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Advances in dermatology and venereology Acta Dermato-Venereologica
Onychomycosis Due to Arthrinium arundinis : A Case Report
Mariusz DYLĄG 1 , Anita HRYNCEWICZ-GWÓŹDŹ 2 and Tomasz JAGIELSKI 3 *
1
Department of Genetics , Institute of Genetics and Microbiology , University of Wrocław , 2 Department of Dermatology , Venereology and Allergology , Wrocław Medical University , Wrocław , and 3 Department of Applied Microbiology , Institute of Microbiology , University of Warsaw , I . Miecznikowa 1 , PL-02-096 Warsaw , Poland . * E-mail : t . jagielski @ biol . uw . edu . pl Accepted Apr 6 , 2017 ; Epub ahead of print Apr 17 , 2017
The genus Arthrinium comprises an environmentally and biochemically diverse group of ascomycetous fungi , most of which display an endophytic lifestyle in a wide range of plant species . To date , only Arthrinium phaeospermum has been implicated in human disease , as a causative agent of superficial infections .
We describe here a case of subungual onychomycosis , due to A . arundinis . Treatment with itraconazole and amorolfine was successful in this case .
CASE REPORT
1 https :// www . medicaljournals . se / acta / content / abstract / 10.2340 / 00015555-2673
Fig . 1 . Clinical and mycological characteristics . ( A ) The big toe nail plate before treatment , and ( B ) after 3-month therapy with oral itraconazole and topical 5 % amorolfine . ( C ) Hyphae of Arthrinium arundinis visualized by direct examination of nail scrapings after 10 % KOH and dimethyl sulfoxide treatment ( original magnification 1,000 ×). ( D ) Macroscopic appearance of A . arundinis culture on potato dextrose agar medium post 14-day incubation at 25 ° C . ( E ) Lactophenol cotton blue-stained slide culture showing the microscopic morphology of A . arundinis ( original magnification 1,000 ×; scale bar 5.26 μm ). ( F ) Scanning electron microscopy ( SEM ) of the fungus , ( original magnification 10,000 ×; scale bar 1 μm ).
In January 2016 a 42-year-old man was examined in the Mycological Laboratory in the Department and Clinic of Dermatology , Venerology and Allergology , Wrocław Medical University , Wrocław , Poland . He presented with a typical distal and lateral subungual onychomycosis ( DLSO ) of the big toenail of the left foot . The nail plate was approximately 70 – 80 % affected , with yellow-grey discoloration and advanced hyperkeratosis . The surface of the nail plate was neither eroded nor deformed . Only a single transverse nail ridge was observed on the border of the lunula , relating to anamnestic trauma . Here , the nail plate was thickened , separating the affected region from the healthy tissue . There was empty space between the nail plate and nail bed . The detachment of the nail plate from the periungual tissue was also visible , especially on the lateral side ( Fig . 1A ). Apart from insulin-dependent diabetes , the patient was in good general condition . Neither systemic disease nor any use of immunosuppressive drugs was evidenced in the patient ’ s history . Approximately 4 months earlier he had struck his foot on a piece of wood while walking barefoot along the shore of the Baltic Sea . A splinter entered deeply under the nail plate , and was removed immediately and nail was disinfected with octenidine hydrochloride solution ( Octenisept ® ). After approximately one month the patient noticed a small wedge-shaped alteration on the nail . During the next 3 months , he intermittently used topical Scholl Fungal Nail Treatment ® , with no effect . The lesion subsequently spread over approximately 75 % of the nail plate .
Mycological examination was performed , followed by molecular speciation . A detailed , step-by-step diagnostic path was followed , as described in Appendix S1 1 . The fungus isolated from the present case was identified as A . arundinis ( Corda ) Dyko & Sutton .
The cultured fungus ( Fig . 1D ) was subjected to drug susceptibility testing , with the Etest method ( AB BIODISK , Solna , Sweden ). Susceptibility assays were performed according to the Etest strip manufacturers ’ instructions , with a 48-h incubation at 25 ° C ( Appendix S1 1 ). In the absence of universally accepted guidelines specific for fungi , and especially Aspergillus , Arthrinium spp ., interpretive criteria and quality control ranges for Aspergillus fumigatus , reported by the European Committee on Antimicrobial Susceptibility Testing were employed ( 1 ). The tested fungus was found to be resistant to fluconazole ( 32 μg / ml ), anidulafungin ( 2 μg / ml ), caspofungin ( 4 μg / ml ); amphotericin B ( 2 μg / ml ) and 5-fluorocytosine (> 32 μg / ml ), but susceptible to itraconazole ( 0.125 μg / ml ), voriconazole ( 0.25 μg / ml ) and posaconazole ( 0.016 μg / ml ).
Although terbinafine is commonly used for the treatment of onychomycosis , it was not considered in the present case , since no gradient strips are available for this drug , and thus its MIC value could not easily be established . Given the in vitro low MIC of itraconazole , its lipophilicity , high affinity for keratinizing tissues , and the high concentration that the drug reaches in the nails and maintains long after discontinuation of therapy ( 2 ), it was used to treat the present case . The drug was given to the patient doi : 10.2340 / 00015555-2673 Acta Derm Venereol 2017 ; 97 : 860 – 861
This is an open access article under the CC BY-NC license . www . medicaljournals . se / acta Journal Compilation © 2017 Acta Dermato-Venereologica .