Fifty-five-year-old man with chronic yeast infections

Abstract

As History of Present IllnessA 55-year-old man was referred to the University of Virginia Immunology Clinic for onychodystrophy of his fingernails and toenails and recurrent oral-esophageal candidiasis. He had the problem with his toenails since childhood, but this had subsequently spread to involve his fingernails ϳ4 -5 years ago. Six months previously, he was diagnosed with oral candidiasis and was successfully treated with nystatin. He had no history of antibiotic or corticosteroid usage. One week later, he again developed thrush, and this pattern continued over the next months. Concomitantly, he was evaluated by the Dermatology Department for the onychodystrophy. Fingernail cultures were positive for Candida and his toenails grew dematiaceous mold. He was treated with fluconazole or itraconazole at various times over the past year and noted improvement with these treatments. Again, once the medications were removed, his symptoms returned. His last course of antifungal medication was completed 2 weeks before presenting to our clinic.During our evaluation, he reported early dysphagia, especially while eating bread. He also described symptoms of gastroesophageal reflux and cough that were persistent and exacerbated after both eating and exercising. The cough would resolve with his ongoing antiyeast treatments. He denied constitutional symptoms as well as sinopulmonary, gastrointestinal, blood, bone, central nervous system, or kidney infections. He denied recurrent herpes, varicella, or human papilloma virus infections. Most importantly, he denied infections with Staphylococcus aureus including furunculosis. He had no history of autoimmune disease such as thyroiditis, autoimmune hemolytic anemia, or idiopathic thrombocytopenic purpura, although he did report transverse myelitis that developed temporally to receiving the tetanus and influenza vaccinations, ϳ17 years before presenting to our clinic. He had no human immunodeficiency virus (HIV) risk factors. Physical ExaminationOn physical examination his oropharynx was without evidence of oral candidiasis. He had no lymphadenopathy and his respiratory exam was normal. Skin examination did not show atopic dermatitis or furunculosis; however, he had significant onychodystrophy of his fingernails and toenails. Laboratory and Other Diagnostic FindingsOur initial immunologic evaluation showed absent delayed-type hypersensitivity testing to Candida and

Good Syndrome, Bad Problem

“…Even outside classical GS, a tendency toward B cell dysfunction is apparent in the observation that anti-acetylcholine receptor autoantibody-associated myasthenia gravis is the most frequent autoimmune complication of thymoma ( 6 ). B cell lymphopenia is also common and in some cases has even led to the initial diagnosis of thymoma ( 7 , Allergy and Asthma Proceedings). Together, these observations underscore the complex interrelatedness of T and B lymphocyte biology.…”

A 73-year-old woman with persistent diarrhea and onychomycosis

“…Th17 cells produce a series of cytokines, among them interleukin 17 (IL-17) and IL-22, which are thought to play a role in preventing fungal infections. 13 Mucocutaneous candidiasis has been observed associated with anti-IL-17 and anti-IL-22 autoantibodies. 4 There have been positive and negative effects attributed to IL-17 during fungal infections.…”

“…Laboratory studies were obtained, and the results are recorded in Tables 1 and 2 [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] and absolute B-cell count was Ͻ1 cells/mm 3 (reference range, 15-495 cells/mm 3 ). The absolute T-cell count was 159 cells/mm 3 (reference range, 603-2990 cells/mm 3 ), absolute T-helper cell count was 58 cells/mm 3 (reference range, 45-1500 cells/mm 3 ), absolute T cytotoxic cell count 99 cells/ mm 3 (reference range, 120 -895 cells/mm 3 ), and CD4/ CD8 ratio was 0.59 (reference range, 1-3).…”

United airway disease

“…The purpose of the POPS series is to provide an innovative and practical learning experience for the allergist-immunologist using a format of clinical presentation, physical findings, appropriate laboratory studies, and differential diagnosis. Kennedy et al, 22 lead the reader through this process, describing the evaluation of a 55-year-old male presenting with onychodystrophy of the toenails and fingernails and recurrent oral-esophageal candidiasis. This case illustrates the complexity of the differential diagnosis for recurrent yeast infections and the importance of a detailed immune assessment.…”