- Email: [email protected]
Trichophyton mentagrophytes onychomycosis
Medical Mycology Case Reports 1 (2012) 76–78
Contents lists available at SciVerse ScienceDirect
Medical Mycology Case Reports journal homepage: www.elsevier.com/locate/mmcr
A case report of a mixed Chaetomium globosum/Trichophyton mentagrophytes onychomycosis Jean Lagace´ a,n, Eric Cellier b a b
´nergie, Shawinigan, G9P 5K1, Que., Canada ´ et de Services Sociaux (CSSS) de l’E Department of General Medicine ,Centre de Sante ´nergie, Shawinigan, G9P 5K1, Que., Canada ´ et de Services Sociaux (CSSS) de l’E Department of Medical Biology ,Centre de Sante
a r t i c l e i n f o
a b s t r a c t
Article history: Received 22 August 2012 Received in revised form 5 September 2012 Accepted 7 September 2012
Recently, an increasing prevalence of nondermatophyte mold onychomycosis was observed, in which Chaetomium globosum was rarely involved as primary pathogenic agent. Besides this, reports of mixed infection associating a dermatophyte and a nondermatophyte mold have become more frequent. Here, we present a clinical case of a mixed onychomycosis infection of a toenail caused by Chaetomium globosum and Trichophyton mentagrophytes. To our knowledge, this specific association is reported for the first time in Canada. & 2012 International Society for Human and Animal Mycology. Published by Elsevier B.V. All rights reserved.
Keywords: Chaetomium globosum Dermatophyte Mixed onychomycosis infection Nondermatophyte mold Trichophyton mentagrophytes
1. Introduction Over the past years, onychomycosis was considered as a fungal nail infection mainly caused by dermatophytes, sometimes yeasts and uncommonly by nondermatophyte molds (NDM) [1]. Then, an increasing prevalence of NDM onychomycosis was observed, Chaetomium globosum identified next as a rare primary pathogenic agent [2]. It is now generally accepted that NDMs account for 2–12% of onychomycosis [3] and reports of mixed infections associating a dermatophyte and a NDM have become more and more frequent, especially with toenail infections and in elderly individuals [4]. Mold species usually isolated in a mixed onychomycosis infection are Scopulariopsis brevicaulis, Fusarium sp, Acremonium, Aspergillus sp, Scytalidium sp and Onychola Canadensis [5]. Most of the time, the identified associate dermatophyte is Trichophyton rubrum [6]. Here, we report a clinical case of a mixed onychomycosis infection of a toenail caused by Chaetomium globosum and Trichophyton mentagrophytes.
2. Case A 66-year-old man complained about painful dystrophic nail of the right first toenail. On examination, the nail plate showed a n
Corresponding author. Tel.: þ1 819 539 8371x8290; fax: þ 1 819 533 3193. E-mail address: [email protected] (J. Lagace´).
well confined spot of yellowish-brown coloration, scattered brown-black punctuations, hyperkeratosis, onycholysis and chronic paronychia of lateral nail fold. (Fig. 1). He did not recall when the problem began. The patient’s medical history included chronic schizophrenia, obesity, diabetes type 2, myocardial infarct and cerebrovascular disease. He used to walk barefoot with a dragging foot secondary to a previous stroke. He was living in a damp and dark basement made of sheetrock and wood materials, in very poor hygienic conditions. On November 2010 (Day 0), nail clippings and scrapings from the hyperkeratosic undersurface of the nail plate were sampled for Calcofluor examination and culture onto both Sabouraud dextrose agar (SDA) and inhibitory mold agar (IMA) test tubes, incubated at 30 1C for 4 weeks. The Calcofluor test showed hyphae and Chaetomium sp was isolated and identified at the Laboratoire de sante´ publique du Que´bec. One month later (Day 30), the same procedure was repeated and yielded Chaetomium sp and Trichophyton mentagrophytes as well. Microscopic examination of culture mounts from positive test tube revealed black globose perithecia, tortuous perithecial hairs and dark septated hyphae. Hyaline hyphae with probable microconidiae were also observed. The patient was examined again in search of fungal skin infection. Tiny and few dead skin debris were found between the first and second toes. The sampled material was too scanty for Calcofluor but culture gave a negative result. Then, a third nail sampling was done and the result yielded Chaetomium sp only (Day 150). Upon request, the Laboratoire de
2211-7539/$ - see front matter & 2012 International Society for Human and Animal Mycology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.mmcr.2012.09.001
J. Lagace´, E. Cellier / Medical Mycology Case Reports 1 (2012) 76–78
Fig. 1. Distal and lateral subungual onychomycosis.
77
mold, has long been considered as a nail contaminant. However, recent evidences suggest that it could also act as a primary pathogenic agent [7–10]. The presence in the second sampling of Trichophyton mentagrophytes in addition to Chaetomium globosum could suggest Chaetomium as a contaminant and a diagnosis of dermatophyte onychomycosis [11] while the sole detection of Chaetomium globosum in both first and third sampling would rather support the occurrence of a NDM onychomycosis. Indeed, such discordant findings in these three consecutive samplings markedly underscore the need for repeated samplings to confirm either a NDM or a mixed onychomycosis infection, thus satisfying Koch’s first postulate at the same time, particularly since contaminant fungi are rarely isolated repeatedly [12,13]. The ecological interactions between dermatophytes and nondermatophytes in mixed onychomycosis infection are complex and not well understood. Nevertheless, Richard C. Summerbell has proposed a useful frame of analysis to differentiate nondermatophytes as colonizers (transient saprophyte or persistent secondary) or invaders (successional or primary), therefore allowing more efficient and specific pharmacological approaches [14]. There is also evidence for coexistence of toenail onychomycosis with other dermatomycoses, especially tinea pedis [15]. Some authors state that tinea pedis almost always precedes onychomycosis and consider the foot as a fungus reservoir [16]. While microscopic examination and culture remain the gold standard in medical Mycology, the underlying pathogenic organisms and pathological pathways could have been further investigated by nail immunohistopathology, PCR-restriction fragment length polymorphism analyses and nested PCR. However, the use of such diagnostic tools is precluded in a daily medical practice. Nevertheless, one could hypothesize a subclinical tinea pedis or, less probably, a superficial white onychomycosis (SWO) caused by Trichophyton mentagrophytes, later transformed into DLSO by Chaetomium globosum, behaving as a successional invader in both cases.
Conflict of interest statement There are none.
Acknowledgments Fig. 2. Twelve months after initiation of treatment.
sante´ publique du Que´bec identified the mold at the species level as Chaetomium globosum, using ITS sequence analysis method (the case isolate was deposited at the Laboratoire de sante´ publique du Que´bec under accession number LSPQ-00972). On Day 180, the patient was offered a continuous three months terbinafine regimen (250 mg/day). Pain disappeared after one month and normal nail growth was observed during the following months (Fig. 2). A sample taken twelve months after treatment initiation was negative for both Calcofluor and culture.
3. Discussion On the clinical and epidemiological plan, this distal and lateral subungual onychomycosis (DLSO) case presents many features found in a NDM or a mixed onychomycosis infection: age, gender, diabetes, repeated nail trauma, altered neurologic and circulatory status of the extremities, periungual inflammation and living environment. Chaetomium globosum, as an ubiquitous and cosmopolitan
We would like to thank Mrs Anny Boutin and Danielle Ge´linas (CSSS de l’E´nergie) for their technical support. We also acknowledge the helpful and positive feedbacks of Dr Richard C. Summerbell (Sporometrics, Canada), Dr Pascale Lanneville (anatomo-pathologist at the CSSS de l’E´nergie) and Mr Guy St-Germain (Laboratoire de sante´ publique du Que´bec). References [1] Kaur R, Kashyap B, Bhalla P. Onychomycosis-epidemioloy, diagnosis and management. Indian Journal of Medical Microbiology 2008;26(2):108–16. [2] Hubka V, Mencl K, Skorepova M, Lyskova P, Zalabska E. Phaeohyphomycosis and onychomycosis due to Chaetomium spp., including the first report of Chaetomium brasiliense infection. Medical Mycology 2011;49:724–33. [3] Moreno G, Arenas R. Other fungi causing onychomycosis. Clinics in Dermatology 2010;28:160–3. [4] Scherer WP, McCreary JP, Hayes WW. The diagnosis of onychomycosis in a geriatric population-a study of 450 cases in South Florida. Journal of the American Podiatric Medical Association 2001;91:456–64. [5] Tosti A, Piraccini BM, Lorenzi S. Onychomycosis caused by nondermatophytic molds: clinical features and response to treatment of 59 cases. Journal of the American Academy of Dermatology 2000;42(2):217–24. [6] Gupta A. Study provides insight into mixed onychomycosis infection. Abstract #5610. In: Proceedings of the 70th Annual Meeting of the American Academy of Dermatology; 2012.
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J. Lagace´, E. Cellier / Medical Mycology Case Reports 1 (2012) 76–78
[7] Stiller MJ, Rosenthal S, Summerbell RC. Onychomycosis of the toenails caused by Chaetomium globosum. Journal of the American Academy of Dermatology 1992;26:775–6. [8] Aspiroz C, Gene´ J, Rezusta A, Charlez L, Summerbell RC. First Spanish case of onychomycosis caused by Chaetomium globosum. Medical Mycology 2007;45:279–82. [9] Falcon CS, Falcon MMS, Ceballos JD, Florencio VD, Erchiga VC, Ortega SS. Onychomycosis by Chaetomium spp. Mycoses 2008;52:77–9. [10] Hattori N, Adachi M, Kaneko T, Shimozuma M, Ichinhe M, Iozumi K. Case Report. Onychomycosis due to Chaetomium globosum successfully treated by itraconazole. Mycoses 2000;43:89–92. [11] Summerbell RC, Cooper E, Bunn U, Jamieson F, A.K. Gupta. Onychomycosis: a critical study of techniques and criteria for confirming the etiologic significance of nondermatophytes. Medical Mycology 2005;43:39–59.
[12] Gupta AK, Drummond-Main C, Cooper EA, Brintell W, Piraccini BM, Tosti A. Systematic review of nondermatophyte mold onychomycosis: diagnosis, clinical types, epidemiology, and treatment. Journal of the American Academy of Dermatology 2012;66:494–502. [13] Weitzman I, Summerbell RC. The dermatophytes. Clinical Microbiology Reviews 1995;8:240–59. [14] Summerbell RC. Epidemiology and ecology of onychomycosis. Dermatology 1997;194:32–6. [15] Szepietowski JC, Reich A, Garlowska E, Kulig M, Baran E. Factors influencing coexistence of toenail onychomycosis with tinea pedis and other dermatomycoses. Archives of Dermatology 2006;142:1279–84. [16] Daniel R, Jellinek NJ. The pedal fungus reservoir. Archives of Dermatology 2006;142:1344–6.
Contents lists available at SciVerse ScienceDirect
Medical Mycology Case Reports journal homepage: www.elsevier.com/locate/mmcr
A case report of a mixed Chaetomium globosum/Trichophyton mentagrophytes onychomycosis Jean Lagace´ a,n, Eric Cellier b a b
´nergie, Shawinigan, G9P 5K1, Que., Canada ´ et de Services Sociaux (CSSS) de l’E Department of General Medicine ,Centre de Sante ´nergie, Shawinigan, G9P 5K1, Que., Canada ´ et de Services Sociaux (CSSS) de l’E Department of Medical Biology ,Centre de Sante
a r t i c l e i n f o
a b s t r a c t
Article history: Received 22 August 2012 Received in revised form 5 September 2012 Accepted 7 September 2012
Recently, an increasing prevalence of nondermatophyte mold onychomycosis was observed, in which Chaetomium globosum was rarely involved as primary pathogenic agent. Besides this, reports of mixed infection associating a dermatophyte and a nondermatophyte mold have become more frequent. Here, we present a clinical case of a mixed onychomycosis infection of a toenail caused by Chaetomium globosum and Trichophyton mentagrophytes. To our knowledge, this specific association is reported for the first time in Canada. & 2012 International Society for Human and Animal Mycology. Published by Elsevier B.V. All rights reserved.
Keywords: Chaetomium globosum Dermatophyte Mixed onychomycosis infection Nondermatophyte mold Trichophyton mentagrophytes
1. Introduction Over the past years, onychomycosis was considered as a fungal nail infection mainly caused by dermatophytes, sometimes yeasts and uncommonly by nondermatophyte molds (NDM) [1]. Then, an increasing prevalence of NDM onychomycosis was observed, Chaetomium globosum identified next as a rare primary pathogenic agent [2]. It is now generally accepted that NDMs account for 2–12% of onychomycosis [3] and reports of mixed infections associating a dermatophyte and a NDM have become more and more frequent, especially with toenail infections and in elderly individuals [4]. Mold species usually isolated in a mixed onychomycosis infection are Scopulariopsis brevicaulis, Fusarium sp, Acremonium, Aspergillus sp, Scytalidium sp and Onychola Canadensis [5]. Most of the time, the identified associate dermatophyte is Trichophyton rubrum [6]. Here, we report a clinical case of a mixed onychomycosis infection of a toenail caused by Chaetomium globosum and Trichophyton mentagrophytes.
2. Case A 66-year-old man complained about painful dystrophic nail of the right first toenail. On examination, the nail plate showed a n
Corresponding author. Tel.: þ1 819 539 8371x8290; fax: þ 1 819 533 3193. E-mail address: [email protected] (J. Lagace´).
well confined spot of yellowish-brown coloration, scattered brown-black punctuations, hyperkeratosis, onycholysis and chronic paronychia of lateral nail fold. (Fig. 1). He did not recall when the problem began. The patient’s medical history included chronic schizophrenia, obesity, diabetes type 2, myocardial infarct and cerebrovascular disease. He used to walk barefoot with a dragging foot secondary to a previous stroke. He was living in a damp and dark basement made of sheetrock and wood materials, in very poor hygienic conditions. On November 2010 (Day 0), nail clippings and scrapings from the hyperkeratosic undersurface of the nail plate were sampled for Calcofluor examination and culture onto both Sabouraud dextrose agar (SDA) and inhibitory mold agar (IMA) test tubes, incubated at 30 1C for 4 weeks. The Calcofluor test showed hyphae and Chaetomium sp was isolated and identified at the Laboratoire de sante´ publique du Que´bec. One month later (Day 30), the same procedure was repeated and yielded Chaetomium sp and Trichophyton mentagrophytes as well. Microscopic examination of culture mounts from positive test tube revealed black globose perithecia, tortuous perithecial hairs and dark septated hyphae. Hyaline hyphae with probable microconidiae were also observed. The patient was examined again in search of fungal skin infection. Tiny and few dead skin debris were found between the first and second toes. The sampled material was too scanty for Calcofluor but culture gave a negative result. Then, a third nail sampling was done and the result yielded Chaetomium sp only (Day 150). Upon request, the Laboratoire de
2211-7539/$ - see front matter & 2012 International Society for Human and Animal Mycology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.mmcr.2012.09.001
J. Lagace´, E. Cellier / Medical Mycology Case Reports 1 (2012) 76–78
Fig. 1. Distal and lateral subungual onychomycosis.
77
mold, has long been considered as a nail contaminant. However, recent evidences suggest that it could also act as a primary pathogenic agent [7–10]. The presence in the second sampling of Trichophyton mentagrophytes in addition to Chaetomium globosum could suggest Chaetomium as a contaminant and a diagnosis of dermatophyte onychomycosis [11] while the sole detection of Chaetomium globosum in both first and third sampling would rather support the occurrence of a NDM onychomycosis. Indeed, such discordant findings in these three consecutive samplings markedly underscore the need for repeated samplings to confirm either a NDM or a mixed onychomycosis infection, thus satisfying Koch’s first postulate at the same time, particularly since contaminant fungi are rarely isolated repeatedly [12,13]. The ecological interactions between dermatophytes and nondermatophytes in mixed onychomycosis infection are complex and not well understood. Nevertheless, Richard C. Summerbell has proposed a useful frame of analysis to differentiate nondermatophytes as colonizers (transient saprophyte or persistent secondary) or invaders (successional or primary), therefore allowing more efficient and specific pharmacological approaches [14]. There is also evidence for coexistence of toenail onychomycosis with other dermatomycoses, especially tinea pedis [15]. Some authors state that tinea pedis almost always precedes onychomycosis and consider the foot as a fungus reservoir [16]. While microscopic examination and culture remain the gold standard in medical Mycology, the underlying pathogenic organisms and pathological pathways could have been further investigated by nail immunohistopathology, PCR-restriction fragment length polymorphism analyses and nested PCR. However, the use of such diagnostic tools is precluded in a daily medical practice. Nevertheless, one could hypothesize a subclinical tinea pedis or, less probably, a superficial white onychomycosis (SWO) caused by Trichophyton mentagrophytes, later transformed into DLSO by Chaetomium globosum, behaving as a successional invader in both cases.
Conflict of interest statement There are none.
Acknowledgments Fig. 2. Twelve months after initiation of treatment.
sante´ publique du Que´bec identified the mold at the species level as Chaetomium globosum, using ITS sequence analysis method (the case isolate was deposited at the Laboratoire de sante´ publique du Que´bec under accession number LSPQ-00972). On Day 180, the patient was offered a continuous three months terbinafine regimen (250 mg/day). Pain disappeared after one month and normal nail growth was observed during the following months (Fig. 2). A sample taken twelve months after treatment initiation was negative for both Calcofluor and culture.
3. Discussion On the clinical and epidemiological plan, this distal and lateral subungual onychomycosis (DLSO) case presents many features found in a NDM or a mixed onychomycosis infection: age, gender, diabetes, repeated nail trauma, altered neurologic and circulatory status of the extremities, periungual inflammation and living environment. Chaetomium globosum, as an ubiquitous and cosmopolitan
We would like to thank Mrs Anny Boutin and Danielle Ge´linas (CSSS de l’E´nergie) for their technical support. We also acknowledge the helpful and positive feedbacks of Dr Richard C. Summerbell (Sporometrics, Canada), Dr Pascale Lanneville (anatomo-pathologist at the CSSS de l’E´nergie) and Mr Guy St-Germain (Laboratoire de sante´ publique du Que´bec). References [1] Kaur R, Kashyap B, Bhalla P. Onychomycosis-epidemioloy, diagnosis and management. Indian Journal of Medical Microbiology 2008;26(2):108–16. [2] Hubka V, Mencl K, Skorepova M, Lyskova P, Zalabska E. Phaeohyphomycosis and onychomycosis due to Chaetomium spp., including the first report of Chaetomium brasiliense infection. Medical Mycology 2011;49:724–33. [3] Moreno G, Arenas R. Other fungi causing onychomycosis. Clinics in Dermatology 2010;28:160–3. [4] Scherer WP, McCreary JP, Hayes WW. The diagnosis of onychomycosis in a geriatric population-a study of 450 cases in South Florida. Journal of the American Podiatric Medical Association 2001;91:456–64. [5] Tosti A, Piraccini BM, Lorenzi S. Onychomycosis caused by nondermatophytic molds: clinical features and response to treatment of 59 cases. Journal of the American Academy of Dermatology 2000;42(2):217–24. [6] Gupta A. Study provides insight into mixed onychomycosis infection. Abstract #5610. In: Proceedings of the 70th Annual Meeting of the American Academy of Dermatology; 2012.
78
J. Lagace´, E. Cellier / Medical Mycology Case Reports 1 (2012) 76–78
[7] Stiller MJ, Rosenthal S, Summerbell RC. Onychomycosis of the toenails caused by Chaetomium globosum. Journal of the American Academy of Dermatology 1992;26:775–6. [8] Aspiroz C, Gene´ J, Rezusta A, Charlez L, Summerbell RC. First Spanish case of onychomycosis caused by Chaetomium globosum. Medical Mycology 2007;45:279–82. [9] Falcon CS, Falcon MMS, Ceballos JD, Florencio VD, Erchiga VC, Ortega SS. Onychomycosis by Chaetomium spp. Mycoses 2008;52:77–9. [10] Hattori N, Adachi M, Kaneko T, Shimozuma M, Ichinhe M, Iozumi K. Case Report. Onychomycosis due to Chaetomium globosum successfully treated by itraconazole. Mycoses 2000;43:89–92. [11] Summerbell RC, Cooper E, Bunn U, Jamieson F, A.K. Gupta. Onychomycosis: a critical study of techniques and criteria for confirming the etiologic significance of nondermatophytes. Medical Mycology 2005;43:39–59.
[12] Gupta AK, Drummond-Main C, Cooper EA, Brintell W, Piraccini BM, Tosti A. Systematic review of nondermatophyte mold onychomycosis: diagnosis, clinical types, epidemiology, and treatment. Journal of the American Academy of Dermatology 2012;66:494–502. [13] Weitzman I, Summerbell RC. The dermatophytes. Clinical Microbiology Reviews 1995;8:240–59. [14] Summerbell RC. Epidemiology and ecology of onychomycosis. Dermatology 1997;194:32–6. [15] Szepietowski JC, Reich A, Garlowska E, Kulig M, Baran E. Factors influencing coexistence of toenail onychomycosis with tinea pedis and other dermatomycoses. Archives of Dermatology 2006;142:1279–84. [16] Daniel R, Jellinek NJ. The pedal fungus reservoir. Archives of Dermatology 2006;142:1344–6.