Proximal subungual onychomycosis caused by Aspergillus flavus in a HIV-positive patient

Sanjiv V Choudhary¹ , Sankha Koley¹ , Sanjay Mallick² , Seema Bose² , Silpi Basak²

¹ Department of Dermatology, Jawaharlal Nehru Medical College, Sawangi, Mahrasthra, India
² Department of Microbiology, Jawaharlal Nehru Medical College, Sawangi, Mahrasthra, India

Correspondence Address:
Sanjiv V Choudhary
28, Modern Nagpur Society, Chhatrapati Nagar, Nagpur - 15 (M.S)
India

Sir,

Onychomycosis is defined as a fungal infection of the nail caused by dermatophytes, nondermatophyte moulds (NDM) and yeasts. Types of onychomycosis are distal-lateral subungual onychomycosis (DLSO), proximal subungual onychomycosis (PSO), white superficial onychomycosis and total dystrophic onychomycosis. D0 LSO is the most common clinical type. PSO is uncommon in the general population but is frequently associated with human immunodeficiency virus (HIV) infection and is mostly caused by Trichophyton rubrum and Trichophyton megninii . PSO is nearly pathognomonic of HIV infection. ^[1],[2] Multiple fungal species and unusual opportunistic fungi are frequently cultured from HIV-infected patients and may be a reflection of the degree of immunosuppresion. ^[3] Previously regarded as contaminants, yeasts and moulds are now being increasingly recognized as pathogens in fungal nail infection. ^[4] Aspergillus flavus is a widespread saprophyte found in soil, seeds, fruits and decaying vegetation. We report a rare case of PSO caused by Aspergillus flavus in an HIV-positive patient.

A 30-year-old male patient, farmer by occupation, presented with severe tingling sensation and burning pain affecting both the lower extremities for the past 2 months. He gave history of unprotected heterosexual genito- genital exposure and loss of weight for the past 1.5 years. General examination revealed thin, cachexis built of the patient. Cutaneous examination revealed diffuse greasy scales involving the scalp, eyebrow and retroauricular region. The oral mucous membrane showed a curdy-white plaque involving the dorsum of the tongue. The left great toe nail revealed whitish discoloration of the proximal nail plate with brittleness [Figure - 1]. Nail folds were normal. Clinically, the possibility of Hansen′s disease was ruled out. With this history and clinical examination, the possibility of underlying immunosuppresion was thought and the case was investigated. Routine investigations revealed gross anemia . Blood sugar levels were normal. Enzyme-linked immunosorbent assay test was positive for HIV antibodies. The proximal nail plate of the left great toe was scraped and pared with surgical blade no. 15. With the help of a curette, material from the proximal nail bed was taken. The sample was sent to the microbiology department for KOH examination and culture. KOH examination revealed septate branching mycelium. Culture carried out on Sabouraud′s dextrose agar with chloramphenicol revealed the characteristic green-colored colony suggestive of Aspergillus flavus [Figure - 2]. Slide culture revealed septate branching mycelium, conidiophore, phialide and conidia of Aspergillus flavus [Figure - 3]. Fruiting bodies of Aspergillus flavus are similar to Syncephalastrum racemosum , but Syncephalastrum racemosum has aseptate hyphae and a merosporangial sac surrounding the sporangiospores. KOH examination of the curdy-white plaque from the dorsum of the tongue revealed budding yeast-like cells with pseudohyphae. The final diagnosis was peripheral neuropathy with seborrhoeic dermatitis, oral candidiasis and PSO due to Aspergillus flavus of the left great toe in an HIV-positive patient.

Nondermatophyte moulds (NDM) were the rare cause of onychomycosis. Tosti et al. in their study found that PSO was the most common type of onychomycosis caused by NDM and that those cases were not associated with significant systemic illness or immunosuppresion. ^[5] Goettmann-Bonvallot, in his article, reported that PSO without fingernail or toenail paronychia is generally caused by Trichophyton rubrum in immunodepressed subjects (patients with acquired immunodeficiency syndrome). ^[6] Recently published reports from India revealed increased incidence of NDM causing onychomycosis in HIV-infected patients. ^[7] Several authors have reported cases of onychomycosis due to Aspergillus species. To the best of our knowledge, there are only few reports of Aspergillus flavus (green mould) causing onychomycosis. ^[8],[9],[10] In our case, Aspergillus flavus species was the pathogen and not a contaminant as (1) KOH examination of nail scrapings revealed a septate branching mycelium, (2) three repeated cultures performed on Sabouraud′s dextrose agar with chloramphenicol revealed characteristic morphology and color suggestive of Aspergillus flavus and (3) slide culture findings were suggestive of Aspergillus flavus only.

PSO is more frequently seen when the CD4 cell count falls below 450 cells/mm ³ . ^[11],[12] But we did not have follow-up of the patient and CD4 cell counts. Usually, periungual inflammation is seen in onychomycosis (especially PSO) caused by Aspergillus species. ^[5] But in our case no periungual inflammation was seen. So far, we know that onychomycosis caused by Aspergillus flavus species is a rare finding. To the best of our knowledge, there are only few reports in the international literature and not a single one from India.

Acknowledgment

The authors would like to acknowledge Dr. Priyesh Jaiswal, 3 ^rd year MD resident of Medicine of Jawaharlal Nehru Medical College, Sawangi.

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