A rare case of onychomycosis in all 10 fingers of an immunocompetent patient
A 42-year-old male vegetable vendor by occupation, presented to the Dermatology out-patient department of our hospital with brownish black discoloration and disfigurement of all the nails of 8 months duration. The patient first noticed it on the nail of the right index and middle finger which gradually spread to the other fingers and all the fingers of the left hand. On examination, all fingernails were brownish black in color with loss of texture and there were dystrophic changes as well as onycholysis in most of the fingers [].\nMultiple specimens of nail scrapings and clippings from different parts of the affected nails were collected from all fingers after cleaning the area with 70% alcohol. The samples were sent to the Microbiology department where direct examination by 40% Potassium hydroxide mount was done that showed branched septate hyphae. The clippings were cultured on two sets of Sabouraud's dextrose agar with and without antibiotics and cycloheximide which were incubated at room temperature and 37°C.\nAfter 3 days, growth was seen in all the tubes in the form of cottony white mycelium growth, which was soon covered with abundant black spores []. No bacterial growth was detected in the culture. Microscopic characterization of the fungal isolate was carried out by preparing a lactophenol cotton blue mount from the growth. They mostly consisted of erect conidiophores. The conidiophores terminated in a vesicle covered with phialides (biseriate). The secondary phialide bore chains of globose conidia were dark and covered the entire surface. The conidial head was large, black, and radiate. The fungal isolate was confirmed to be Aspergillus niger by these features. Repeat culture of the nail samples yielded the same organism.\nComplete blood count was normal except for a slight anemia with a hemoglobin of 11 g/dl. The fasting and postprandial blood sugar levels were normal; the tests for Human Immunodeficiency Virus(HIV) and Hepatitis B surface antigen (HBsAg) were negative. The patient gave no history of alcohol consumption, smoking, or any drug addiction. The patient was started on oral itraconazole 200 mg BD for 7 days for 2 consecutive months (oral Itraconazole pulse therapy). After 2 months, his nails did not show much improvement in the appearance, though the microscopy and culture of the nail scrapings were negative for fungal elements. So he was given pulse therapy of itraconazole for a further 2 months and was reassured that the nail color and texture will take some time to regain normalcy.