Comparison of diagnostic methods in onychomycosis

Year 2023, Volume: 6 Issue: 2, 353 - 358, 27.03.2023

Ece Altun , Elif Kuzucular , Ayşe İstanbullu Tosun

https://doi.org/10.32322/jhsm.1204419

Abstract

Aim: Onychomycosis is a chronic fungal infection of the nail bed, plate, or matrix. This study aimed to compare the sensitivity of three diagnostic methods in the diagnosis of onychomycosis.
Material and Method: This study included 39 patients with a clinical diagnosis of onychomycosis of the toenails, who presented to Medipol Mega University Hospital between May 2019 and August 2022. Using the nail samples taken from the patients, the results of the direct microscopic examination with standard potassium hydroxide (KOH), histopathological examination performed with periodic acid-Schiff (PAS) staining, and fungal agents that grew in fungal culture were noted.
Results: Eleven (28.2%) patients were female, and 28 (71.8%) were male, with the mean age being 43.1±13.9 years. Of the patients, 53.8% had distal subungual onychomycosis and 46.2% had total subungual onychomycosis. The mean disease duration was 38.8±24.5 (12-120) months. Fungal infection was detected on direct microscopic examination with standard KOH in 66.7% of the patients, culture growth in 38.5%, and PAS staining on histopathological examination in 71.8%, and the sensitivities of these methods were determined as 74.3%, 49.2%, and 80%, respectively, with the negative predictive values being 30.8%, 16.7%, and 36.4%, respectively.
Conclusion: Among the investigated methods, histopathological examination with PAS staining was found to have the highest sensitivity and negative predictive value in the diagnosis of onychomycosis.

Keywords

Onychomycosis, potassium hydroxide examination, periodic acid-Schiff staining, fungal culture

References

• Gupta AK, Stec N, Summerbell RC, et al. Onychomycosis: a review. J Eur Acad Dermatol Venereol 2020; 34: 1972-90.
• Gupta AK, Versteeg SG, Shear NH. Onychomycosis in the 21st century: an update on diagnosis, epidemiology, and treatment. J Cutan Med Surg 2017; 21: 525-39.
• Maraki S, Mavromanolaki VE. Epidemiology of onychomycosis in Crete, Greece: a 12-year study. Mycoses 2016; 59: 798-802.
• Leung AKC, Lam JM, Leong KF, et al. Onychomycosis: an updated review. Recent Pat Inflamm Allergy Drug Discov 2020; 14: 32-45.
• Lipner SR, Scher RK. Onychomycosis: clinical overview and diagnosis. J Am Acad Dermatol 2019; 80: 835-51.
• Pang SM, Pang JYY, Fook-Chong S, Tan AL. Tinea unguium onychomycosis caused by dermatophytes: a ten-year (2005-2014) retrospective study in a tertiary hospital in Singapore. Singapore Med J 2018; 59: 524-7.
• Summerbell RC, Gueidan C, Guarro J, et al. The protean Acremonium. A. sclerotigenum/egyptiacum: revision, food contaminant, and human disease. Microorganisms 2018; 6: 88.
• Bongomin F, Batac CR, Richardson MD, Denning DW. A review of onychomycosis due to Aspergillus species. Mycopathologia 2018; 183: 485-93.
• Subramanya SH, Subedi S, Metok Y, Kumar A, Prakash PY, Nayak N. Distal and lateral subungual onychomycosis of the finger nail in a neonate: a rare case. BMC Pediatr 2019; 19: 168.
• Ghannoum M, Mukherjee P, Isham N, Markinson B, Rosso JD, Leal L. Evvxamining the importance of laboratory and diagnostic testing when treating and diagnosing onychomycosis. Int J Dermatol 2018; 57: 131-8.
• Karaman BFO, Açıkalın A, Ünal İ, Aksungur VL. Diagnostic values of KOH examination, histological examination, and culture for onychomycosis: a latent class analysis. Int J Dermatol 2019; 58: 319-24.
• Murray P, Rosenthal K, Pfaller M (editors). In: Medical microbiology. Eighth ed., Elsevier; 2015: 585-94.
• Reisberger EM, Abels C, Landthaler M, Szeimies RM. Histopathological diagnosis of onychomycosis by periodic acid-Schiff-stained nail clippings. Br J Dermatol 2003; 148: 749-54.
• Shemer A, Trau H, Davidovici B, Grunwald MH, Amichai B. Collection of fungi samples from nails: comparative study of curettage and drilling techniques. J Eur Acad Dermatol Venereol 2008; 22: 182-5.
• Fletcher CL, Hay JR, Smeeton NC. Onychomycosis: The development of a clinical diagnostic aid for toenail disease: Part I. Establishing discriminating historical and clinical features. Br J Dermatol 2004; 150: 701-5.
• Daniel CR 3rd, Elewski BE. The diagnosis of nail fungus infection revisited. Arch Dermatol 2000; 136: 1162-4.
• Borkowski P, Williams M, Holewinski J, Bakotic B. Onychomycosis: an analysis of 50 cases and a comparison of diagnostic techniques. J Am Podiatr Med Assoc 2001; 91: 351-5.
• Shenoy MM, Teerthanath S, Karnaker VK, Girisha BS, Krishna Prasad MS, Pinto J. Comparison of potassium hydroxide mount and mycological culture with histopathologic examination using periodic acid-Schiff staining of the nail clippings in the diagnosis of onychomycosis. Indian J Dermatol Venereol Leprol 2008; 74: 226-9.
• Jeelani S, Ahmed QM, Lanker AM, Hassan I, Jeelani N, Fazili T. Histopathological examination of nail clippings using PAS staining (HPE-PAS): gold standard in diagnosis of onychomycosis. Mycoses 2015; 58: 27-32.
• Weinberg JM, Koestenblatt EK, Tutrone WD, Tishler HR, Najarian L. Comparison of diagnostic methods in the evaluation of onychomycosis. J Am Acad Dermatol 2003; 49: 193-7.
• Aydıngöz İE, Akkaya AD, Aker F, Adaleti R. Comparison of methods for the diagnosis of onychomycosis in a series of 50 cases. Türkderm 2006; 40: 20-2.
• Ceren E, Ekmekci TR, Sakız D, Köşlü A, Bayraktar B. Comparison of the methods for the diagnosis of onychomycosis. Türkderm 2008; 42: 91-3.
• Grover C, Reddy BSN, Chaturvedi KU. Onychomycosis and the diagnostic significance of nail biopsy. J Dermatol 2003; 30: 116-22.
• Erkan F, Kaçar SD, Özuğuz P, Aşık G, Tokyol Ç, Karaca Ş. Comparison of the efficacy and cost-effectiveness of five different diagnostic methods in the evaluation of onychomycosis. Türkderm 2014; 48: 21-5.
• Arca E, Saracli MA, Akar A, Yildiran ST, Kurumlu Z, Gur AR. Polymerase chain reaction in the diagnosis of onychomycosis. Eur J Dermatol 2004; 14: 52-5.
• Wilsmann-Theis D, Sareika F, Bieber T, Schmid-Wendtner M-H, Wenzel J. New reasons for histopathological nail-clipping examination in the diagnosis of onychomycosis. J Eur Acad Dermatol Venereol 2011; 25: 235-7.
• Hsiao Y-P, Lin H-S, Wu T-W, et al. A comparative study of KOH test, PAS staining and fungal culture in diagnosis of onychomycosis in Taiwan. J Dermatol Sci 2007; 45: 138-40.
• Yurtoğlu F, Yıldız L, Şentürk N, et al. Comparison of diagnostic methods for onychomycosis: a controlled, prospective study. Turk J Dermatol 2011; 5: 48-52.
• Karimzadegan-Nia M, Mir-Amin-Mohammadi A, Bouzari N, Firooz A. Comparison of direct smear, culture and histology for the diagnosis of onychomycosis. Australas J Dermatol 2007; 48: 18-21.
• Gianni C, Morelli V, Cerri A, et al. Usefulness of histological examination for the diagnosis of onychomycosis. Dermatology 2001; 202: 283-8.
• Gupta A. The incremental diagnostic yield of successive re-cultures in patients with a clinical diagnosis of onychomycosis. J Am Acad Dermatol 2005; 52: 129.
• Hajar T, Fernández-Martínez R, Moreno-Coutiño G, Vásquez Del Mercado E, Arenas R. Modified PAS stain: a new diagnostic method for onychomycosis. Rev Iberoam Micol 2016; 33: 34-7.
• Jung MY, Shim JH, Lee JH, et al. Comparison of diagnostic methods for onychomycosis, and proposal of a diagnostic algorithm. Clin Exp Dermatol 2015; 40: 479-84.