Internal Medicine Resident Uses VisualDx to ID Patient’s Nail Infection

Fares A., an internal medicine resident at King Abdulaziz Medical City in Saudi Arabia, shares how VisualDx confirmed her patient’s nail infection diagnosis.

“A 45-year-old female complained of 1-month worsening nail discoloration. The first nail affected was the right ring finger before gradually involving other fingernails and right toenail. This was the first time the patient had such symptoms. There was no associated fever or systemic symptoms. Her past medical history is significant for bronchial asthma and chronic bronchiectasis. Her current medications include inhaled budesonide/formoterol, tiotropium, montelukast, doxophylline, and omeprazole. She had 3 bronchiectasis exacerbations this year requiring prolonged antibiotics and courses of oral prednisone. She lives in a rural village in Pakistan and has never traveled anywhere.

On examination, the right ring finger and right toes exhibit a green and brown subungual discoloration in the proximal nail with mild tenderness. The nail does not come off. I went through the VisualDx app’s algorithm of nail lesions and entered relevant information and the first diagnosis that appeared was onychomycosis. The images and clinical synopsis were consistent with the clinical presentation. I ruled out the other differentials that the article pointed out. I referred the patient to a dermatologist to perform the potassium hydroxide test and fungal culture to confirm the diagnosis and started her on terbinafine.”

Onychomycosis pictured here is not the patient in this case study. See more pictures of onychomycosis in VisualDx.

What is onychomycosis?

Onychomycosis, commonly known as a fungal nail infection, is infection of the fingernails or toenails by forms of fungi and yeast. Fungal nail infections account for nearly one-half of all nail disorders. In the most common form of fungal nail infections, fungus grows under the growing portion of the nail and spreads up the finger (proximally) along the nail bed and the grooves on the sides of the nails. A less common type of fungal nail infection may occur in those with HIV/AIDS.

What should we be aware of when making a diagnosis?

In general, toenails are most commonly affected with fungal nail infection. If the fingernails are affected, the toenails are usually affected as well. Nails often become thicker and lift from the nail bed (onycholysis) starting at the growing portion of the nail. You might then see debris under the nails and discoloration of the affected area.

How can we treat this?

Oral antifungal treatments offer the best chance for curing fungal nail infection. The most commonly used agents are terbinafine, itraconazole, and fluconazole. The medications may cause liver problems or may affect blood cell counts. Blood tests are usually performed before starting therapy and during therapy to look for possible side effects.