3- Study of Clinically Suspected
`f Onychomycosis in a Podiatrlc
`Population
`
`Maureen B. Jennings, DPM’t
`Jeffrey M“ Weinberg, M01-
`Evelyn K. Koestenblatt, M81:
`Christine Lesczczynski§
`
`is a myootic inlection of the keratinized
`Onychomycosis, by definition,
`tissue of the nail plate. Although it is commonly considered to be caused
`by one oi the dermatoiroplo fungi, a variety of other organisms have
`been implicated as etiologic agents in the disease‘ including some bac-
`teria and yeasts; When it is caused by a fungus, any or all of three
`types of organisms can be involved: dermatophytes, yeasts, and non»
`dermatophyte organisms, The purpose ot this study was to identity the
`microorganisms found in fungal cultures of clinically suspected ony-
`chomycosis in the patient population of the Foot Clinics of New York in
`New York City, the largest foot clinic in the world, Of the 1,800 medical
`charts reviewed. 214 had culture results, of which 120 were positive.
`Tr/chophyton rubrum was the most prevalent pathogen, found in 67%
`at positive cultures The most remarkable risk factor was age, with 80%
`ol aiiected individuals older than 35 years. False-negatives may ac~
`count lor the high percentage (44%) of negative cultures in this study.
`(J Am Podiatr Med Assoc 92(6): 327630, 2002)
`m
`
`a
`s
`
`Ulli'fihvmycosis, by definition. is 21 mycoiic infertion
`Hi the komtmized tissue of the nail plate.‘ Urgychomy-
`rosis accounts For approxnnaloly 30% of all fungal in»
`fi‘t'lltllls and is the most frequently encountered nail,
`disease? The [55 Health and Nutrition Exmnlnatinn
`Study of more than 20.000 subjects aged 1 to 74 were
`ililltld a prevalence of 3.2% for (myrrltotnyco "S5;
`Although t)nycltomycosis ts ('otmtmnly commuted
`to be caused by one of the clortnntottopiv fungi. :1 me
`”91}? 0f other orgzutisms have been implicated n9 (ti~
`fling? agents in the ljiSk’ZlSQ, including eome hm‘tm'la
` it ”\nslsiant Dean for Rosenrr'h‘ New York (‘nllege of 170'
`“Ml!
`cd'tcixm 1800 1’;ka AVQL New York. NY ”30535
`"llirevior oft‘linica! lleseart‘lt. St. l,ul<t=‘5~Roosewll flow
`52ml lit-mm: New York,‘ NY
`\ *‘ililtil‘finl Anslsram Professor, New York Mmlivztl Ciollt‘llt",
`«I‘lmlzolltnn i‘lospilétl Center. New York NY=
`«fitment Research Associam. I301‘¢‘”““““ Of “autumn“!
`ffysvarcha M‘W York College 03‘ Podit‘ttl’w Medicine} New
`mrk, 33y"
`'
`
`and yeasts,” When onychomycosis is caused by a
`fungus, any or all of three types of organisms can be
`involved: Llermatophytes, yeasts. and nontlermato-
`phyle organisms} The etiology of onychomycosis
`seems to differ by geographic location, The Llennzmy
`phytes, in pill‘ilt‘llléu‘ ’I‘Vicitopfzyton mbmm are most
`frequently seen in the United Swim; whereas (Tan-
`dtdu. has been repx’mod with high frequency in Bel—
`gium? and Spain,” 01‘ we positive cultures examined
`in Hung Kong for single intentions. 447%) were '1’
`'min'um and 203% were Candida (other than Candi
`do ominous)“ A Canadian study” of 131 patients
`with myrrolngically confirmed pedal Unyt‘homycosls
`found that the causative pathogens were predomi-
`nantly (92.9%) (lemtntopltyl‘ositit‘fli; '1’ rubmm and
`29% Triohophylon mm:loym;)hylo& Seylalidium, a
`rtnnilermalopltyte. is more frequent in tropical cli-
`males.“ In Britain T rubrum was the most frequent
`pailiologic agent, with T mmIngrown/(cs and Epi—
`
`Joumal 0‘ ihe American i°odiatric Medical Association - Vol 92 . No 6 - June 2002
`
`Page 1 of 4
`
`327
`
`
`
`Kaken Exhibit 2201
`
`Acrux V. Kaken
`
`IPR2017-00190
`
`

`

`demnoplzylon floccosum being less common.” In
`eastern Saudi Arabia, one study 15 revealed C‘Wfid‘l
`to be the pathogen in 204 of 248 cases of cultinnlly
`positive onychomycosis.
`There are striking differences in the frequency
`with which each group of ftmgi is responsible for the
`mycotic infection.7 Distal and lateral subungual ony—
`chomycosis, which is an infection of the nail bed and
`plate, is often caused by T mbi’llm, but it may also
`be caused by T mentagz'ophyies and E floccosmn.
`Distal and lateral subungual onychomycosis is the
`most. frequent type of onychomycosis. Once the hy—
`ponychium is infected, the fungi advance to the nail
`bed epithelium. The fungi are sheltered by the nail
`plate, creating a moist and soft subungual environ‘
`ment. ideal for fungus. Once the pathogen invades the
`matrix, the fungus is entrapped in the newly formed
`nail and infiltrates the entire nail plate.2 Proximal
`submiguai onychomycosis is an infection of the prox-
`imal nail fold (the eponychium), with the infection
`extending distally under the nail plate. Trichophyz’on
`rubrmn is most frequently implicated in proximal
`subungusl onychomycosisfiz Triclzophytmz meg-
`mfm‘ 2‘, Trichophymn to-nsumns, Trichoplzylon
`sclzomzlcz’ 11 ii.
`'1‘ mentagmphyfes, and E floccosum
`have also been reported to cause oroximai subun—
`gual onychomyt'osis.E White superficial onychomyco-
`sis, which is found in toenails only, affects the nail
`plate and is usually caused by T meniagrophylcs,
`which is better suited biochemically to invade the
`nail plate;‘3 Whiie superficial onychomycosis can be
`caused by nondermatophyte molds such us As»
`pm‘gill’us species, Ammnonirzml species, Fusarinm
`(nil/spomm, and Scopztlm‘iopsis In‘cvicoulisfi 1*?
`Although onyclmmycosis is rare in children, its in
`cidence increases with age.” Studiesi ‘? have shown
`a higher prevalence in males than in females. it; is by
`pothesized that occupational facims may play a role
`in sex prevalence.” Psoriasis has been shown to in—
`crease the risk of developing onychomycosis.” The
`consensus is that there is probably not a higher
`prevalence of onychomycosis in lhe diabetic nail. but
`increased Candida infections of the nail ancl‘sun
`rounding tissues can pose a serious risk in the dia-
`betic patient. 3‘
`
`The diagnosis of onychomycosis is made through
`clinical obsewation, direct inicrosmpic exzunination
`with potassium hydroxide (ROI-i). fungal culture, and
`biopsy with histologic :malysis. The clinical signs of
`tinea unguium include thickening subungual debris,
`discoloration, and sulfate irregularity. Examination
`with KOH is a screening tool for ihe presence or ab
`sence of fungus, but it does not identify the organism
`Sabouraud’s dextrose agar, with the antibacterial
`
`agent chloramphenicol and the mold inhibitor (‘de
`heximide, is used to aid in the identification of llmga]
`pathogens. Histologic analysis evaluates the mpg.
`graphic distribution, density, and nature of fungi, The
`histologio preparation can be used to confirm or
`negate the culture results.”
`The purpose of this study was to identify the mi.
`croorganisms found in fungal cultures of clinically
`suspected onychoniycosis in the patient population of
`the Foot Clinics of New York in New York City, the
`largest foot clinic in the world. This was a systematic,
`retrospective, epidemiologic sruvey of onychomyco
`sis based on laboratory data. To the authors‘ knowl.
`edge, these data have not, been collected in the past.
`Other data, such as KOH results, patient demographic
`information, and incidence of other systemic dis
`eases, were also collected.
`
`Materials and Methods
`
`Eighteen hundred median chums from patients attire
`Foot Clinics of New York who had a clinical diagno
`sis of onychomycosis were ramlomly chosen and 1?-
`Viewed. Nail clippings, subungual debris, and scrap
`ings were taken from patients clinically suspected of
`having onycllomycosis. The nail samples were. care
`fully iranspon'ed to the laboratory. \ail portions were
`taken for cleaning with 1.0% KOl-l and direct. micro-
`scopic examination. Nail cultures were simulated at
`30°C) and were examined weekly for 4 weeks. The
`lnborntmy used Sabwrnudfs dextrose agar contain
`ing cyclohexiinide (0.5 lug/mu) and chimnmpheuicol
`(0.05 rug/mil). (fluids with a culture report had peni-
`nent data cxtrzu’tfed. All (law, were (locwnented on the
`3330 report forms, including patient dcmogznphic in-
`fonnaliion (age, race, and sex) zuul culture results.
`
`Resuhs
`
`Table 1. lists [he species of missiblo infective organ-
`isms from posit ivc cultures of patients with a cl‘uu'cd
`diagnosis of onychomycosis. 0f the 1,800 charts If?
`Viewed, 214: had culture results, of which 120 W9“?
`positive. 'I‘l'ic/mphytzm rubrum was the most 91:9“?
`lent pathogen ((37%). lilighty percent of affected null»
`viduuls were older than 235 years. Of 2H puliGlllSs 20%
`were yolmger than 3:3 yours, 25994.: were age<135 to ”3}
`years. and 41% were older than 3-3 years; 61%“?1'9 m
`nude; and 14% were diabetic. ’l‘wcnty’i’lght perch“
`(59/2l4) of the patients clinically diagnosed as having:
`onychcnnycosis had negative KOH results. F0113“???
`percent (941214) of the fungal cultures were negami'
`'l‘wonty-one percent of patients with onychonn’CD-‘b
`(from whom a culture was taken) had concur?“I
`
`828
`
`June 2002 ' Vol 92 ' No 6 - Journal of the American Podiatric Medical Association
`
`Page 2 of 4
`
`

`

`W T
`
`able 1. Fungal Organisms Found in 120 Positive Cultures
`from Patients with OnychomycosisW
`
`Organism Number (%)MW
`Dermatophytes
`Trichophyton rubrum
`Trichophyion mentagrophytes
`Yeasts
`Candida aibicans
`Candida parapsi/osis
`Rhodotaruia rubra
`Trichosporon beige/ii
`Cryptococcus uniguttularus
`
`80 (87)
`2 (2)
`
`2 (2)
`8 (7)
`8 (7)
`2 (2)
`1 (1)
`
`ei: al found that T mom-m was the most common iso
`
`late among the dermatophytes, Ghannoum et» 3.1, how-
`ever, found Acremomum to be the most common
`nondermatophyte; the present study showed Penicil—
`lium and Aspergz‘llus to be the most common nonder-
`matophytes. In the study by Gharmoum et al, C pamp-
`siZosis represented 66.7% of the yeast species, whereas
`the present study showed C pd'rapsilosis at 88%, the
`same percentage as for Rhodotomla mom.
`In a similar study by Srinivas et 3121 in 1998, nail
`scrapings and clippings were collected from 300 pa-
`tients, The culture positivity for molds was 22%, with
`Aspergiltus species predominating. The criteria for
`reporting the mold as a pathogen were KOH positivi-
`ty pins an isolation of the same fungus in culture on
`three consecutive occasions at intervals of at least 7
`days each and absence of systemic or local antifim-
`gal treatment during the period of investigation.
`
`Discussion
`
`Onychomycosis, a fungal infection of the toenails
`and fingernails, can affect standing, walking, and ere
`excising, resulting in pain and discomfort A definitive
`diagnosis is crucial for effective treatment because
`other dexmato’logic disorders mimic: onychomycosis.
`The easiest. and quickest way to confirm the diagno
`sis is with KOH preparation in which spores and fun.
`gal filaments are, easily detected? Mycologic culture
`is a generally accepted method of continuing the di-
`agnosis.
`The yield of positive cultures can be disappointing,
`as indicated by this study, in which 56% (120/214) of
`the. cultures were positive. Often, not enough speci-
`men is inoculated onto culture media. Therefore it. is
`important to curette into the “spongy” area to in-
`crease the chance of obtaining a positive culture.
`When interpreting negative culture results. false-neg
`olives are frequent, which may account for the high
`percentage (44%) of negative cultures in this study.
`Negative cultures are mostly caused by lack of living
`fungi in the collection of sulmngual debris When a
`dermatopliyte and a nondermatophytc are grown,
`the dermatophyte is consirlered the pathogen. al-
`though both may play a role in the clinical, picture;3
`Further studies warrant serial cultures and micro-
`scopic findings for yeast: cells as definitive proof that
`nondcrnuitophyie molds and yeasts are causative
`ijiatiiogens rather than contaminants.
`The results of this study show the increasing num-
`bers of nondennutopl'iyle molds and yeasts present.
`in nail infection (Aspe’ryillns. 3%; (.7 para-psilosis.
`7%). Candida albicans is usually secondary to chron-
`ic pzuonyclu‘a and is found more tremently in finger-
`
`Hyalohyphomyceies (nonpigmented fungi)
`Penicillium species
`Aspergillus species
`Scopulariopsis brevicaulis
`Paecilomyces species
`Fusarium species
`
`Phaeohyphomyceies (pigmented fungi)
`Aureobasidium pullulans
`Chaeiomium species
`Cladospan’um species
`
`3 (3)
`3 (3)
`1 (1) -
`1 (1)
`1 (l)
`
`2 (2)
`1 (t)
`1 (1)
`
`Zygomyceles
`Fifi/zopus species
`Mixed infection
`2 (2)
`T rubrum, C parapsilosis
`
`Trubrum, Aspergil/us niger l (1)W
`
`1 (1)
`
`tinea pedis. Twenty-nine percent (35/120) of the pa-
`tients with positive cultures had concurrent tinea
`pedis, whereas 11% (10194) of the patients with nega—
`tive cultures had concurrent tinea pedis.
`Five types of molds were isolated from nine on
`iients: Fusmimn (n = l), :lspcljgiltus (n = :3), S brew-
`Willis (11 2 l), Pacoilomyr‘es (n = 1), andPenicillitmt
`in = 3:) (Table 1). As no serial cultures were avail-
`able, these nondermntophyte molds are listed for
`purposes of information and the reporting of organ—
`ism distribution. Without, serial cultures, it cannot. be
`determined whether they are pathogens or contami-
`@183“ Right. percent of the positive cultures showed
`Candida, with 80% (8/10) of those with (I'mrd'ida
`pa'rahsilosis and 20% (2/10) with C albicdns. Der—
`Inatophyte onychomycosis affected more male pa-
`tients, whereas all ten patients with Candida ony‘
`(‘llOIl’lth’lSiS were female.
`A study by Ghannoum et 21]” of 2133 onychomy—
`cotic nail samples showed dermatophytes as the
`most commonly isolated fungi (59%), A specimen
`Was considered positive if septate hyphae were seen
`on microscopic: examination, culture. or both Non—
`demtatophyte molds and yeasts represented approxi-
`mately 20% each. As in the present study, Ghannoum
`
`JWillal of the American Podiatric Medical Association
`
`- Vol 92 ° No 6 - June 2002
`
`329
`
`Page 3 of 4
`
`

`

`nails, whereas C pampsflosis is a less active pathogen
`and is found mainly in toenails. The nondemiatc-
`.
`.
`V
`phyte fungi may reflect colonization of an already
`damaged nail, since dermatophytes are probably the
`only primary nail invaders. it is important to note,
`however, the presence of nondematophyte molds,
`yeasts, and mixed infections when considering treat—
`.
`.
`.
`men: For future culture anaIEfSls’ it may b? we to
`use two culture Platwne “nth and one “71310“ ‘33"
`clohexiimide.2 Cycloheximiéeeontaining cultures do
`not allow for the recovery of fungi such as Hm;
`sonqu and Scytalidz‘um, which are capable of cane
`l
`.
`.
`,
`.
`.
`a
`mg onychomycosis, uneapedis, and mea palmans.
`Onychomycosm occurs more frequently in males
`than in females. This Stuéy, however, shows a pre»
`ponderance of females ((61%). The patient popuiation
`of the Foot Clinics of New York is 62% female and
`38% male, which accounts for the increased inci—
`d
`.
`f
`.
`.
`ence m emaJesmtlussmdy.
`
`Acknowledgment. Laura Gael-in, BS, and Shibu
`Philips, MPH, for their assistance with data coilection.
`'
`
`3973911693
`
`1. LUNDBEN (3W: Lumen-N RO: Onychomycosis: itn classi‘
`ficailon, paihcphysmlogy and etiology. JAPA 68: 395i
`19.8.
`I
`_
`2. Hwexa £1: Fungal infections of the nail. Semin Denna-
`$01 10: 413 1991.
`.
`.
`3. Prevalence, mOrbldlty and cost of dermatological dis-
`@3595 '[editonail J EVER Dermatoi 73: 395, 1979.
`4. Annmson‘ (3. WiLToN J: Nail dust aerosols from ony-
`chomycotic toenails: part II. Clinical and seroiogical
`KSDGC‘IS- JAEVIA 752'531, 198%
`_
`o, T311145: D: buoerficml mycoses'
`1f :, 19va
`.
`6, FREUNU PA: ()nychomycosis: diagnosis and treatment
`,.
`J-APA 64: 421: 19%
`r.
`\renez A. LINARES’ MJ, FHRN:\NI>EZ~ROLIMN JC, 81‘ A1,:S‘tudy
`
`.3 invest. Dermatol 67:
`
`of onychomycosis in Cordoba, Spain; prevailing fungi
`and pattern of infection. Mycopathologia 137; 1, 1991
`8. ZAIAS N: “Onychomycosis,” in The Nail in Heallh and
`Disease, 2nd Ed, ed by N Zam, p 87‘ Appleton & Lange
`’
`Nomalk’ CT, 1990‘
`9. Amen G, Wanm-Rmnxno J: Onychomycoses in the lab.
`oratory Mykosen Suppl 1: 125, 1978.
`10' :32? EQUINE DR MAST”: :24’ 1PWENWELIAJ’ FIT A"
`n 10
`e as OmCOIIUCOSL
`9 area
`e pomente
`almericnse‘ Actas Dermosifiliogr 85: 407, 1994,
`ll. KAM KM, Au WF, Wono PU, ET AL: Onychomyccsis in
`Hong Kong Int J Dermatol 36: 757, 1997,
`12. GUPTA AK, JAIN HC, Lynne CW, ET AL: Prevalence and
`ePiimizlogy 0:?n5l13tpfiflfglonynfliogni<goeisznpageants
`v151mg
`erma c was s o ices m .n ano, mm a: a
`multimeter survey of 2001 patients. Int. J Dermaloi 36:
`783’ 1997,
`13. Ennwsxi B, Gimme DL:11e-miersonulatoruloidea and Scy-
`(glidium hyalinum: review and update Arch Dcrma~
`£21 127‘ 131221;:91‘
`.d
`.
`I
`f
`3
`‘
`,
`‘ WW”
`"
`e 0‘” 9mm ogy 0 .fny('10m'cosm m
`Britain. Br J Dcrmatol l29: 101, 1996.
`15, AirSoswn SM, Mow“; MK,
`.Alrl'ILEMAlDAN YM: Fungal
`infection as a cause of skin disease in the eastern
`
`14
`
`province of Saudi Arabia: prevailing fungi and pattern
`9f immonl MYCOSiS 34‘ 333 1991‘
`l6. GUPTA AK, Ennwsni BE: Nondcrmatophyte causes of
`onychomycosis and superficial mycosis. Curr Top Med
`Myeol 79: 87, 1996,
`17. GUPTA AK. LYNDE CW, JAIN HC, or AL: A higher preva-
`lence of onyciiomycosis in psoriatics compared with
`non-psc,3riatiesz a mnlticemre study, Br J Dermam] 136:
`786‘ 1,997.
`18. Rim P; Special patient populations: onychomywsis in
`the diabetic patient J Am Acad Dermatoi 35: 5&0. 1996.
`l9, PIERARD GE, Manse JE: DeDoNCKER P, ET AL: Present.
`and potential diagnostic techniques in onychomymsis-
`J Am Acad Dermatol 34; 27:}, 1996.
`20. GIMNNUUM MA, IlAJJEuR:\,S(:1u~1n R, mm; A large—scale
`North American study of fungal isolates from mils: 11“?
`frequency of onychomycosis, fungal distribution, and
`antifungal susceptibility patterns. .1 Am Acad Dermfl‘U‘
`48: 641, 26011
`‘21. Smmvns CR, Roms-i A, (3mm RA‘FNA KEMARI T‘ ET AL?
`Molds in onychcmycosis. Int, J Dermatol 32; 377, 19.93.
`
`380
`
`June 2002 - Vol 92 - No 6 ' Journa
`
`5 of the American Podiatric Medical Association
`
`Page 4 of 4
`
`