Fungi in Nails.

Walshe, Margaret; English, Mary P.

doi:10.1111/j.1365-2133.1966.tb12205.x

Cited by 142 publications

(51 citation statements)

References 14 publications

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“…Regarding onychomycosis due to Aspergillus spp., the first cases were reported in the 1940s by Bereston and Kiel [19]and by Moore and Weiss [20], who documented primary invasion of the nail by Aspergillus spp. Additional supportive evidence was provided later by Kaben [21]and Walshe and English [22]. …”

Section: Discussionmentioning

confidence: 70%

Clinical and Histological Aspects of Toenail Onychomycosis Caused by <i>Aspergillus</i> spp.: 34 Cases Treated with Weekly Intermittent Terbinafine

Gianni

Romano

2004

Dermatology

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Background: Non-dermatophytic onychomycoses represent 1.45–17.6% of all fungal nail infections. Epidemiological studies have shown that Aspergillus spp. are emerging fungal agents of toenail onychomycosis. Indeed, after Scopulariopsis spp. the genus Aspergillus is the second most common agent of non-dermatophytic onychomycosis. The diagnosis and treatment of toenail onychomycosis caused by non-dermatophyte moulds are not always straightforward. Objectives: The aims of this study were to describe the clinical appearance of toenail onychomycosis due to Aspergillus spp., to investigate the pathogenetic role of these agents and to evaluate the efficacy and safety of weekly intermittent terbinafine (500 mg/day for 1 week each month for 3 months) in the treatment of these patients. Patients and Methods: Mycological study of 2,154 patients with onychodystrophy revealed 1,228 onychomycoses (57%) including 71 cases due to non-dermatophytic fungi (5.6%). Non-dermatophytic onychomycosis caused by Aspergillus spp. represented 2.6% of all onychomycoses. The subjects were 34 patients (22 females, 12 males, age range 30–82 years) observed between September 1999 and December 2001, with toenail onychomycosis caused by Aspergillus spp. confirmed by standard techniques (microscopic examination and culture according to the criteria of English), histological examination of nail clippings and scanning electron microscope examination of the cultures whenever necessary. Results: The clinical features suggesting onychomycosis due to Aspergillus spp. are chalky deep white nail, rapid involvement of lamina and painful perionyxis without pus. Standard mycological tests (direct microscopy and fungal culture) and histological examination confirmed the pathogenetic role of Aspergillus spp. in onychomycoses. In particular, the histological examination was positive in 28 cases (82%) and useful in identifying typical aspects of Aspergillus spp. nail infections. At the follow-up, 12 months after the start of therapy with pulsed terbinafine, clinical and mycological recovery was confirmed in 30 of the 34 patients (88%). Conclusions: Treatment of non-dermatophytic onychomycosis with terbinafine usually requires at least 3 months of continuous systemic therapy. Our study of 34 patients confirms that terbinafine is particularly effective in the treatment of Aspergillus spp. nail infections and that a pulsed regimen is more economical and less demanding.

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Section: Discussionmentioning

confidence: 70%

Clinical and Histological Aspects of Toenail Onychomycosis Caused by <i>Aspergillus</i> spp.: 34 Cases Treated with Weekly Intermittent Terbinafine

Gianni

Romano

2004

Dermatology

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“…The above analysis makes it clear that the specific inoculumcounting criterion recommended by Walshe and English (42) cannot be validly used. This criterion-namely, that 5 or more of 20 inocula from a KOH-positive sample consistently growing the same mold should be taken as an indicator of opportunistic onychomycosis-yields a false-positive rate of at least 75%, in comparison to results determined by long-term follow-up consistent with Koch's first postulate.…”

Section: Discussionmentioning

confidence: 99%

Utility of Inoculum Counting (Walshe and English Criteria) in Clinical Diagnosis of Onychomycosis Caused by Nondermatophytic Filamentous Fungi

et al. 2001

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Opportunistic onychomycosis caused by nondermatophytic molds may differ in treatment from tinea unguium. Confirmed diagnosis of opportunistic onychomycosis classically requires more than one laboratory analysis to show consistency of fungal outgrowth. Walshe and English in 1966 proposed to extract sufficient diagnostic information from a single patient consultation by counting the number of nail fragments positive for inoculum of the suspected fungus. Twenty fragments were plated per patient, and each case in which five or more fragments grew the same mold was considered an infection by that mold, provided that compatible filaments were also seen invading the nail tissue by direct microscopy. This widely used and often recommended method has never been validated. Therefore, the validity of substituting any technique based on inoculum counting for conventional follow-up study in the diagnosis of opportunistic onychomycosis was investigated. Sampling of 473 patients was performed repeatedly. Nail specimens were examined by direct microscopy, and 15 pieces were plated on standard growth media. After 3 weeks, outgrowing dermatophytes were recorded, and pieces growing any nondermatophyte mold were counted. Patients returned on two to eight additional occasions over a 1-to 3-year period for similar examinations. Onychomycosis was etiologically classified based on long-term study. Opportunistic onychomycosis was definitively established for 86 patients. Counts of nondermatophyte molds in initial examinations were analyzed to determine if they successfully predicted both true cases of opportunistic onychomycosis and cases of insignificant mold contamination. There was a strong positive statistical association between mold colony counts and true opportunistic onychomycosis. Logistic regression analysis, however, determined that even the highest counts predicted true cases of opportunistic onychomycosis only 89.7% of the time. The counting criterion suggested by Walshe and English was correct only 23.2% of the time. Acremonium infections were especially likely to be correctly predicted by inoculum counting. Inoculum counting could be used to indicate a need for repeat studies in cases of false-negative results from laboratory direct microscopy. Inoculum counting cannot serve as a valid substitute for follow-up study in the diagnosis of opportunistic onychomycosis. It may, nonetheless, provide useful information both to the physician and to the laboratory, and it may be especially valuable when the patient does not present for follow-up sampling.

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“…When a predefined number of inocula grow the same fungal species, the species is presumed to be causative of the onychomycosis infection. The criteria of Walshe and English 19 presumed that a species grown from at least 5 of 20 fragments was a true pathogen, provided that compatible filaments were also seen in direct microscopy of the nail samples, and that no dermatophytes grew in cultures seeded from those samples. Most studies using this criterion continue to state a requirement of 5 or more inocula, although the number of seeded nail fragments is frequently omitted.…”

Section: Inoculum Countingmentioning

confidence: 99%

Systematic review of nondermatophyte mold onychomycosis: Diagnosis, clinical types, epidemiology, and treatment

Gupta¹,

Drummond-Main²,

Cooper³

et al. 2012

Journal of the American Academy of Dermatology

226

235

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Fungi in Nails.

Cited by 142 publications

References 14 publications

Clinical and Histological Aspects of Toenail Onychomycosis Caused by <i>Aspergillus</i> spp.: 34 Cases Treated with Weekly Intermittent Terbinafine

Clinical and Histological Aspects of Toenail Onychomycosis Caused by <i>Aspergillus</i> spp.: 34 Cases Treated with Weekly Intermittent Terbinafine

Utility of Inoculum Counting (Walshe and English Criteria) in Clinical Diagnosis of Onychomycosis Caused by Nondermatophytic Filamentous Fungi

Systematic review of nondermatophyte mold onychomycosis: Diagnosis, clinical types, epidemiology, and treatment

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