A clinicomycological study of onychomycosis in a rural hospital in Central India.

Background: Onychomycosis; fungal infection of nails account for about half of the nail diseases. Common site of involvement is toenails. Various etiological agents including dermatophytes, yeasts and non-dermatophytic moulds (NDM) are responsible. It is difficult to treat onychomycosis as compare to other dermatophytic infections because of the inherent slow growth of the nail. Aim: To diagnose etiological agents of onychomycosis on KOH, Calcofluor white (CFW), KOH treated Nail Clipping with Periodic Acid Schiff (KONCPA) and SDA culture. Objectives: 1) To determine the fungal etiological agents of onychomycosis. 1) To correlate clinical parameters with the mycological findings. Methods: The study was carried out in department of Microbiology, MGIMS, Sewagram, Wardha. A total of 44 cases with signs of onychomycosis were enrolled in the study which were subjected for microscopic examination by 20% KOH, CFW and KONCPA. Mycological culture was done on Sabouraud’s dextrose agar (with and without antibiotics). Results: On analysis, the positivity by 20% KOH and CFW was 45.5%, 63.4% respectively while by KONCPA it was found to be 25%. In 38.6% fungal cultures revealed growth. At present, the etiological agents were dermatophytes (12.5%), especially Trichophyton rubrum, nondermatophytic isolates (75%) include Aspergillus spp., Penicillium species, Rhizopus and Candida spp. (8.3%). In our study toenails were affected in 84% and distolateral subungual onychomycosis (DLSO) was the commonest clinical presentation. Conclusion: Along with dermatophytes, NDM and yeasts are also important etiological agents of onychomycosis in our set up.

KONCPA Findings of Onychomychotic Nail Samples Where Non-dermatophytic Fungi were Cultured / 대한의진균학회지

BACKGROUND: When Candida species and molds (non-dermatophytic filamentous fungi) are cultured from the onychomycotic nail samples, it is sometimes difficult to consider whether they are the causative fungi or not. Although repeated culture is the most effective method to solve the problem, it is time-consuming and not cost-effective. But KONCPA (KOH + Nail clipping + PAS stain) is an inexpensive, quick, sensitive and very useful supportive test for considering whether the cultured non-dermatophytic fungi are real causative fungi or not. OBJECTIVES: This study was aimed to know whether KONCPA test would increase the diagnostic sensitivity of onychomycosis and whether KONCPA findings would be of help to diagnose the accurate causative fungi in case where the Candida species and molds were cultured. METHODS: Nail saacmples were obtained from 213 patients with onychomycosis for fungus culture and KONCPA test. And the KONCPA findings were reviewd for the onychomycotic nail samples where the non-dermatophytic fugi such as Candida species and molds were cultured. RESULTS: The results of this study were summarized as follows: 1. From 93 onychomycotic nail samples, dermatophytes were cultured in 24 (11.3%), Candida spp. in 36 (16.9%), and molds in 33 samples (15.5%). 2. Of the 36 samples where the Candida spp. were cultured, 24 (66.7%) showed findings of dermatophytes, 2 (5.6%) of Candida spp. and remaining 10 (27.7%) samples were inadequate for diagnosis. 3. Of 33 samples where the molds were cultured, 30 (90.9%) showed findings of dermatophytes, 1 (3.0%) of molds and remaining 2 (6.1%) samples were inadequate for diagnosis. CONCLUSIONS: Among 93 onychomycotic nail samples where the non-dermatopytic fungi were cultured, only 3 samples were compatible with KONCPA findings. Therefore, in cases where Candida spp. and molds were cultured and the KONCPA findings were not compatible with the cultured fungi, the cultured fungi should not be considered as the definite causative fungi until other material evidence was obtained.

Diagnoses and Differential Diagnoses of Superficial Mycoses / 대한의진균학회지

The diagnoses of superficial mycoses such as dermatophytosis, cutaneous candidiasis and Malassezia infections are relatively easy, and direct smear with KOH and culture with Sabouraud's dextrose agar media are the most useful and valuable methods. Recently, the incidence of onychomycosis has been increasing and some other diagnostic methods, especially for onychomycosis, and their significance has been introduced and investigated. This review was focused especially on the findings and significance of histopathologic and KONCPA methods (KOH Treated Nail Clippings Stained with PAS) for the diagnosis of onychomycosis. Summaries and brief comments were also made for the findings and significance of other diagnostic methods as well as for the differential diagnoses of superficial mycoses.

Significance of Polymerase Chain Reaction for the Detection of Causative Fungi of Onychomycosis: Comparison with Fungus Culture and KONCPA(KOH+Nail Clipping+ PAS(periodic acid-Schiff) stain) / 대한피부과학회지

BACKGROUND: It has been known that the polymerase chain reaction(PCR) test of clinical specimens including blood, sputum, urine, and cerebrospinal fluid collected from patients with systemic fungal infection is a highly sensitive diagnostic method. Recently, the PCR test was applied to the diagnosis of onychomycosis. OBJECTIVE: This study was aimed to explore whether the PCR test would be a more sensitive diagnostic tool than the KOH smear, fungus culture and KONCPA(KOH+Nail Clipping+ PAS(periodic acid-Schiff) stain) test in diagnosing the onychomycosis. METHODS: Using 50 nail samples from 50 patients with onychomycosis, the result of the PCR test was compared with those of the KOH smear, fungus culture and KONCPA test. RESULTS: The results were as follows: 1. The positive rates for detecting the causative fungi from the KOH smear, fungus culture, KONCPA test and PCR test were 64.0%, 46.0%, 90.0%, and 100.0% respectively. 2. The fungus culture identified the causative fungi from 23 samples, of which 21(91.2%) were T. rubrum, 1(4.4%) Candida sp. and 1(4.4%) C. albicans. KONCPA test yielded higher positivity by detecting the pathogenic fungi in 45 samples: dermatophytes 35(77.8%), mixed infections of dermatophytes and Candida sp. 6(13.3%), molds 2(4.4%) and unclassified 2(4.4%). The PCR test yielded the highest positivity by detecting the pathogenic fungi in all samples ; T. rubrum 44(88.0%) and unclassified 6(12.0%). 3. Compared with the results of fungus culture and KONCPA test, that of PCR test showed some differences. The case of Candida sp. in fungus culture was identified as T. rubrum in PCR ; the case of C. albicans in fungus culture as unclassified in the PCR. Five cases of mixed infection and 2 cases of mold infection in the KONCPA test were diagnosed as T. rubrum infection in the PCR test. CONCLUSION: The PCR test is useful in diagnosing the onychomycosis because of its highest positive rate in detecting the causative fungi compared with fungus culture and the KONCPA test. Furthermore, a more accurate diagnostic method such as the PCR test will be necessary in case Candida sp. or mold is cultured from the infected nail specimen.

A Comparative Study for Diagnosing Onychomycosis Using KOH Smear, Fungal Culture, KONCPA and Fungi-Fluor(R) Stain / 대한의진균학회지

BACKGROUND: Onychomycosis is common nail problem and requires administration of antifungal agent for long period. But several cutaneous diseases can produce similar nail changes and an inexpensive, quick and sensitive test is essential for screening nail specimens. Recently, there have been several reports of new method for diagnosing onychomycosis and fungi-Fluor(R)stain, which had been used to detect fungal elements in the tissue, was not used for diagnosing onychomycosis. OBJECTIVE: This study was undertaken to evaluate the usefulness of the new method using Fungi-Fluor(R)solution for the diagnosis of onychomycosis, and compare with other methods. METHODS: During the study period, nail samples obtained from 72 patients with onychomycosis were tested for Fungi-Fluor(R)solution and the results of that were compared with those of KOH smear, fungal culture and KONCPA test. RESULTS: The results of this study are summarized as follows: 1. The positive rates of conventional KOH nail scraping preparation, fungal culture, KONCPA and Fungi-Fluor(R)staining were 47.2%,40.3%, 77.8%, and 86.1%, respectively. 2. Fungi-Fluor(R)staining proved to be less time-consuming than KONCPA test. 3. Compared to KONCPA and Fungi-Fluor(R)staining, KOH preparation and fungal culture showed high false positive rate. 4. Though both KONCPA and Fungi-Fluor(R)staining showed higher positive rate in toenail than fingernail, there were no statistic significance. CONCLUSION: The Fungi-Fluor(R)solution staining is rapid, inexpensive, and highly sensitive method to detect fungal elements in the nails.

The Significance of KONCPA Test in Onychomycosis / 대한피부과학회지

BACKGROUND: It has been reported that KONCPA(KOH+Nail clipping+PAS reaction) test might be a useful complementary method with a high positive rate and an exellent view for making the diagnosis of onychomycosis. OBJECTIVE: KONCPA test, Onyehomycosis This study was aimed to know whether KONCPA test would increase the diagnostic sensitivity of onychomycosis, and agree with the findings of fungus culture and whether KONCPA finding would be of help in diagnosing the causative fungi even in case that KOH smear and fungus culture fail to identify the causative fungi. METHODS: Using 95 onychomycotic nail samples obtained from 87 patients, the KONCPA findings were compared with those of KOH smear and fungus culture. RESULTS: The results were as follows ; 1. The positive rates for dtecting the causative fungi from KOH srnear, fungus culture and KONCPA test were 779%, 45.3% and 95.8% respectively. The time required for KONCPA test, showing the highest positive rate, was only about 2 to 3 hours. 2. The fungus culture identified the causative fungi from 43 samples, of which dermatophytes were found in 31 samples(72.1%), Candida spp. in 5 samples(11.6%) and molds in 7 samples(16. 3%). KOH smear revealed the causative fungi in 63 samples : dermatophytes 56(88.9%), Candida spp. 4(6.3%) and molds 3(4.8%). KONCPA yielded the highest positivity by detecting the pathogenic fungi in 86 samples(95.8%): dermatophytes 60(69.8%), Candida spp. 8(9.3%), molds 10 (11.6%) and mixed infections 8(9.3%). 3. Compared with the results of fungus culture, 3 groups of fungi showed morphologic differences on KONCPA test: dermatophyte showing septated long and thin hyphae and a few arthrospores, Candida sp. showing blastospores and/or grape-like clusters of regular spores and pseudohyphae, and mold showing irregular hyphae with variable width and aggregates of irregular spores. 4. Of the 52 samples which were negative in fungus culture, 33(63.5%) showed findings of dermatophyte, 2(3.8% ) of Candida sp., 2(3.8% ) of mold and the remaining 11 samples(21.2% ) were negative on KOH smear, Of these 52 samples, KONCPA diagnosed 34(65.4%) to be dermatophytes, 6(11.5%) Candida syp., 6(11.5%) molds, 1(1.9%) mixed infection and 2 samples(3.8%) to be negative. CONCLUSION: KONCPA test is useful in the diagnosis of onychomycosis because of its higher positive rate in detecting the causative fungi compared with fungus culture or KOH smear. It is also a timesaving and simple procedure Furthermore, in case that KOH smear and fungus culture fail to identify the causative fungi, it is possible to make a presumptive diagnosis by the findings of KONCPA test.

Clinical and Mycological Studies on the Psoriatic Nails / 대한피부과학회지

BACKGROUND: Nail involvement in psoriasis is common. But their manifestions may often be difficult to differntiate clinically from onychomycosis, and results on fungal infections in psoriatic nails are still conflicting. OBJECTIVE: The purpose of this study was to observe the clinical signs and mycolgical profiles of psoriatic nails. METHODS: The frequency and types of clinical signs were observed prospectively according to sex, age, site, and accompaning tinea pedis. Repeated direct micrscopic and culture examinations, and KONCPA(KOH+Nail Clipping+PAS) study were done in the nails showing subungual kera tosis, and/or onycholysis. RESULTS: Fifty nine(59%) out of 100 patients with psoriasis had psoriatic nail changes. Nail changes were more common in fingers than in toes(55% vs 34%), in males than in females(68.9 % vs 43.6%). The types of frequent nail changes were different in fingers and in toes. Dermatophytes were isolated in 2 cases(8%) and yeasts and non-dermatophytic moulds were isolated in 20-40% of psoriatic nails CONCLUSION: Psoriatic nail changes of fingers and toes showed different clinical signs. Thus we recommended psoriatic nails to be diagnosed according to the involved site. The isolation of dermatophytes in the psoriatic patients were not so rare. Repeated culture was thought to be the most valuable test because yeasts and moulds were frequently isolated as saprophytes or contaminants.