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CASE REPORT
Year : 2004  |  Volume : 22  |  Issue : 4  |  Page : 258-259
 

Onycholysis caused by Candida Krusei


Department of Microbiology, BLDEA's Shri BM Patil Medical College, Bijapur - 586 103, Karnataka, India

Date of Submission01-Mar-2004
Date of Acceptance19-May-2004

Correspondence Address:
Department of Microbiology, BLDEA's Shri BM Patil Medical College, Bijapur - 586 103, Karnataka, India

 ~ Abstract 

Onycholysis caused by Candida krusei is rare. A 21 years old male patient presented with grayish discolouration and elevation of all fingernails since one year. Patient was refractory to treatment with fluconazole. Potassium hydroxide preparation of subungual debris revealed fungal elements. Growth on Sabouraud dextrose agar was identified by cultural characteristics, morphotyping, microscopy and biochemical tests as Candida krusei. The isolate was resistant to fluconazole and amphotericin-B but susceptible to nystatin and clotrimazole. Patient responded well to clotrimazole and terbinafine.

How to cite this article:
Rao S D, Wavare S, Patil S. Onycholysis caused by Candida krusei. Indian J Med Microbiol 2004;22:258-9


How to cite this URL:
Rao S D, Wavare S, Patil S. Onycholysis caused by Candida krusei. Indian J Med Microbiol [serial online] 2004 [cited 2014 Sep 19];22:258-9. Available from: http://www.ijmm.org/text.asp?2004/22/4/258/12820


Onychomycosis is commonly caused by dermatophytes and Candida spp. Candida albicans is the most frequent species causing the candidial onychomycosis.[1] Among the non-albicans candida species- C. parapsilosis, C. guilliermondii, C. tropicalis and C. krusei may cause onychomycosis.[1],[2] Candidial onychomycosis generally presents as proximal subungual infection, or superficial white onychomycosis or onycholysis.[1] Onycholysis is painless separation of nail plate from nail bed. Separation usually occurs in the distal groove and progresses irregularly on the lateral side. The separated nail is opaque with white, yellow, green or blue tinge.[3]
In recent years infection due to C.krusei has been described increasingly both in immunocompromised and non-immunocompromised hosts.[4] C.krusei is responsible for fungaemia in neonates, intra-abdominal abscess, endocarditis, infective arthritis, oesophagitis, ocular infection,[4] vaginitis[5] and rarely nail infection.[1],[2] C. krusei is intrinsically resistant to fluconazole.[6],[7] The success of treatment depends on the isolation, identification and antifungal susceptibility based treatment.

 ~ Case Report Top

A 21 year-old male presented with complaints of discolouration of fingernails since one year. On examination, nails of all the fingers were grayish, brittle and elevated from nail bed. The chalky white debris was present in subungual space. The patient was diagnosed as having onycholysis. He was on fluconazole for last six months. Potassium hydroxide (KOH) preparation of the subungual debris showed septate, non-branching hyphae like fungal elements. Haematological investigations were with in normal limits. The patient was negative for HIV antibodies.
Subungual debris was inoculated on Sabouraud dexrtrose agar (SDA) with and without cycloheximide and incubated at room temperature. On the third day, dry, white, flat and spreading colonies developed on plain SDA but no growth was seen on SDA with cycloheximide. The colonies were inoculated in Sabouraud dextrose broth and incubated at 37C which formed thick pellicle, rising on the wall of the test tube [Figure - 1]. Germ tube test was negative. Long pseudohyphae with clusters of blastospores developed on corn meal agar but chlamydospores were not observed [Figure - 2]. Gram stain revealed gram positive, ovoid, elongated, yeasts cells about 2-5 x 4-15 m. The sugar fermentation and assimilation tests showed fermentation of glucose but not lactose, maltose, sucrose and these sugars were not assimilated. Urease test was negative. Depending on morphology, cultural and biochemical characteristics the isolate was identified as C. krusei.
Antifungal susceptibility test was carried out by disc diffusion method on yeast nitrogen agar base.[6] The isolated strain of C. krusei was resistant to fluconazole and amphotericin-B but sensitive to clotrimazole and nystatin. The patient responded well to systemic terbinafine (250 mg/day) and topical clotrimazole, in three months.

 ~ Discussion Top

There is increase in the prevalence of onychomycosis and the number of microorganisms recognized as possible fungal pathogen is growing. Candida affects fingernails more often (51% to 70%) than toe nails either as primary pathogen or in combination with dermatophytes. Primary candidial infection is seen in patients with chronic mucocutaneous candidiasis or in immunocompromised individuals. In these patients, distal and lateral subungual onychomycosis may develop initially and might progress to total dystrophic disease. In other individuals, Candida causes onychomycosis of constantly wetted or damaged nails.[1] C. albicans is considered to be the most pathogenic species. C. krusei is less well known species which currently gaining clinical interest as an emerging pathogen.[4] Candidial onycholysis due to C. krusei is often found in patients with immunocompromised state due to diabetes mellitus, HIV infection and steroid therapy. [5]
The isolated strain of C. krusei was resistant to fluconazole and amphotericin-B. Patient did not respond to fluconazole and itraconazole therapy. Treatment with fluconazole might have provided an opportunity to colonization of C. krusei and leading to the development of onycholysis. Infection due to C. krusei should not be treated with fluconazole or itraconazole because of the high likelihood of resistance to the triazole antifungals. The intrinsic resistance of C. krusei to azole antifungals (fluconazole and itraconazole) may be due to decreased susceptibility of the target enzyme, Lanosterol 14 demethylase to these drugs. The mechanism of amphotericin-B resistance appears to be due to alteration or decrease in the amount of ergosterol in the cell membrane.[5] Isolated strain of C. krusei have been found to be sensitive to clotrimazole and nystatin. Our patient responded well to systemic terbinafine and topical clotrimazole, indicating that these antifungal agents can be effectively used for the treatment of onycholysis caused by C. krusei. The species identification and antifungal susceptibility testing of Candida isolate helps in the selection of antimycotic agents and successful treatment. 

 ~ References Top

1.Gupta AK, Ryder JE, Baran R, Richard C, Summerbell. Non-dermatophytic Onychomycosis. Dermatol Clin 2003;21:257-268.   Back to cited text no. 1    
2.PK Guha, SK Panja. Clinocomicrobiological study of chronic paronychia. Indian J Dermtol Venerol Leprol 1992;58:73-76.   Back to cited text no. 2    
3.Habie TP. Clinical Dermatology, 3rd edition. Mosby 1996: 770.   Back to cited text no. 3    
4.Samaranayake YH, Wu PC, Samaranayake LP, So M, Yuen KY. Adhesion and colonization of Candida krusei on host surface. J Med Microbiol 1994;41:250-258.   Back to cited text no. 4    
5.Sing S, Sobel JD, Bhargava P, Boikov D, Vazquez JA. Vaginitis due to Candida krusei. epidemiology, clinical aspects and therapy. Clin Infect Dis 2002;35(9):1066-1070.   Back to cited text no. 5    
6.Perea S, Patterson TF. Antifungal resistance in pathogenic fungi. Clin Infect Dis 2002;35(9):1073-1080.  Back to cited text no. 6    
7.Segal E, Elads D. Topley and Wilson's Microbiology and Microbial infections, Medical Mycology 1998;4:423-60.  Back to cited text no. 7    
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2004 - Indian Journal of Medical Microbiology
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