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Gross Image of Green Nail Syndrome Co-infected with Trichophyton rubrum

Yong Woo Choi,Osung Kwon,Hyun Chung ,Joonsoo Park
http://dx.doi.org/10.17966/KJMM.2017.22.3.146 Epub 2017 September 29

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Abstract





Keywords


Chromonychia Green nail syndrome Pseudomonas aeruginosa



Green nail syndrome (GNS) is characterized by greenish chromonychia caused by pyocyanin, a metabolite produced by Pseudomonas aeruginosa (P. aeruginosa)[1]. Predisposing factors of pseudomonal colonization include onychomycoses, nail dystrophies, working in wet conditions, diabetes mellitus, paronychia and immunosuppressive states[2]. A number of reports states that there are strong relationship between fungal and P. aeruginosa infection of the nail[3],[4]. Fungal infection stimulates bacterial colonization within the nail and overgrowth of P. aeruginosa[4].


Greenish-black discoloration in central area of the nail is observed, which is a key characteristic of GNS. Also, visible dystrophy with thickened plates and fissures is observed (Fig. 1A). On the medial side of the nail body, subungual hyperkeratosis and yellowish discoloration are observed. (Fig. 1B) While discoloration of the nail is a distinguishing feature of P. aeruginosa infection, nail dystrophies with subungual hyperkeratosis can be seen in both P. aeruginosa and fungal infection. In this case, P. aeruginosa and Trichophyton rubum (T. rubum) infection were confirmed through culture. On Sabouraud glucose agar, colonies with powdery texture and white-to-red color were observed, which are key characteristics of T. rubum (Fig. 1C). Also, through staining with periodic Acid-Schiff with diastase predigestion (D-PAS), numerous fungal organisms including hyphae were observed (Fig. 1D). Approach to GNS, which is mainly caused by P. aeruginosa, should also include identifying signs of onychomycosis and proper examinations to detect fungal infections.

Figure #1

Fig. 1. A: Green coloration of the toe nail with onychodystrophy is observed B: Medial side of toe nail shows onychodystrophy with subungual hyperkeratosis. C: Powdery textured and white to wine red colored colonies are seen on Sabouraud's dextrose agar after 5 days on 25℃ D: Numerous hyphae are seen in nail plate staining with periodic acid-schiff with diastase predigestion (D-PAS stain ×400)


References



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