Moo Kyu Suh

Onychomycosis Due to Nondermatophytic Molds

Background Although there have been many studies about onychomycosis due to nondermatophytic molds (NDM), few studies about etiologic agents including NDM in onychomycosis have been reported in Korea. Objective: This study investigated onychomycosis due to NDM in the Gyeongju area of Korea. Objective This study investigated onychomycosis due to NDM in the Gyeongju area of Korea. Methods In the 10-year period from 1999~2009, we reviewed 59 patients with onychomycosis due to NDM. The etiologic agents were identified by cultures on Sabourauds Dextrose agar with and without cycloheximide. In some cases, internal transcribed spacer sequence analysis was done. NDM isolated considered pathogens when the presence of fungal elements was identified by direct microscopy observation and in follow-up cultures yielding the same fungi. Results Onychomycosis due to NDM comprised 2.3% of all onychomycosis. Of the 59 patients with onychomycosis due to NDM, 84.7% were toenail onychomycosis and 15.3% were fingernail onychomycosis. The incidence rate was highest in the fifth decade (27.1%). The ratio of male to female patients was 1:1.6. The frequency of associated diseases, in descending order, was hypertension, diabetes mellitus, and cerebral hematoma. Distal and lateral subungual onychomycosis (86.4%) was the most common clinical type of onychomycosis. Aspergillus spp. was the most frequently isolated etiologic agent of onychomycosis due to NDM (83.0%). Other causative agents were Scopulariopsis brevicaulis (10.2%), Acremonium spp. (3.4%), Fusarium solani (1.7%), and Chaetomium globosum (1.7%). Conclusion Because of the increase in onychomycosis due to NDM, we suggest the need of a careful mycological examination in patients with onychomycosis.

Onychomycosis in Children: An Experience of 59 Cases

Background Although tinea unguium in children has been studied in the past, no specific etiological agents of onychomycosis in children has been reported in Korea. Objective The purpose of this study was to investigate onychomycosis in Korean children. Methods We reviewed fifty nine patients with onychomycosis in children (0~18 years of age) who presented during the ten-year period between 1999 and 2009. Etiological agents were identified by cultures on Sabourauds dextrose agar with and without cycloheximide. An isolated colony of yeasts was considered as pathogens if the same fungal element was identified at initial direct microscopy and in specimen-yielding cultures at a follow-up visit. Results Onychomycosis in children represented 2.3% of all onychomycosis. Of the 59 pediatric patients with onychomycosis, 66.1% had toenail onychomycosis with the rest (33.9%) having fingernail onychomycosis. The male-to-female ratio was 1.95:1. Fourteen (23.7%) children had concomitant tinea pedis infection, and tinea pedis or onychomycosis was also found in eight of the parents (13.6%). Distal and lateral subungual onychomycosis was the most common (62.7%) clinical type. In toenails, Trichophyton rubrum was the most common etiological agent (51.3%), followed by Candida albicans (10.2%), C. parapsilosis (5.1%), C. tropicalis (2.6%), and C. guilliermondii (2.6%). In fingernails, C. albicans was the most common isolated pathogen (50.0%), followed by T. rubrum (10.0%), C. parapsilosis (10.0%), and C. glabrata (5.0%). Conclusion Because of the increase in pediatric onychomycosis, we suggest the need for a careful mycological examination of children who are diagnosed with onychomycosis.

Fingernail Onychomycosis Due to Aspergillus niger.

Onychomycosis is usually caused by dermatophytes, but some species of nondermatophytic molds and yeasts are also associated with nail invasion. Aspergillus niger is a nondermatophytic mold which exists as an opportunistic filamentous fungus in all environments. Here, we report a case of onychomycosis caused by A. niger in a 66-year-old female. The patient presented with a black discoloration and a milky white base and onycholysis on the proximal portion of the right thumb nail. Direct microscopic examination of scrapings after potassium hydroxide (KOH) preparation revealed dichotomous septate hyphae. Repeated cultures on Sabourauds dextrose agar (SDA) without cycloheximide produced the same black velvety colonies. No colony growth occurred on SDA with cycloheximide slants. Biseriate phialides covering the entire vesicle with radiate conidial heads were observed on the slide culture. The DNA sequence of the internal transcribed spacer region of the clinical sample was a 100% match to that of A. niger strain ATCC 16888 (GenBank accession number AY373852). A. niger was confirmed by KOH mount, colony identification, light microscopic morphology, and DNA sequence analysis. The patient was treated orally with 250 mg terbinafine daily and topical amorolfine 5% nail lacquer for 3 months. As a result, the patient was completely cured clinically and mycologically.

Onychomycosis Caused by Chaetomium globosum

Onychomycosis is usually caused by dermatophytes, but some nondermatophytic molds and yeasts are also associated with invasion of nails. The genus Chaetomium is a dematiaceous nondermatophytic mold found in soil and plant debris as a saprophytic fungus. We report the first Korean case of onychomycosis caused by Chaetomium globosum in a 35-year-old male. The patient showed brownish-yellow discoloration and subungual hyperkeratosis on the right toenails (1st and 5th) and left toenails (1st and 4th). Direct microscopic examination of scraping on the potassium hydroxide preparation revealed septate hyphae and repeated cultures on Sabourauds dextrose agar (SDA) without cycloheximide slants showed the same fast-growing colonies, which were initially velvety white then turned to dark gray to brown. However, there was no growth of colony on SDA with cycloheximide slants. Brown-colored septated hyphae, perithecia and ascospores were shown in the slide culture. The DNA sequence of internal transcribed spacer region of the clinical sample was a 100% match to that of C. globosum strain ATCC 6205 (GenBank accession number EF524036.1). We confirmed C. globosum by KOH mount, colony, and light microscopic morphology and DNA sequence analysis. The patient was treated with 250 mg oral terbinafine daily and topical amorolfine 5% nail lacquer for 3 months.

Chromoblastomycosis Caused by Fonsecaea pedrosoi.

We report herein a case of chromoblastomycosis caused by Fonsecaea (F.) pedrosoi in a 39-year-old male, who showed multiple, asymptomatic, scaly erythematous plaques on the left shin for 12 months. Histopathologically, chronic granulomatous inflammation and either sclerotic or muriform cells were observed. The fungal culture produced typical black colonies of F. pedrosoi. The DNA sequence of the internal transcribed spacer (ITS) region of the clinical sample was 100% match to that of F. pedrosoi IFM 47061 (GenBank accession number AB240943). The patient was treated with 200 mg of itraconazole daily, for 3 months. Skin lesions were improved. In Korea, only 9 cases of chromoblastomycosis, including this case, have been reported until now. The etiologic agent was F. pedrosoi in the majority of cases (6/9;67%). The incidence of chromoblastomycosis was slightly higher in female, and the upper limbs were more affected than the lower limbs in patients.

Onychomycosis Caused by Scopulariopsis brevicaulis: Report of Two Cases

Onychomycosis is usually caused by dermatophytes, but some nondermatophytic molds and yeasts are also associated with invasion of nails. Scopulariopsis brevicaulis is a nondermatophytic mold found in soil as a saprophyte. We report two cases of onychomycosis caused by S. brevicaulis in a 48-year-old male and a 79-year-old female. The two patients presented with a typical distal and lateral subungual onychomycosis. Direct microscopic examination of the potassium hydroxide preparation revealed fungal elements. From toenail lesions of the patients, brown colonies with powdery surface, which are a characteristic of S. brevicaulis, were cultured on two Sabourauds dextrose agar plates. Three cultures taken from nail plates within a 2-week interval yielded similar findings. Numerous branched conidiophores with chains of rough walled, lemon-shaped conidia were observed in slide culture by light microscopy and scanning electron microscopy. The nucleotide sequences of the internal transcribed spacer for the two clinical isolates were identical to that of S. brevicaulis strain WM 04.498. To date, a total of 13 cases of S. brevicaulis onychomycosis including the two present cases have been reported in Korea. Mean age of the patients was 46.1 years, with a higher prevalence in males (69.2%). Toenail involvement was observed in all cases including a case involving both fingernail and toenail. The most frequent clinical presentation was distal and lateral subungual onychomycosis in 12 cases, while one case was proximal subungual onychomycosis.

Molecular phylogenetics of exophiala species isolated from Korea.

Background Recently, identification of fungi have been supplemented by molecular tools, such as ribosomal internal transcribed spacer (ITS) sequence analysis. According to these tools, morphological Exophiala species was newly introduced or redefined. Objective This study was designed to investigate the phylogenetics based on ribosomal ITS sequence analysis from clinical Exophiala species isolated in Korea. Methods The strains of Exophiala species were 4 clinical isolates of phaeohyphomycosis agents kept in the department of dermatology, Dongguk University Medical Center(DUMC), Gyeongju, Korea. The DNAs of total 5 strains of Exophiala species were extracted by bead-beating method. Polymerase chain reaction of ITS region using the primer pairs ITS1-ITS4, was done and phylogenetic tree contributed from sequences of ITS region from 5 Korean isolates including E. dermatitidis CBS 109154 and comparative related strains deposited in GenBank. Results The strains of Exophiala species were 3 strains of E. dermatitidis, 1 strain of E. jeanselmei and 1 strain of Exophiala new species. Among the 3 subtypes (type A, B, C) of E. jeanselmei, E. jeanselmei DUMC 9901 belonged to type B. Of the 2 main types of E. dermatitidis (type A, B) and 3 subtypes of E. dermatitidis type A (A0, A1 and A2), two strains (E. dermatitidis CBS 709.95, E. dermatitidis CBS 109154) belonged to A0 subtypes, 1 strain (E. dermatitidis DUMC 9902) A1 subtype, respectively. Conclusion Phylogenetic analysis of ITS region sequence provided useful information not only for new species identification but for the subtyping and origin of Exophiala species.

A Case of Axillary Adenoid Basal Cell Carcinoma

Basal cell carcinoma (BCC) is the most common skin cancer with a steadily increasing incidence. Ultraviolet radiation is considered the single most important risk factor for BCC, because the tumor occurs most frequently in sun-exposed areas of the body, with approximately four of five BCCs occurring on the face. BCC occurs infrequently in non-sun-exposed skin. The axilla is one of the most sun-protected areas of the body, and BCC arising at this site is very rare. We herein report a case of adenoid BCC which arose from the axilla in a 33-year-old woman.

Deformity of the earlobe caused by fixed cutaneous sporotrichosis in a pediatric patient.

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Longitudinal melanonychia caused by Fusarium oxysporum in immunocompetent patient

Kui Young Park, Jin Woong Lee, In Su Kim, Moo Kyu Suh, Jong Soo Choi, Nam Ju Moon and Seong Jun Seo Departments of Dermatology, Chung-Ang University College of Medicine, Seoul, South Korea, Departments of Dermatology, College of Medicine, Dongguk University, Kyongju, Korea, Department of Dermatology, College of Medicine, Yeungnam University, Daegu, Korea and Departments of Ophthalmology, Chung-Ang University College of Medicine, Seoul, South Korea