Onychomycosis Due to Rhizomucor in Psoriatic Patient with HIV Infection
A 35-year-old man, laborer by occupation, presented with discolored and thickened fingernails of both the hands. He gave a history of loss of weight for the past 1 year and development of multiple crusted to scaly, erythematous papules and plaques all over the trunk, both arms, and lower limbs. There was extensive scaling of the scalp also. Mild itching was associated with the skin lesions. About 2-3 months after the appearance of skin lesions, he noticed discoloration and brittleness of the nail of little finger of the left hand. Gradually, the rest of the finger nails of both the hands got involved. General examination revealed thin, cachexic build of the patient. Cutaneous examination revealed hyperpigmented macules, scaly erythematous papules, and few lichenoid plaques with adherent scales diffusely present over the trunk and extremities. The fingernails showed yellowish discoloration, subungual hyperkeratosis, and pitting shown in clinical Figures and . With this clinical history and physical examination, possibility of underlying immunosuppression was contemplated. The patient was advised for HIV testing, which revealed that he was HIV-positive. It was found that his CD4+ count was 118/mm3. He was started on anti-retroviral therapy (ART) at the ART clinic and referred back to the dermatology department for management of skin lesions. Further, he was sent for histopathological investigations, which demonstrated psoriasiform hyperplasia of the epidermis, focally diminished granular layer, suprapapillary thinning and congested vessels in the dermis. The PAS stain for fungal hyphae was negative. Nail clippings and subungual debris were taken for mycological examination. KOH examination of the scrapings revealed wide, ribbon-like hyphae typical for Zygomycetae. The nail clippings were seeded on Sabouraud dextrose agar. There was a rapid growth seen in two days, which filled the tube. The colony was woolly, white initially and turned gray with time. The reverse was white to pale. Slide culture revealed non-septate broad hyphae with internodal rhizoids, irregularly branched sporangiophores with sporangia at their apices. Sporangia were brown in color and round in shape. Apophysis was absent. Columellae were prominent and spherical to pyriform in shape. Sporangiospores were small, unicellular, and round in shape. The isolate was able to assimilate sucrose. The diagnosis of Rhizomucor pusillus was made. After the first diagnosis, a second sample was taken, the laboratory procedures were repeated, and the diagnosis was confirmed. Clinician dermatologists were informed about the diagnosis, and the patient was started on fluconazole. The patient did not return for therapeutic success evaluation.