Aspergillus flavus onychomycosis in the right fourth fingernail related to phalynx fracture and traumatic inoculation of plants: A vegetable vendor case report

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Merad Y Moulay AA, Derrar H, Belkacemi M et .al^*

Citation: Merad Y, Moulay AA, Derrar H, Belkacemi M, Larbi-cherrak NA, Ramdani FZ, Belmokhtar Z, Messafeur A, Drici A, Ghomari O, and Adjmi-Hamoudi H, ”Aspergillus flavus onychomycosis in the right fourth fingernail related to phalynx fracture and traumatic inoculation of plants: A vegetable vendor case report, vol 2, no. 1, 2020, pp. 1-4.

Copyright Merad Y, et al . This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract:

Aspergillus genus is responsible of post-traumatic fungal infections like mycetomes and onychomycosis.A 30 year-old male vegetable vendor by occupation presented in our institution with brownish black discoloration of 1 year duration. On examination the right fourth fingernail was brownish black in color with loss of texture and dystrophic changes.Direct mycological analysis combined to inoculation of nail scraping on Sabouraud medium revealed Aspergillus flavus as causative agent of onychomycosis.Opportunistic fungi such Aspergillus flavus are not keratinolytic pathogens, they usually grow on damaged keratin, our patient reported previous finger fracture and sustained traumatic incoculation of plants. This case was managed by oral terbinafine administered 250 mg/day in addition to the local application of amorolfine 5% nail lacquer.To our best Knowledge this is the first report of onychomycosis secondary  to both phalynx fracture and traumatic inoculation of plant.

KEYWORDS: Aspergillus flavus, onychomycosis, superficial infection, nail trauma, phalynx fracture, vegetable vendor

Description:

INTRODUCTION

Aspergillus   flavus   has   a   worldwide   distribution.   This   probably  results  from  the  production  of  numerous  airborne  conidies. It grows and thrives in hot and humid climates (1).Aspergillus  flavus  causes  a  broad  spectrum  of  disease  in  humans,  ranging  from  hypersensitivity  reactions  to  invasive  infections  associated  with  angioinvasion.  The  most  common  clinical   forms   associated   with   Aspergillus  flavus   include   chronic  sinusitis,  keratitis,  cutaneous  aspergillosis,  wound  infections and osteomyelitis following inoculation and trauma (1).Onychomycosis   usually   caused   by   dermatophytes   and   nondermatophytic mold and yeast, accounts for approximately 50% of ungueal diseases (2).The incidence rate of onychomycosis caused by Aspergillussp  has  been  described  as  2.6%  to  6.1%,  varying  depending  upon the reporter (3,4,5).onychomycosis affected toenails (59.1%) more often than fingernails (38.3%), probably due to toenails’ slow growth, which  facilitates  the  invasion  of  the  fungus  and  is  perhaps  supported by factors such as trauma and poor circulation (6).

Repeted trauma is a common cause of onychomycosis due to Aspergillus species (7,8,9).Opportunistic    onychomycosis    is    seen    more    among    individuals  with  occupational  exposures  such  as  vegetable  vendors (8) and among babassu coconut breakers (7).In this case report, we descibe the clinical and mycological features   of   an   onychomycosis   due   to   Aspergillus  flavus following  fingernail  fracture  and  traumatic  inoculation  of plants.Case reportA   30   year-old   male   vegetable   vendor   by   occupation   presented in our institution with brownish black discoloration of the right fourth fingernail of 1 year duration (figure 1),  and history of traumatic fracture of the distal phalynx 2 years ago.

The patient sustained a penetrating plant injury to his finger  while working, the area became infected. Physical  examination,  determined  his  general  physical  condition to be well with no specific findings other than an ungueal lesion. There  were  no  lesions  on  his  hands,  feet,  or  toenails  and  past medical history and family history were unremarkable. Direct microscopic examination of nail scraping specimens showed the presence of dichotomous septate hyphae. Cultures were  subsequently  grown  in  2  Sabouraud’s  dextrose  agar (SDA)  slants  without  cycloheximide  that  were  incubated  at 25°C for one week. At day 5 large number of the same colonies were observed to grow rapidly in the 2 slants (figure 2). 

Initially  the  growths  appeared  whitish  but  turned  green  and granular with time. There was no colony growth on SDA slants with cycloheximide.Microscopic  characterization  of  the  fungal  isolate  was  carried out by preparing a lactophenol cotton blue mount from the growth, revealing Aspergillus flavus, hyphae were septate







and  hyaline,  conidiophores  were  rough  and  colorless,  and  phialide were biseriates (figure 3). Repeated culture of the nail samples yielded the same organism.Likewise, in our case, oral terbinafine was administered 250 mg/day in addition to the local application of amorolfine 5% nail lacquer.DiscussionThere  are  approximately  more  than  900  species  in  the complex  Aspergillus  which  are  common  in  the  soil  and  decaying   vegetation   throughout   the   world,   but   are   also   found in all types of organic debris (9). Aspergillus flavus has  a  worldwide  distribution.  This  probably  results  from  the  production  of  numerous  airborne  conidia,  which  easily  disperse  by  air  movements  and  possibly  by  insects  (1),  its  a  fast growing, filamentous and opportunistic fungi (10).Onychomycosis  is  a  fungal  infection  of  the  nail,  that  is  largely  underdiagnosed  in  developing  countries,  it  is  caused  by dermatophytes, yeasts and opportunistic non dermatophytic molds (NDM) (10).

The  main  risk  factors  of  mycosis  include  warm,  damp  conditions,  and  trauma  (11,12).  The  severity  of  the  fungal  infections depends on the type of injury (perforating, trauma, presence  of  foreign  material),  the  body  localisation  and  the  general condition of the patient (13). Furthermore, mycetomes are  known  to  be  post-traumatic  fungal  infections,  including  Aspergillus as a etiological agent (13). Moreover, Aspergillus flavus  has  been  already  described  as  etiological  agent  of otomycosis induced by auricular trauma (12). Onychomycosis is more common in the immunocompressed and the elderly (5,14,11).

However, Aspergillus onychomycosis is seen more among individuals with occupational exposures such as vegetable vendors (8) and among babassu coconut breakers (7), which is consistent with our case report. Morevover, in kim and al. (9) case report, the patient had grown  bean  sprouts  for  a  long  period  of  time  and  thus  her  hands  were  regularly  exposed  to  water.  As  such,  her  job  is  presumed  to  be  closely  related  to  the  disease  pathogenesis,  which is in accordance with our findings. The regular exposure of  vegetable  vendors  to  geophilic  fungi  and  phytopathogens  like Aspergillus flavus predisposes them to fungal superficial mycosis. 

The  right  sided  infection  could  be  promoted  when  handling contamined plants. Kim and al. (9) case involved women’s fingernails, while our case occurred in a man’s fingernails.In  the  recent  literature,  onychomycosis  cases  related  to  Aspergillus had no tinea pedis or tinea manus (15,9), which is consistent with our results.Fungal  melanonychia  is  characterized  by  dark  brown  to  black  pigmentation  of  the  nail,  this  discoloration  is  caused  by the black conidia of Aspergillus in nail keratin (9), this coloration was suggesting onychomycosis in our case. Black pigment were obseved in the toenails and fingernails lesions of previous onychomycosis reports (9,15).

The   most   commonly   described   species   of   NDM   are  Scopulariopsis sp, Fusarium sp, Acremonium sp and Aspergi-illus sp. Repeated sample collection is required to prove opp- ortunistic onychomycosis. In the Aspergillus flavus species, phialides are both uniseriate (arranged in one row) and biser- iates. Conidia are typically globose to subglobose, and consp- icuously echinulate (1), these features were observed in   our  cultures.It    is    known    that    onychomycosis    caused    by    non-dermatophytic   mold   does   not   respond   well   to   common   treatment (16), however, In Tosti and Piraccini’s cases, oral terbinafine  was  administered  250  mg  a  day  for  3  months leading to a complete cure (15). The aim of this case report is to empasize on onychomycosis etiopathogenesis, with regard to physical exposure related to job task, especially manuals jobs like vegetable vendors.

Acknowledge:

We  would  like  to  thank  all  the  «  Hassani  Abdelkader  »  hospital, department of dermatology staff

Conflicts of interest
None to disclose.

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