Clinical presentation of onychomycosis in hiv/aids: a review of 280 mexican cases.

Sir,

The incidence of onychomycosis caused by dermatophytes has diminished since the introduction of the highly active antiretroviral therapy in the 1990s. Nonetheless, onychomycosis still is a common and recurrent finding, four times more common in HIV infected individuals than in the general population, which is reported to be up to 23%.[1] The main etiological agent continues to be Trichophyton rubrum.[2]

The currently used classification of onychomycosis is the one proposed by Baran et al. It is based upon the clinical appearance of the fungal invasion on the nail plate, regardless of the etiological agent. The distal and lateral subungual onychomycosis (DLSO) is the most common, and may progress to total dystrophy. Superficial white onychomycosis (SWO) affects the dorsal aspect of the nail plate. The proximal subungual onychomycosis (PSO), also known as white PSO, initiates at the proximal nail fold and may advance with nail growth or progress to affect the entire nail plate. This pattern is frequently reported in immunosuppressed patients. Endonyx onychomycosis (EO) is rare, caused by Trichophyton soudanense and Trichophyton violaceum. The total dystrophic onychomycosis (TDO) is the result of the nail infection that progresses to affect the entire nail plate, regardless of the initial characteristics.[3]

Retrospectively, we reviewed 280 medical charts of adult HIV infected patients and searched for data of onychomycosis diagnosis and its clinical presentation. Fifty-four (20%) had onychomycosis, affecting toenails in all the cases. Of these, DLSO and TDO were the most frequent (61 and 55%, respectively). Thirty-one percent of these patients had at least two different clinical presentations at the same time. DLSO was the only diagnosis in 13 patients (24%), and in 12 (22%) patients, it was combined with another pattern. TDO was the only pattern in 11 (20%) patients, and mixed in 12 (22%) patients. The white forms (mycotic leukonychia), SWO and PSO, were the only pattern in 4 (7%) patients, but in 12 (22%) patients we observed more than one clinical form.

Three patients (5%) had fingernail onychomycosis, all associated with toenail infections. We did not find any case of paronychia.

The first reports of onychomycosis in HIV patients have mentioned extremely high (70–89%) percentages of white forms.[45]

Nonetheless, this is not what we currently observe in our clinical practice. The TDO and OSDL are still the most common clinical presentation.

Although clinical classification of onychomycosis patterns of dermatophyte infection is useful, particularly in SWO and EO where the etiological agent can be suspected, in HIV infected individuals, where different patterns can be seen at the same time, the clinical appearance is not always relevant for the choice of treatment other than considering if the nail matrix is involved or not.