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Clinically Both Diseases Present Practically the Same Symptoms

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Clinically Both Diseases Present Practically the Same Symptoms ABSTRACT OF DISCUSSION The side or base of the nail, however, may occa- first involved. the whole nail Dr. Ernest L. McEwen, Chicago : Cases of bromoderma sionally be Rarely and there is a are sometimes found in epileptics in which the skin eruption appears to be simultaneously attacked, or whole closely simulates blastomycosis. I recently saw a bromoderma more less universal involvement of the horny not in a girl of 16, an epileptic, who for a long time had been substance. If the nail does flake and break away, taking large doses of bromids. The lesion in this case leaving a rough, uneven, diseased surface, it is very appeared suddenly and extended rapidly, totally unlike what we see in true blastomycosis. Dr. Oliver S. Ormsby of Chicago, reported a similar case some years ago, in which the lesion spread with astonishing rapidity and closely simulated blastomycosis. Dr. A. Ravogli, Cincinnati : Not long ago I saw a child with massive tumors on the face and head. The child had been treated with the Roentgen rays and was getting worse and the treatment had also set up a Roentgen dermatitis. On inquiry, it was learned that the child had been taking bromids, and when this was discontinued, the lesions healed under simple treatment. I have also seen an acneiform erup¬ tion on the legs, due to bromid which was very difficult to diagnose. Dr. M. L. Ravitch, Louisville : I do not agree with Dr. Weiss that these cases are so very unusual ; I think many cases of bromodermas have been reported in the literature, and I have seen many cases more in private practice than in the asylums. The insane patients stand bromids better than normal people. I recall one case of bromoderma in an infant in which the diagnosis of small-pox was made and the child sent to an isolation hospital. I do not think bromo¬ derma is confined to any particular season of the year. I have seen cases of bromoderma simulating blastomycosis, in winter, fall and summer. Dr. George M. MacKee, New York : I had the opportunity of this case very carefully, and it offered consider¬ studying Fig. 1.—Ringworm of nails. able difficulty in the diagnosis. Among other things, we considered tuberculosis, syphilis and blastomycosis, and finally arrived at the correct diagnosis by the process of much thickened and deformed. Only One nail may be elimination. involved, or several or all. The thumb, index-finger Dr. Ludwig Weiss, New York : Bromoderma is not a very and middle fingers are the ones most commonly rare condition, but in my case there were some unusual fea¬ attacked, and as the nails are generally infected from tures. The hemorrhages from the vegetations were at times very profuse, owing to the dilated venous loops in the papil¬ lary layer. I mentioned the seasonal occurrence of bromo¬ derma only as a curiosity. We find that erythema nodosum and other forms of erythema are worse in cold weather and improve in the summer. As Dr. MacKee has already pointed out, the lesions in this case had to be and were differentiated from a syphilid, pemphigus and other forms of eruption. FAVUS AND RINGWORM OF THE NAILS MILTON H. FOSTER, A.M., M.D. Surgeon, U. S. Public Health Service NEW YORK Favus and ringworm of the nails are supposed to be rather rare conditions. The finding of 101 such cases among the aliens arriving at Ellis Island during the first eight months of the present fiscal year goes to show that these disorders are probably more common, at least among our foreign population, than is gen- erally believed. Clinically both diseases present practically the same symptoms. The affected nail is thickened, brittle and sometimes even caseous. The natural color and Fig. 2.—Favus of the nails. transparency of the involved portion is lost and it becomes opaque and yellow or dirty-white in appear- scratching the scalp, this distribution would be ance. The process generally starts at the distal end and expected. slowly infiltrates the nail toward the base, the diseased The disease does not appear to be painful nor does portion crumbling away gradually, because of the it seem, at least in our experience, to predispose trauma to which the part is necessarily exposed in the toward setting up any acute inflammatory conditions ordinary vocations of life (Figs. 1, 2, 3, 4 and 5). of the surrounding soft parts. Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/06/2015 PROGNOSIS METHOD OF EXAMINATION The process is essentially chronic, and if untreated Several drops of a 20 per cent, solution of potas¬ continues indefinitely. The youngest patient whom sium hydroxid in water are placed on a slide and a we have encountered was 3 years old, the oldest 72. few fine scrapings from the suspected areas dropped Reliable histories were hard to obtain, but one unfor¬ in the solution. The slide is moderately heated once tunate asserted that this condition had been present for or twice and allowed to stand a few minutes. In a fifty-two years. little time the suspected material becomes increased in DIAGNOSIS size and soft in consistency. The "clearing-up" pro¬ While the mottled, yellow, thickened and crumbly cess may be hastened by gently separating and divid¬ condition of the nails affected is characteristic, ing the specimen with an ordinary teasing-needle. highly of there are other conditions, besides an infiltration of Several the smaller bits of the softened scrapings are then placed on another slide and a drop or the Fig. 6.—Simple hypertrophy of nails, end view, natural size. The patient, an alien, asserted that the condition had existed from birth. Fig. 3.—Ringworm of the nails enlarged, showing peculiar deformity. Fig. 7.—Simple atrophy of nails, asserted to exist from birth. Fig. 4.—Favus showing crumbling of the nails. This case was of four years' duration. Fig. 5.—Ringworm of nails showing general yellow infiltration but Fig. 8.—Atrophie condition of nails due to severe burn received dur¬ no loss of substance. ing childhood. these specific fungi, which resemble it very closely. solution of potassium hydroxid added and a cover- These are syphilis, psoriasis, eczema, simple atrophy slip placed over all. The slip is gently pressed down and hypertrophy, grave constitutional disorders, and so as to make a fairly thin preparation. some other skin diseases (Figs. 6, 7, 8, 9 and 10). Examined with a 4 eye-piece and a 7 objective with When the nails are affected by some general consti¬ subdued light, the fungi appear as highly refractive, tutional process, it is usual to find all of them slightly greenish, transparent, branching threads involved. In ringworm and favus one or more often among the partly disintegrated elements of the nail. escape. Hypertrophie and atrophie conditions of the If properly applied the potassium hydroxid solution nails likewise involve all of them and the entire nail clears up and partially dissolves the normal nail substance. material, leaving the fungi standing out distinctly in Fortunately it is not necessary to endeavor to find the field (Figs. 11, 12, 13 and 14)! clinical points of difference, as a microscopic examina¬ If the clearing-up process is too slow, reheating tion enables us to make the diagnosis with certainty. will materially hasten it. A little search may be Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/06/2015 necessary to find them, but in many specimens every DIAGNOSIS OF FAVUS FROM RINGWORM field will be found to contain a number of the threads. As stated above, both disorders the of both favus and present clinically Generally organism ringworm the same and the of when obtained from the nails as practically symptoms, fungi ring¬ appears plain, worm and favus when obtained from the nails resem¬ threads which here and there show hyaline, branching ble each other so closely when examined microscopi- faintly the separation into spores or which contain at more or less regular intervals a small, round, highly refractive spore. Occasionally, as in the illustrations, the spore formation is very prominent ; but such a dis¬ tinct separation into spores is not the rule. INVOLVEMENT OF THE SKIN OF THE PALMS AND FINGERS In a number of these cases I have noted that the skin of the palm and palmar surface of the fingers was unusually hard, horny, calloused, and had a tendency to crack and peel off in flakes. While this condition is generally observed to a moderate degree in laborers Fig. 10.—Idiopathic loss and destruction of two nails. Case was kept under observation for a number of weeks and repeated examina¬ tions made, but no cause for the condition could be discovered. cally that a separation of the two diseases on these findings alone is generally impracticable. If there be favus of the scalp or elsewhere on the body, or if the scalp bear the scars of old favus, it is proper to assume that the condition of the nails is also due to the same organism. Similarly if other parts are involved with ringworm, it is likely that this is also the cause of the onychomycosis. If neither active favus nor ringworm is present elsewhere, and there is Fig. 9.—Syphilis of the nails. The palm of this case is shown in Figure 17. who use the pick and shovel constantly as a means of livelihood, yet it is unusual to see it to the extent pres¬ ent in many of these nail cases. We have lately been examining scrapings from these hands and have found the.
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