and toes show total dystrophic variant of onychomycosis

Mentions: The 150 cases recruited for the study accounted for 0.16% of the outpatient attendance. The average age of the study population was 34.6 ± 18 years, and most of the cases were in the third decade (n = 50, 33.33%), with age ranging from 5 to 71 years [Table 1]. Males (n = 110, 73.33%) were found to be more commonly affected than females (n = 40, 26.66%) with male to female ratio of 2.75:1. Ninety seven cases were from urban areas, and 53 were from rural areas. The agriculturists, students, and housewives constituted 22%, 20%, and 13.33% of the total cases respectively. Among the predisposing factors, barefoot walking was recorded in 31 cases (20.66%), ill-fitting shoes and contact with pets and domestic animals in 13% each, excessive detergent use in 8.66%, and history of nail biting in 6.66% cases. At presentation, duration of nail changes was less than 12 months in 79 patients (52.66%), 13–60 months in 53 (35.53%) and >60 months in 18 (10.66%) cases. TDO was seen in 69 (46%) [Figure 1], DLSO in 52 (34.6%) [Figure 2], MO in 16 (10.66%), SWO in 11 (7.33%) [Figure 3], PSO in 2 cases [Figure 4]; none had the endonyx variant [Table 2]. Among patients with the MO variant, SWO + TDO was seen in five cases, DLSO + SWO in 4, DLSO + TDO in 4, DLSO + SWO + TDO in 1, and SWO + PSO in 1 case. Fingernails alone were affected in 38% of cases and toenails alone in 33.33% cases. Both toenail and fingernail were involved in 15% cases. Nail discoloration was observed in the majority of cases (n = 106, 70.6%), nail dystrophy in 100 (66.66%), subungual hyperkeratosis in 77 (51.33%), onycholysis in 73 (48.6%), thickening in 44 (29.33%), crumbling in 41 (27.33%), and pitting in 17 (11.33%) cases. Of the 150 cases, 97 (64.66%) had associated superficial fungal infection, and most cases had Tinea manuum (n = 46, 32.33%). Others were Tinea corporis (n = 26, 17.33%), Tinea pedis (n = 12, 8%), and Tinea cruris (n = 10, 6.66%). None of them had Tinea faciei and Tinea capitis. The area of nail involvement was moderate, that is, 25–50% area in 64% of cases, severe, that is, >50% area in 32% cases and mild (<25%) in 4% cases. Direct microscopic examination of clipping mounted with 40% KOH demonstrated fungal elements in 86 (55.33%) cases, indicating a sensitivity of 68% and specificity of 51%. Rate of isolation of organisms by culture was 96 (64%), indicating a sensitivity of 78.68% and specificity of 41.79% [Table 3]. Out of 96 total culture positive cases, Aspergillus flavus was isolated in 24 (16%) [Figure 5a and b], Aspergillus niger in 15 (10%) [Figure 6], Aspergillus fumigatus in 6 [Figure 7a and b], Candida species in 20 (13.3%), Trichophyton species in 28 (18.66%). Other species were Scopuloriopsis species, Rhizopus species [Figure 8], Fusarium species, Penicillium species [Figure 9], and Curvularia species [Table 4]. In DLSO, Aspergillus species was grown in 17 cases, Candida species in 7 cases, dermatophytes in only 5 cases. In TDO, Aspergillus species was isolated in 24 cases (A. niger 7, A. flavus in 13, and A. fumigatus in 4 cases) Candida species in 5, Contaminants in 12, Penicillium species in 1, Rhizopus species in 1, and Trichophyton species in 13 cases respectively. In SWO, the majority species isolated were dermatophytes. In MO, the majority grown were Trichophyton species, but six cases revealed no fungal growth [Table 5].


The nondermatophyte molds: Emerging as leading cause of onychomycosis in south-east Rajasthan.

Raghavendra KR, Yadav D, Kumar A, Sharma M, Bhuria J, Chand AE - Indian Dermatol Online J (2015 Mar-Apr)

All fingers and toes show total dystrophic variant of onychomycosis
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4375773&req=5

Figure 1: All fingers and toes show total dystrophic variant of onychomycosis
Mentions: The 150 cases recruited for the study accounted for 0.16% of the outpatient attendance. The average age of the study population was 34.6 ± 18 years, and most of the cases were in the third decade (n = 50, 33.33%), with age ranging from 5 to 71 years [Table 1]. Males (n = 110, 73.33%) were found to be more commonly affected than females (n = 40, 26.66%) with male to female ratio of 2.75:1. Ninety seven cases were from urban areas, and 53 were from rural areas. The agriculturists, students, and housewives constituted 22%, 20%, and 13.33% of the total cases respectively. Among the predisposing factors, barefoot walking was recorded in 31 cases (20.66%), ill-fitting shoes and contact with pets and domestic animals in 13% each, excessive detergent use in 8.66%, and history of nail biting in 6.66% cases. At presentation, duration of nail changes was less than 12 months in 79 patients (52.66%), 13–60 months in 53 (35.53%) and >60 months in 18 (10.66%) cases. TDO was seen in 69 (46%) [Figure 1], DLSO in 52 (34.6%) [Figure 2], MO in 16 (10.66%), SWO in 11 (7.33%) [Figure 3], PSO in 2 cases [Figure 4]; none had the endonyx variant [Table 2]. Among patients with the MO variant, SWO + TDO was seen in five cases, DLSO + SWO in 4, DLSO + TDO in 4, DLSO + SWO + TDO in 1, and SWO + PSO in 1 case. Fingernails alone were affected in 38% of cases and toenails alone in 33.33% cases. Both toenail and fingernail were involved in 15% cases. Nail discoloration was observed in the majority of cases (n = 106, 70.6%), nail dystrophy in 100 (66.66%), subungual hyperkeratosis in 77 (51.33%), onycholysis in 73 (48.6%), thickening in 44 (29.33%), crumbling in 41 (27.33%), and pitting in 17 (11.33%) cases. Of the 150 cases, 97 (64.66%) had associated superficial fungal infection, and most cases had Tinea manuum (n = 46, 32.33%). Others were Tinea corporis (n = 26, 17.33%), Tinea pedis (n = 12, 8%), and Tinea cruris (n = 10, 6.66%). None of them had Tinea faciei and Tinea capitis. The area of nail involvement was moderate, that is, 25–50% area in 64% of cases, severe, that is, >50% area in 32% cases and mild (<25%) in 4% cases. Direct microscopic examination of clipping mounted with 40% KOH demonstrated fungal elements in 86 (55.33%) cases, indicating a sensitivity of 68% and specificity of 51%. Rate of isolation of organisms by culture was 96 (64%), indicating a sensitivity of 78.68% and specificity of 41.79% [Table 3]. Out of 96 total culture positive cases, Aspergillus flavus was isolated in 24 (16%) [Figure 5a and b], Aspergillus niger in 15 (10%) [Figure 6], Aspergillus fumigatus in 6 [Figure 7a and b], Candida species in 20 (13.3%), Trichophyton species in 28 (18.66%). Other species were Scopuloriopsis species, Rhizopus species [Figure 8], Fusarium species, Penicillium species [Figure 9], and Curvularia species [Table 4]. In DLSO, Aspergillus species was grown in 17 cases, Candida species in 7 cases, dermatophytes in only 5 cases. In TDO, Aspergillus species was isolated in 24 cases (A. niger 7, A. flavus in 13, and A. fumigatus in 4 cases) Candida species in 5, Contaminants in 12, Penicillium species in 1, Rhizopus species in 1, and Trichophyton species in 13 cases respectively. In SWO, the majority species isolated were dermatophytes. In MO, the majority grown were Trichophyton species, but six cases revealed no fungal growth [Table 5].

Bottom Line: Nondermatophytes were isolated in 53 (35.33%), dermatophytes in 28 (18.66%), and yeasts in 15 (10%) of cases.The most commonly isolated species was Aspergillus in 45 (30%) cases.Aspergillus flavus was more commonly isolated compared to Aspergillus niger.

View Article: PubMed Central - PubMed

Affiliation: Department of Skin and VD, Government Medical College, Kota, Rajasthan, India.

ABSTRACT

Background: Onychomycosis is a fungal disease of the nail apparatus caused by both dermatophytic and nondermatophytic strains. Treatment involves long duration antifungal therapy. However, long treatment duration without identifying the causative species may lead to resistance. Confirmation of diagnosis and speciation by culture before administering antifungal therapy is ideal.

Aims: To study the clinical and epidemiological aspects of onychomycosis in Hadoti region (south-east Rajasthan) and identify various mycological strains and predisposing factors causing onychomycosis.

Materials and methods: A prospective study of clinically diagnosed cases of onychomycosis attending the outpatient Department of Dermatology in our institute conducted from June 2012 to May 2013. The clippings were subjected to potassium hydroxide (KOH) examination and culture in the appropriate medium.

Results: A total of 150 cases were enrolled in our study. There were 110 males (73.33%) and 40 females (26.66%) and male to female ratio was 2.75:1. The total dystrophic onychomycosis was the most common presentation seen in the majority of cases (46%) followed by distal lateral subungual onychomycosis in 52 cases (34.6%), mixed onychomycosis in 16 cases (10.66%), superficial white onychomycosis in 11 cases (7.33%), and proximal subungual onychomycosis in 2 cases. None had the endonyx variant. Direct microscopic examination of the nail clipping mounted with 40% KOH demonstrated fungal elements in 83 (55.33%) cases. Rate of isolation of organisms by culture was 64%. Nondermatophytes were isolated in 53 (35.33%), dermatophytes in 28 (18.66%), and yeasts in 15 (10%) of cases. The most commonly isolated species was Aspergillus in 45 (30%) cases. Aspergillus flavus was more commonly isolated compared to Aspergillus niger.

Conclusion: The nondermatophyte molds appear to be more common causative agents of onychomycosis compared to usual dermatophyte species in south-east Rajasthan. Our study re-emphasizes the importance of culture for diagnosis of onychomycosis in every suspected case prior to therapy.

No MeSH data available.


Related in: MedlinePlus