Journal of Pakistan Association of Dermatologists 2012; 22 (4):370-372.

Case Report dubliniensis : A rare cause of nail infection J Kalsy*, J Kaur**

*Department of Dermatology Venereology, Leprosy Government Medical College Amritsar, Punjab. **Department of Dermatology Venereology, Leprosy Sri Guru Ram Das Institute of Medical Sciences and Research Amritsar, Punjab.

Abstract Candida dubliniensis is a newly described fungal opportunistic pathogen that is closely related phylogenetically to C. albicans . It is mostly isolated from patients with immunodeficiency and few cases develop quick resistance to routine treatment and delay in result outcome. Here we report a case of 21-year-old healthy female who presented clinically with onychomycosis of the toe nail resistant to terbinafine and .

Key words Candida dublinienisis , nail infection.

Introduction Case report

Candida dubliniensis is a newly described A 21-year-old female came to our skin out fungal opportunistic pathogen that is closely patient department for consultation for her toe related phylogenetically to C. albicans and is nail infection. Her problem was persisting for commonly associated with in the last one year. She took various medications human immunodeficiency virus patients and like fluconazole, terbinafine in varying regimes occasionally isolated from immunocompetent from different practitioners with no relief. There individuals.1,2 It was first described in 1995.3 was history of wearing socks and shoes Until then it had been misidentified as candida continuously during her duty for long hours. albicans if only germ tube test was used for There was no complaint of pain or swelling in identification as both the species have many the toes. On examination right foot toe nail was similarities in their microscopic morphology and discolored at the distal end. Clinically she was ability to form germ tubes in serum.4,5 diagnosed as having fungal toe nail infection. Nail clippings were sent for fungal culture in the Here we report a case of 21-year-old female department of microbiology. with toe nail infection due to Candida dubliniensis . On direct examination fungal hyphae were observed. Address for correspondence Dr. Jyotika Kalsy On culture, growth of Candida dubliniensis was 129 A Race Course Road Opp. Beams hospital found positive on CHROMagar®. While going Amritsar, Punjab 143001 through literature it was found that this infection Phone: 9814134141 is more common in immunocompromised E mail: [email protected]

370 Journal of Pakistan Association of Dermatologists 2012; 22 (4):370-372.

, and . So it was hypothesized that C. dubliniensis has the ability to rapidly develop resistance to fluconazole, especially in patients who are on long-term therapy.7 Like in C. albicans first line treatment for C. dubliniensis is also fluconazole but few cases develop quick resistance to treatment as happened in our case who was earlier put on fluconazole and terbinafine by various practitioners in different regimens with no relief. Amphotericin B and itraconazole are Figure 1 Discoloration of the toe nail seen at the two other anti fungal medications effective in distal end. treating C. dubliniensis . So we started her with individuals so a battery of investigation was itraconazole 100mg twice daily for one month done to find out any immunosuppression. and then in monthly pulses for three months with which she showed significant Hemoglobin was 12.6 gm% and fasting blood improvement. sugar 86 mg%. Peripheral blood film did not show immature cells. ELISA for HIV was One publication suggested that C. dubliniensis is nonreactive. Patient was not on steroids for any less virulent than C. albicans and is more disease. susceptible to the fungicidal effect of human neutrophils which explains the overall low Discussion incidence of C. dubliniensis even among the susceptible hosts.8 Although it is mostly seen in Candida dubliniensis is a cosmopolitan immunocompromised patients but our case was and various retrospective studies have shown healthy young female of 21 years with no that previously it had been identified as C. obvious cause of immunosuppression except for albicans , with which C. dubliniensis is closely the fact that she used to wear socks and shoes related and shares a number of characteristics. regularly and continuously which is otherwise One test for distinguishing C. dubliniensis from also a risk factor for developing fungal C. albicans , is laboratory culture of the organism infections. This can be the reason why her at 42°C when only most of C. albicans strains disease was limited to toe nail only for the last grow.3,6 There are also significant differences in one year. This fact is also supported by more the conditions that lead to the formation of recent studies which suggest that C. dubliniensis in C. albicans and C. becomes resistant to fluconazole during the dubliniensis , although they are otherwise course of therapy, thereby, causing difficulty in phenotypically very similar.3 clinical result outcome.9

Mostly the isolates of C. dubliniensis are Conclusion sensitive to fluconazole. In one study it was observed that 16 out of 20 isolates were This case is being presented for its rarity and to sensitive to fluconazole, while four were emphasize the need for early diagnosis and cure resistant but all 20 were susceptible to of the infection since antifungal agents have to

371 Journal of Pakistan Association of Dermatologists 2012; 22 (4):370-372. be given for long time. Correct diagnosis will Pfaller MA et al, editors. Manual of Clinical th shorten the treatment and limit the side effects. Microbiology, 7 ed . Washington DC: ASM Press; 1999; 1184-99. So it is recommended that whenever a fungal 5. Odds FC, Nuffel LV, Dams G. Prevalence culture is sent to the laboratory for fungal of Candida dubliniensis isolates in a examination, if candida is isolated, further stock collection. J Clin Microbiol. 1998;36 :1467. Letter. subcultures for species identification should be 6. Kamiyama A, Niimi M, Tokunaga M,. performed. With this characterization, specific Nakayama H. Adansonian study of Candida treatment can be given to eliminate the infection albicans: intraspecific homogeneity excepting C. stellatoidea strains. J Med Vet and hence prevent resistance. Mycol 1989;27 :229-41. 7. Moran GP, Sullivan DJ, Henman MC et al . References Antifungal drug susceptibilities of oral Candida dubliniensis isolates from human immunodeficiency virus (HIV)-infected and 1. Gilfillan GD, Sullivan DJ, Haynes K et al . non-HIV-infected subjects and generation of Candida dubliniensis: Phylogeny and stable fluconazole-resistant derivatives in putative virulence factors. Microbiology vitro. Antimicrob. Agents Chemother 1998;144 :829-38. 1997; 41 :617. 2. Pincus DH, Coleman DC, Pruitt WR et al . 8. Vilela MMS, Kamei K, Sano A et al. Rapid identification of Candida dubliniensis Pathogenicity and virulence of Candida with commercial yeast identification dubliniensis comparison with C. albicans. systems. J Clin Microbiol 1999; 37 ;3533-39. Med Mycol 2002: 40 :249-57. 3. Sullivan D, Westerneng TJ, Haynes KA et 9. Jabra-Rikz MA, Falkler WA, Merz WG et al . Candida dubliniensis sp. phenotypic and al . Retrospective identification and molecular characterization of a novel characterization of C. dubliniensis isolates species associated with oral candidosis in among C. albicans, clinical laboratory HIV infected individuals. Microbiology isolates from human immunodeficiency 1995; 141 :1507-21. virus infected and non HIV infected. J Clin 4. Warren NG, Hazen KC. Candida, Microbiol. 2000. 38:2423-26. Cryptococcus and other yeast of medical importance. In: Murray PR, Baron EJ,

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