THERAPEUTIC MANAGEMENT OF A GREEN NAIL SYNDROME – PSEUDOMONAS AERUGINOSA AND TRICOPHYTON
TONSURANS COINFECTION DETECTED BY MASS SPECTROMETRY
Case Presentation
THERAPEUTIC MANAGEMENT OF A GREEN NAIL
SYNDROME – PSEUDOMONAS AERUGINOSA AND
TRICOPHYTON TONSURANS COINFECTION DETECTED
BY MASS SPECTROMETRY
CONDUITA TERAPEUTICĂ A SINDROMULUI
UNGHIILOR VERZI – COINFECŢIA CU PSEUDOMONAS
AERUGINOSA ŞI TRICOPHYTON TONSURANS
DETECTATĂ PRIN SPECTROMETRIE DE MASĂ
Alin Laurentiu Tatu1, Cristiana Voicu2, Victor Gabriel Clatici3
University Dunarea de Jos, Faculty of Medicine and Pharmacy, Dermatology, Galati, Romania
2
Dermatology Department, Polisano Clinic, Bucharest, Romania
3
Dermato-oncology and Allergology Department, Elias Emergency Hospital, Bucharest, Romania
1
Corresponding author:
Alin Laurentiu Tatu MD, PhD
Al.I.Cuza Str, No 39, Galati, Postal code 800101, Romania
Phone: 00-40-728 267 435; Fax 00-40-236-415705; E-mail:[email protected]
Abstract
Keywords:
green nail syndrome,
Pseudomonas
aeruginosa,
spectrometry,
Tricophyton tonsurans,
coinfection
Cite this article:
Alin Laurentiu Tatu,
Cristiana Voicu,
Victor Gabriel Clatici.
Therapeutic management
of a green nail syndrome Pseudomonas aeruginosa
and Tricophyton tonsurans
coinfection detected by
mass spectrometry.
RoJCED 2016;3-4(3):
167-169.
Open Access Article
Background: Fungal infection stimulates bacterial colonization
within the nail and overgrowth of Pseudomonas aeruginosa
in culture inhibits the isolation of fungus. We present the case
of a 51-year-old patient who was referred from the general
practitioner for the evaluation of an old green yellowish
discoloration of a painful nail and to establish a treatment to
control the disease.
Materials and methods: On examination there was a green
yellowish discoloration of the finger nail starting from the
distal part of the nail and extending to the proximal part. On
the distal nail area there was also onychodistrophy, central
onycholysis and a degeree of subungual hyperkeratothic
deposit. Around the nail plate there were scales and a slight
basal erythema with pruritus. Laboratory investigations were
performed.
Results: The laboratory findings were normal except the
bacteriologic culture from nail scraping that came up positive
for P. aeruginosa and was also confirmed by MALDI-TOF
spectrometry. Direct mycological microscopy (with KOH) of
nail scrapings was negative, but the mycological culture was
positive for Trichophyton tonsurans. One year after initiating
treatment, the nail was normal.
Conclusions: Because P. aeruginosa expresses pyocyanin, a
blue-green exopigment, green coloration of the nails should
raise suspicion for Pseudomonas infection. Broad-spectrum
antibiotics enhance fungal colonization by destroying
competing bacterial flora.
3-4/2016
167
Case Presentation
THERAPEUTIC MANAGEMENT OF A GREEN NAIL SYNDROME – PSEUDOMONAS AERUGINOSA AND TRICOPHYTON TONSURANS COINFECTION DETECTED BY MASS SPECTROMETRY
Rezumat
Cuvinte-cheie:
sindromul unghiei
verzi, Pseudomonas
aeruginosa,
spectrometrie,
Tricophyton tonsurans,
coinfectie
Introducere: Infecţia fungică stimulează colonizarea bacteriană la
nivelul unghiei şi dezvoltarea de Pseudomonas aeruginosa pe mediul
de cultură împiedică izolarea fungilor. Prezentăm cazul unui pacient
în varstă de 51 ani care se prezintă pentru evaluarea unei unghii
dureroase, cu modificări pigmentare galben-verzui şi pentru stabilirea
conduitei terapeutice adecvate.
Materiale şi metode: Examenul clinic a evidenţiat prezenţa discoloraţiei
verzi-gălbui, începând de la extremitatea distală a lamei unghiale şi
întinzându-se până la extremitatea proximală, la nivelul unei unghii
ale unui membru superior. În plus, extremitatea distală prezenta
de asemenea zone de onicodistroie, onicoliză centrală şi depozite
hiperkeratozice subunghiale. Zona periunghială prezenta scuame
şi zone eritematoase, pruriginoase. Au fost efectuate investigaţii de
laborator.
Rezultate: Rezultatele examenelor de laborator au fost în limite normale,
cu excepţia culturii bacteriene care a fost pozitivă pentru P. aeruginosa,
confirmată prin spectrometrie MALTI_TOF. Examenul micologic direct
(cu KOH) a fost negativ, dar cultura micologică a evidenţiat prezenţa de
Trichophyton tonsurans. La un an de la iniţierea tratamentului, unghia a
avut aspect normal.
Concluzii: Întrucât P. aeruginosa secretă piocianina, un exopigment
albastru-verzui, coloraţia veruzie a unghiilor ar trebui să ridice suspiciunea
de infecţie cu P. aeruginosa. Antibioticele cu spectru larg augmentează
colonizarea fungică prin distrugerea florei bacteriene rezidente.
Case presentation
A 51 years old patient was referred from the
general practitioner with a discoloration of a nail
within one year. He had been previously trated
with topical antifungals, but the condition worsened. He worked in a swimming pool facility and
reported a previous trauma.
On examination there was a green yellowish discoloration of the finger nail starting from the distal
part of the nail and extending to the proximal part
(Figure 1.a). On the distal nail area there was also
onychodistrophy, central onycholysis and a degeree of subungual hyperkeratothic deposit. Around
the nail plate there were scales and a slight basal
erythema with pruritus and pain upon palpation.
Bacteriologic culture from nail scraping was posi-
Figure 1a. Green yellowish discoloration of the nail
168
Figure 1b. Pseudomonas aeruginosa confirmed
spectrometry
tive for Pseudomonas aeruginosa and confirmed by
MALDI-TOF spectrometry (Figure 1.b). Direct mycological microscopy (with KOH) of nail scrapings was
negative but the mycological culture was positive
for Trichophyton tonsurans (Figure 1.c). The diagnosis of Green Nail Syndrome-coinfection with Pseudomonas aeruginosa and Trichophyton tonsurans
was made. Bacterial infection with Pseudomonas
aeruginosa was treated with Ciprofloxacin 500 mg/day
for three weeks and local with tobramycin – 0.3%
ophthalmic solution twice daily on and under the
distal nail plate, followed by topical gentamicin
and silver sulfadiazine for the same period.
After the first three weeks of antibacterial treatment, the patient was indicated to start an antifungal treatment for Tricophyton tonsurans with systemic itraconazole 400 mg/day for seven days per
month for three months and topical ciclopirox as a
nail lacquer 14 day per month for the same period.
R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY
Tatu Alin Laurentiu, Voicu Cristiana, Clatici Victor Gabriel
Figure 1c. Trichophyton tonsurans culture was
positive
Figure 1d. Distal dermoscopy after one year
Around the nail plate the use of a bifonazole cream
for five weeks was recommended. One year later
after the treatment was started, the nail was normal
from dermoscopic, bacteriologic and mycologic
point of view (Figure 1.d).
Discussion
Fungal infection stimulates bacterial colonization
within the nail and overgrowth of P. aeruginosa in
culture inhibits the isolation of fungus. Because
P. aeruginosa expresses pyocyanin, a blue-green
exopigment green coloration of the nails should
raise suspicion of a Pseudomonas infection (1-4).
Itraconazole is often prescribed in “pulse doses”
one week per month for two or three months. It
can interact with some commonly used drugs such
as the antibiotic erythromycin or certain asthma
medications. The most frequent side effects of
itraconazole include increased liver function tests,
skin rash, high triglycerides, and gastrointestinal
effects (nausea, bloating, and diarrhea) (5). Creams
and other topical medications are usually not effective against nail fungus. This is because nails are
too hard for external applications to penetrate. Ciclopirox and amorolfine are currently available nail
lacquers which are effective for the treatment or
prevention of fungal infections such as onychomycosis. The film is resistant to multiple washings and
is effective in the treatment of onychomycosis (5, 6).
Ciclopirox targets a variety of metabolic processes in the fungal cell. It chelates with the polyvalent
cations (Fe3+ and Al3+) that are involved in fungal
enzymatic activity, ultimately interrupting intracellular energy production and toxic peroxide degradation. Ciclopirox may also inhibits fungal nutrient
uptake, resulting in depletion of amino acids and
nucleotides and reduction in protein synthesis.
The most common are rash-related adverse effects
such as periungual erythema and erythema of
the proximal nail fold, which were reported more
frequently in patients treated with ciclopirox nail
lacquer topical solution, i.e., 8%. Other adverse
effects which were thought to be causally related
included nail disorders such as shape change, irritation, ingrown toenail, and discoloration (6, 7).
Broad-spectrum antibiotics (e.g., third-generation
cephalosporins) enhance fungal colonization by
destroying competing bacterial flora (8, 9).
Conflicts of interest: none declared.
Financial support: none declared.
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