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CASE REPORT
Year : 2019  |  Volume : 20  |  Issue : 3  |  Page : 249-251

A rare case of onychomycosis due to Aspergillus species in a neonate


1 Department of Dermatology, Venereology and Leprosy, SNMC, Agra, Uttar Pradesh, India
2 Department of Dermatology, Venereology and Leprosy, IGMC, Shimla, Himachal Pradesh, India
3 Department of Microbiology, IGMC, Shimla, Himachal Pradesh, India

Date of Web Publication28-Jun-2019

Correspondence Address:
Dr. Kuldeep Verma
1365, Ram Janki Puram Colony, Mehndi Bagh, Jhansi - 284 001, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_116_18

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  Abstract 


Onychomycosis is a common condition affecting 5.5% of the population worldwide and represents 20%–40% of all onychopathies and about 30% of cutaneous mycotic infections. It is common in elderly, uncommon in children, and rare in neonates. Onychomycosis is caused by dermatophytes, nondermatophytic molds (NDM), and yeasts. Onychomycosis due to NDM is even rarer in neonates. Here, we report a case of a 3-week-old neonate who was diagnosed as a case of onychomycosis due to Aspergillus species. The neonate was started on topical antifungal amorolfine 5% and improved in 8 weeks.

Keywords: Aspergillus, neonate, onychomycosis


How to cite this article:
Verma K, Tegta GR, Verma G, Verma S. A rare case of onychomycosis due to Aspergillus species in a neonate. Indian J Paediatr Dermatol 2019;20:249-51

How to cite this URL:
Verma K, Tegta GR, Verma G, Verma S. A rare case of onychomycosis due to Aspergillus species in a neonate. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Aug 23];20:249-51. Available from: http://www.ijpd.in/text.asp?2019/20/3/249/261865




  Introduction Top


Onychomycosis is quite a common condition that affects 5.5 % of the worldwide population.[1] It can be caused by dermatophytes, non dermatophytic molds (NDM) and yeasts Dermatophytes are the most frequent cause of onychomycosis and involved in 90% cases of toenail and 50% of fingernail “onychomycosis” or more specifically “Tinea unguium.”[1] NDM can also invade nails and account for 1.5%–6% of all cases of onychomycosis which include Aspergillus species, Scopulariopsis brevicaulis, Fusarium species, Alternaria, Acremonium, and Curvularia. Yeasts are now increasingly recognized as pathogens in fingernail infections. Candida albicans accounts for most of these cases (70%), while C. parapsilosis, C. tropicalis, and C. krusei account for the remainder.[2] Here, we report a case of onychomycosis due to NDM in a neonate due to Aspergillus species.


  Case Report Top


A 3-week-old neonate was brought to our dermatology outpatient department with a chief complaint of yellowish discoloration and thickening of six nails of the hand and both nails of great toe from the last 2 weeks. Nails were apparently normal at birth, but 1 week after birth, the patient started developing yellowish discoloration and thickening of hand nails followed by toe nails. The child was born through full-term normal delivery at hospital, and there was no history of perinatal hypoxia. The neonate was nondiabetic, nonreactive for HIV, and there were no features suggestive of inherited immunodeficiency syndromes. No congenital malformations were seen. The mother had no history suggestive of abnormal vaginal discharge during pregnancy or postpartum. There was no history of fungal infection in family. There was no history of pets at home. Immune status of both parents was nonreactive for HIV.

On examination, there was yellowish discoloration and subungual hyperkeratosis of the hand nails, with the clinical findings suggestive of distal lateral subungual onychomycosis [Figure 1] and [Figure 2], while examination of the toe nails revealed brownish discoloration of the proximal nail fold with yellowish discoloration, thickening, and splitting of proximal nail plate, simulating a proximal subungual onychomycosis [Figure 3]. Mucocutaneous examination revealed no skin or mucosal lesions suggestive of fungal infection. Examination of nail clippings in 10% KOH revealed fungal hyphae [Figure 4], and the culture showed growth of Aspergillus species [Figure 5]. The culture was repeated on two occasions, but no growth of dermatophytes was observed. Additionally, lactophenol cotton blue mount showed conidiophores with half of vesicle covered with phialides and conidia in chains [Figure 6].
Figure 1: Initial picture of hand nails showing yellowish discoloration, thickening, and mild hyperkeratosis suggestive of distal lateral subungual onychomycosis

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Figure 2: Closer view

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Figure 3: Bilateral great toe nail showing brownish proximal nail fold. Yellowish discoloration, thickening, and splitting of proximal part of nail plate suggestive of proximal subungual onychomycosis

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Figure 4: 10% KOH mount reveals fine septate hyphae (×10)

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Figure 5: Tube – Sabouraud's dextrose agar showing dark brown-to-smoky green, woolly colonies of Aspergillus

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Figure 6: Photomicrograph – Lactophenol cotton blue mount showing conidiophores with half of vesicle covered with phialides and conidia in chains

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The patient was started on topical amorolfine 5% nail lacquer. The mother of the child was instructed to apply nail lacquer once daily. The infected nails improved in 8 weeks with no residual dystrophy or discoloration. A repeat culture and KOH mount were negative at 10 weeks [Figure 7] and [Figure 8]. At 12 weeks, the child was doing well with no evidence of nail infection or any side effects from the use of topical amorolfine nail lacquer.
Figure 7: The patient was started on topical amorolfine 5% nail lacquer and after 10 weeks, there was complete clinical improvement

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Figure 8: Closer view (improvement)

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  Discussion Top


Onychomycosis is generally a disease of elderly and has been rarely reported in neonates, with NDMs being even more rare causative agents. The prevalence of onychomycosis is low in children when compared to adults due to reduced exposure to infected environments, less trauma due to smaller and thinner nail surface, and faster linear nail growth.[3] Predisposing factors include family history of onychomycosis, habit of walking barefoot, hyperhidrosis, close contact with soil, frequent emersion of hands in water, hot humid climate, systemic immunosuppression, and diabetes.[4] Onychomycosis is rare in neonates. The earliest dermatophytic onychomycosis was reported in an 8-week-old infant by Borbujo-Martínez et al.[5] Another case was reported by Kurgansky and Sweren[6] in a 10-week-old infant. In addition, 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.[7] Psoriasis, lichen planus, contact dermatitis, and yellow nail syndrome are common differentials of onychomycosis.

Nail infections caused by NDMs have been increasing.[8] Six major criteria are used for the identification of NDMs. These are (a) microscopic examination of NDM using KOH preparation, (b) isolation by culture, (c) repeat isolation by culture, (d) inoculum counting, (e) failure to isolate dermatophyte in culture, (f) failure to isolate dermatophyte on histology. Gupta et al. have recommended three out of six criteria for the diagnosis of NDM onychomycosis.[9] In our case, culture was repeated twice which showed growth of Aspergillus with no dermatophytes along with positive KOH examination for hyphae, thus fulfilling the criteria of NDM onychomycosis. Recently in 2016, Samir et al. reported a case of onychomycosis in a 3-year-old child due to NDM Aspergillus niger.[10]


  Conclusion Top


We report this case because onychomycosis is rarely reported in a neonate, though there are few cases of onychomycosis due to dermatophyte in literature. Onychomycosis due to NDMs in a neonate is even rarer finding and to the best of our knowledge, this is the first case of NDM infection of the nails due to Aspergillus species in a neonate. The diagnosis of onychomycosis due to Aspergillus spp. is both clinical and mycological. Since there are no specific signs associated with onychomycosis due to Aspergillus spp., it is not possible to diagnose it based solely on physical appearance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's guardian has given his consent for his child's images and other clinical information to be reported in the journal. The patient's guardian understands that the child's name and initial will not be published and due efforts will be made to conceal the child's identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kaur R, Kashyap B, Bhalla P. Onychomycosis – Epidemiology, diagnosis and management. Indian J Med Microbiol 2008;26:108-16.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Jayatilake JA, Tilakaratne WM, Panagoda GJ. Candidal onychomycosis: A mini-review. Mycopathologia 2009;168:165-73.  Back to cited text no. 2
    
3.
Gulgun M, Balci E, Karaoglu A, Kesik V, Babacan O, Fidanci MK, et al. Prevalence and risk factors of onychomycosis in primary school children living in rural and urban areas in central Anatolia of Turkey. Indian J Dermatol Venereol Leprol 2013;79:777-82.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Ranawaka RR, Silva N, Ragunathan RW. Non-dermatophyte mold onychomycosis in Sri Lanka. Dermatol Online J 2012;18:710-2.  Back to cited text no. 4
    
5.
Borbujo-Martínez JM, Fonseca Capdevila E, Martínez G. A rare case of onychomycosis in a neonate due to Aspergillus species. Actas Dermo Sifiliogr 1987;78:207-8.  Back to cited text no. 5
    
6.
Kurgansky D, Sweren R. Onychomycosis in a 10-week-old infant. Arch Dermatol 1990;126:1371.  Back to cited text no. 6
    
7.
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. 7
    
8.
Guilhermetti E, Takahachi G, Shinobu CS, Svidzinski TI. Fusarium spp. As agents of onychomycosis in immunocompetent hosts. Int J Dermatol 2007;46:822-6.  Back to cited text no. 8
    
9.
Gupta AK, Drummond-Main C, Cooper EA, Brintnell W, Piraccini BM, Tosti A, et al. Systematic review of nondermatophyte mold onychomycosis: Diagnosis, clinical types, epidemiology, and treatment. J Am Acad Dermatol 2012;66:494-502.  Back to cited text no. 9
    
10.
Samir MS, Asha GS, Madhu SM, Nataraja HV, Lakshmi DV. Encounter with an unusual organism in a 3-year-old child with onychomycosis! Indian J Paediatr Dermatol 2016;17:312-4.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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