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Combined infections affecting the nail and periungual tissue

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Combined bacterial and fungal infections of nails and periungual tissue.

  • Diseases affecting  nails and  periungual tissue   are very common in dermatovenereology.
  • Interesting, but bothersome manifestations occur after chemotherapy, biologics, retinoids  in diabetic or immunodeficient patients.
  • Due to the increasingly popular nail design, we see manifestations which had been rare.
  • Problems may occur in: Mentally challenged individuals (due to behaviour problems, addiction, obsession), mobbed individuals
  • Stressed children

 

Differential diagnostics of nail diseases

  • Is crucial in order to determine:
  • Coincident bacterial and fungal infection
  • Concomitant infection
  • Neglected therapy of one or the other pathogen   prolongs healing and patient discomfort

Question:

  • Which infection has priority – fungal or bacterial?  
  • Is the combination of the two types of infection a rule or rather an exception?
  • What are the bottlenecks of complex therapy?

Important and inevitable:

  • Targeted bacteriological and mycological examination (microscopy and culture)

Immunodeficiency

  • Disrupted mechanisms of specific and non-specific immunity
  • Due to origin:

      primary

  •    secondary -  caused by physical,chemical, biological, psychosocial factors
    • Complicate the underlying disease
    • Chronic mucocutaneous Candida infections
    • Frequent skin infections

            (Staphylococcus aureus)

Combined mould and bacterial infection in an immunodeficient patient

  • Male born in 1949 diabetic, alcoholic, smoker
  • High amputation of both legs in 2000 - AS obliterans, gangrena pedis l. sin., 2001 - gangrena dig. I  et flegmona pedis et cruris l. dx
  • 2002 – therapy due to seborrhoeic dermatitis, anguli infectiosi (Candida albicans)

l      hands – onychomycosis on the first and third fingernails on both hands with progressive changes on all nail plates

l      four nails were coloured green

l      Mycological culture – scales from both hand skin and nails – revealed massive microscopic positivity

l      Later with the result of: T. rubrum

l      Mycological examination of mouth corners – massive Candida albicans

l      bacteriological examination - Pseudomonas aeruginosa, Staphylococcus aureus

 

Chemotherapy

  • Suppresses the immune system
  • Affects growing cells (hair, nails), resulting in undesired changes, although temporary, they cause severe mental distress in patients
  • nails – susceptible to injury and infection
  • Possible changes: dryness, thinning, fragility, slow growth, brittleness, nail plate detachment

 

Case report

  • Female aged 52 years - breast CA with liver  MTS .
  • On Xeloda 4-0-4 (500 mg), Taxotere Pamitor
  • Changes on hand nails after three weeks of therapy
  • Cultures revealed: Staph. Aureus, Candida albicans

The same female patient

  • Toenails:
  • Culture: Pseudomonas aeruginosa
  • Mycology: negative

Occupation in agriculture

  • Female aged 48 years
  • Sow breeder
  • Mycological culture on hands and feet: Trichophyton rubrum, Candica  torulopsis
  • Bacteriological test – Staph. Epidermidis, Staph. epidermidis

Occupation in horse breeding

  • Male aged 54 years
  • Mycology: T. rubrum
  • Bacteriology:  Streptococcus equi, E. colli

Occupation in forestry

  • 65-year-old male
  • Has worked in the forest for 36 years in boots and without gloves
  • Problematic hygiene, sees no health issue with his nails, the family made him see a doctor
  • Mycological culture revealed a massive  Trichophyton rubrum  infection
  • Bacteriological tests - Staph. Epidermidis

Sports

  • Unguis incarnatus recidivans
  • Male sportsman aged 25 years
  • Condition after 2 months of unsuccessful home therapy
  • Skin culture: massive Staphylococcus aureus inf.
  • Nail culture: Trichophyton mentagrophytes

Occupation in nail design

  • Female aged 52 years,
  • Nail changes in 2 months
  • Gradual discoloration , deformities
  • She attributed the changes to the new material she started working with
  • Cultures revealed Pseudomonas aeruginosa, Torulopsis candida
  • Combined therapy with ANB and antifungals

Occupation in healthcare

  • 38 year-old female, a nurse in dentistry, works in gloves
  • Changes in  nail plate of the 4 fingernail on the right hand for over one year
  • In the last two months there was inflammation around the nail  of the second and third fingernail
  • Topical ointments had no effect
  • Skin culture: mass. Staphylococcus aureus,
  • Nail culture: Candida albicans

Occupation in healthcare

  • Female aged 36 years
  • Dental hygienist
  • Manifestations  relapsing in 4 years
  • Skin culture: Staphylococcus aureus,
  • Nail culture:   Candida albicans
  • Combined topical therapy antibiotics and antifungals

Discussion

  • It is not easy to distinguish between bacterial and fungal nail and periungual tissue infections
  • Clinical assessment is not sufficient, bacteriological and mycological cultures should be performed in chronic cases
  • Problems must be assessed in a complex manner (determine occupation, hobbies, possible injuries, traumas, etc.)
  • Manifestations of misdiagnosed and thus improperly treated combined infection prolong the health problems of the  patient
  • Often they are caused by adverse effects of systemic drugs or other severe conditions
  • Inform the patient on proper treatment  and preventive measures, tell them to:
    • Maintain proper personal hygiene
    • Avoid detergents, chemicals, strong soap, washing fluids,
    • Wear gloves when performing risky activities
    • Perform proper manicure and pedicure
    • Take care of the cuticle
    • Etc, ...

 

Conclusion

  • We have only mentioned some combined fungal and bacterial diseases affecting nails and periungual tissue.
  • We have not mentioned therapeutic procedures, which would provide enough material for another presentation.

 

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