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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 17  |  Issue : 4  |  Page : 312-314

Encounter with an unusual organism in a 3-year-old child with onychomycosis!


Department of Dermatology, Venereology and Leprology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Date of Web Publication7-Oct-2016

Correspondence Address:
Mukherjee Samipa Samir
Department of Dermatology, Venereology and Leprology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.175658

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  Abstract 

Onychomycosis refers to the nondermatophytic and dermatophytic involvement of nails. Literature suggests its increasing prevalence from the younger to the older age group. In addition to the important clinical consequences that the infection holds, it also acts as a reservoir of infection. We, hereby, report a case of a 3-year-old immunocompetent child with single nail onychomycosis due to Aspergillus niger. To the best of our knowledge, this is the youngest reported case of onychomycosis due to A. niger.

Keywords: Aspergillus niger, immunocompetent, onychomycosis, single nail, youngest


How to cite this article:
Samir MS, Asha G S, Madhu S M, Nataraja H V, Lakshmi D V. Encounter with an unusual organism in a 3-year-old child with onychomycosis!. Indian J Paediatr Dermatol 2016;17:312-4

How to cite this URL:
Samir MS, Asha G S, Madhu S M, Nataraja H V, Lakshmi D V. Encounter with an unusual organism in a 3-year-old child with onychomycosis!. Indian J Paediatr Dermatol [serial online] 2016 [cited 2020 Sep 24];17:312-4. Available from: http://www.ijpd.in/text.asp?2016/17/4/312/175658


  Introduction Top


Onychomycosis is an umbrella term for fungal infections of the nail caused by dermatophytes, nondermatophytic moulds, or yeast. It includes five types: Distal lateral subungual onychomycosis, superficial white onychomycosis (SWO), proximal subungual onychomycosis, total dystrophic onychomycosis (TDO), and the newly described variant endonyx onychomycosis. It is generally considered as a disorder of the older age group with a progressively increasing prevalence from childhood to adulthood.[1] We hereby describe a 3-year-old immunocompetent child with onychomycosis of the thumb nail caused by Aspergillus niger.


  Case Report Top


A 3-year-old male child, born to nonconsanguineous parents, was presented with dystrophy of the right thumb nail for the last 2 months. There was no history suggestive of any trauma preceding the onset of lesions, the habit of thumb sucking, or any habit disorders (like a tic). His past medical and surgical history was also insignificant. Apart from the thumb nail, no other nail was affected. Systemic examination was within normal limits, no other disease and no history of congenital or acquired immunodeficiency was stated. Family history for the similar condition was negative.

Cutaneous examination was normal. Nail examination revealed dystrophy of the cuticle with edematous over hanging proximal and lateral nail folds of the thumb. The nail showed yellow-brown discoloration with total dystrophy of the nail [Figure 1]. Destruction of the nail was noted in the form of loss of distal end with transverse ridging. Hair and mucosal evaluation was normal.
Figure 1: Involvement of right thumb nail

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An initial potassium hydroxide (KOH) mount was negative for fungal elements. As the mother was very concerned, a fungal culture was done from nail clipping which revealed A. niger as the causative organism [Figure 2] and [Figure 3]. Sensitivity testing was deferred due to cost constraints.
Figure 2: Aspergillus niger growth on sabouraud dextrose agar

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Figure 3: Aspergillus niger growth on agar medium (on plate)

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The child was treated with oral terbinafine 62.5 mg/day along with topical amorolfine nail lacquer. The child was lost to posttreatment follow-up.


  Discussion Top


Onychomycosis is one of the most prevalent nail disease and accounts for approximately 50% of all onychopathies, and tinea unguium is a specific sub-diagnostic category of onychomycosis. While onychomycosis is a general terminology, tinea unguium refers specifically to the infections by dermatophytes. The reported prevalence of onychomycosis ranges from 0.2% to 2.6% among the children approximately 1/30th that of adults.[2],[3] Dystrophic nails in children must alert the clinician of a possibility of onychomycosis and it should be differentiated from the congenital causes of nail dystrophy. The low prevalence of pediatric onychomycosis is postulated to be due to the faster nail growth, smaller surface area available for exposure to onychomycotic pathogens, lack of cumulative trauma, and reduced environmental exposure to public places such as locker rooms and public showers that harbor the high densities of infective hyphae and spores.[1],[2],[4],[5]

Literature suggests that SWO has been reported to be caused by Trichophyton mentagrophytes, Trichophyton interdigitale, and Candida species and rarely by Fusarium, Aspergillus and Cladosporium species, and dermatophytes, including Trichophyton rubrum and Trichophyton verrucosum.[6] In spite of an extensive literature search, we were unable to find any literature showing A. niger as the causative agent for TDO in pediatric age group. Furthermore, of note, is the fact that in our patient, there was no history of any contributing factor toward the development of onychomycosis. In children <2 years old having onychomycosis, Bonifaz found an association with Down's syndrome, fungal infection on other body parts, premature birth, perinatal hypoxia, and infection in other family members of which none of the factors was noted in our patient.[7]A. niger generally causes a distal subungual infection which then further grows backward toward the cuticle. As the species is known to produce pigment, nail infection may appear in green, black, brown or various other shades. The most commonly isolated mould from nails is Scopulariopsis brevis followed by A. niger as reported in studies.[8] Although literature reports A. niger as a cause of onychomycosis in immunocompromised patients, occurrence in immunocompetent hosts is rare.

The patient was treated with oral terbinafine which was chosen over itraconazole because of the better safety profile of the drug.


  Conclusion Top


We hereby state that a fungal culture should be done in the cases of dystrophic nails in children in spite of a negative KOH mount repot. Furthermore, to the best of our knowledge, this is the youngest reported case of onychomycosis with A. niger as a causative agent in an immunocompetent individual.

Acknowledgment

The author would like to express his heart full thanks to the Department of Dermatology, Bangalore Medical College and Research Institute, for their valuable contribution and support.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Rodríguez-Pazos L, Pereiro-Ferreirós MM, Pereiro M Jr, Toribio J. Onychomycosis observed in children over a 20-year period. Mycoses 2011;54:450-3.  Back to cited text no. 1
    
2.
Gupta AK, Sibbald RG, Lynde CW, Hull PR, Prussick R, Shear NH, et al. Onychomycosis in children: Prevalence and treatment strategies. J Am Acad Dermatol 1997;36:395-402.  Back to cited text no. 2
    
3.
Gunduz T, Metin DY, Sacar T, Hilmioglu S, Baydur H, Inci R, et al. Onychomycosis in primary school children: Association with socioeconomic conditions. Mycoses 2006;49:431-3.  Back to cited text no. 3
    
4.
Zac RI, Café ME, Neves DR, E Oliveira PJ, Barbosa VG. Onychomycosis in a very young child. Pediatr Dermatol 2009;26:761-2.  Back to cited text no. 4
    
5.
Sachdeva S, Gupta S, Prasher P, Aggarwal K, Jain VK, Gupta S. Trichophyton rubrum onychomycosis in a 10-week-old infant. Int J Dermatol 2010;49:108-9.  Back to cited text no. 5
    
6.
Piraccini BM, Tosti A. White superficial onychomycosis: Epidemiological, clinical, and pathological study of 79 patients. Arch Dermatol 2004;140:696-701.  Back to cited text no. 6
    
7.
Bonifaz A, Saúl A, Mena C, Valencia A, Paredes V, Fierro L, et al. Dermatophyte onychomycosis in children under 2 years of age: Experience of 16 cases. J Eur Acad Dermatol Venereol 2007;21:115-7.  Back to cited text no. 7
    
8.
Rippon JW. Medical Mycology: Pathogenic Fungi and Pathogenic Actinomycetes. 3rd ed., Vol. 226-9. Philadelphia: W.B. Saunders Co.; 1988.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]


This article has been cited by
1 A rare case of onychomycosis due to Aspergillus species in a neonate
Kuldeep Verma,GitaRam Tegta,Ghanshyam Verma,Santwana Verma
Indian Journal of Paediatric Dermatology. 2019; 20(3): 249
[Pubmed] | [DOI]



 

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