Background:Onychomycosis of the fingernails and toenails is generally caused by dermatophytes and yeasts. Toenail mycoses involve mainly dermatophytes but when Candida is also involved, the strain most commonly isolated worldwide is C. albicans.Aims:To determine Candida strains prevailing in onychomycosis.Materials and Methods:A retrospective, observational and descriptive study of fungal cultures retrieved from the registry of the microbiology laboratory of the Pontificia Universidad Católica was performed. Specimens obtained from patients attending the healthcare network between December 2007 and December 2010 was analyzed.Statistical Analysis:A descriptive statistical analysis was performed.Results:Candida was retrieved from 467 of 8443 specimens (52% fingernails and 48% toenails). Cultures were negative in 5320 specimens (63.6%). Among Candida-positive cultures, parapsilosis was the most commonly isolated strain with 202 cases (43.3%). While isolates of Candida guillermondii were 113 (24.2%), those of Candida albicans were 110 (23.6%), those of spp. were 20 (4.3%) and there were 22 cases of other isolates (4.71%). Among the 467 patients with positive cultures for Candida, 136 (29,1%) were men and 331 (70,9%) were women. All patients were older than 18 years old. Clinical files were available for only 169 of the 467 patients with positive cultures for Candida. For those, age, gender, underlying illnesses and use of immunossupresive agents during the trial was reviewed.Conclusions:The present study shows that both C. parapsilosis as well as C. guillermondii appear as emerging pathogens that would be in fact taking the place of C. albicans as the most commonly isolated pathogen in patients with Candida onychomycosis. The relative percentage of C parapsilosis increases every year. Identification of Candida strains as etiological agents of nail candidiasis becomes relevant to the management both nail as well as systemic candidiasis, in view of the resistance to conventional treatments readily reported in the literature.

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We describe a case of a male patient, 38 years old, HIV-positive (most recent CD 4 count about 259/ mm 3 ), with abdominal pain, nausea, vomiting, anorexia, weight loss, and vespertine high fever with chills. His hemogram showed normocytic and normochromic anemia, with a high erythrocyte sedimentation rate (ESR) and gross granulations in the neutrophils. Transaminases were normal. Bone marrow biopsy evidenced a chronic disease anemia pattern and a lack of infectious agents. Abdominal ultrasound examination showed a normal-size spleen, which exhibited heterogeneous parenchyma and multiple small hypoechoic images, together with small ascites, peripancreatic and para-aortic lymphadenopathy. These findings were confirmed by abdominal CT. The liver was normal in size, but had a hyperechoic image, which was not visualized on CT. Histopathological analysis of one of the multiple abdominal lymph nodes obtained by laparoscopic biopsy exhibited a chronic granulomatous inflammatory process, with caseous necrosis. Tissue sections were positive for BAAR (acid-alcohol-resistant bacillus), and the cultures were positive for Mycobacterium tuberculosis. Antituberculosis treatment was begun, and the patient evolved with improvement of his general state, fever remission and weight gain. Splenic tuberculosis is a rare disease, occurring predominantly in patients in late stages of AIDS and/or disseminated tuberculosis. It is a difficult diagnosis, since there are no specific findings. Hence, complementary examinations, such as abdominal ultrasound/ CT, or fine needle aspiration, are usually necessary for investigation and differential diagnosis. Often, lesion regression after anti-tuberculosis regimens can be seen, and splenectomy is restricted to complicated or refractory disease.

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INTRODUCTION: Amyotrophic lateral sclerosis (ALS) is the most common motor neuron disorder.1 Recent data has demonstrated chronic elevation of cardiac specific troponin at baseline.1-4 We present a case of an 89-year-old gentleman with ALS and chronically elevated cardiac specific troponins. CASE PRESENTATION:A ventilator dependent 89-year-old male with a past medical history of rapidly progressive amyotrophic lateral sclerosis, coronary artery disease status post coronary artery bypass grafting and percutaneous coronary intervention transferred from a nursing facility to our ICU due to worsening sepsis. Upon presentation, he was hypotensive, bradycardic, and hypoxic on his baseline ventilator settings. Laboratory investigations were significant for white cell count of 11,300 cells/mL, hemoglobin of 7.6 g/dL, estimated glomerular filtration rate of 83.7 mL/min/1.73m*2, troponin I of 0.12 ng/mL, and respiratory cultures were positive for Pseudomonas aeruginosa. There were no significant EKG changes. Transthoracic echocardiogram revealed an ejection fraction of 40% and diffuse mild hypokinesis with some regional variation, without obvious regional wall motion hypokinesis. Troponin I levels peaked at 1.16 ng/mL. His CK and CK-MB did not rise. He received piperacillin-tazobactam and metoprolol tartrate. Per cardiology, no further work up was indicated.DISCUSSION: Troponin T (cTnT) and troponin I (cTnI), are highly sensitive biomarkers of myocardial injury.5 Very limited data has suggested that amyotrophic lateral sclerosis (ALS) may be associated with persistent low-level elevations of cardiac specific troponins.1-4 Our patient may have had demand ischemia in the setting of sepsis. On chart review, however, he had persistent elevation of cTnI that coincided with the onset of his ALS. The clinical significance of this finding on the prognosis of this disease, as well as the origin and the reason why cTnT and cTnI rises in ALS, is not completely understood. It is possible that cTnT/cTnI are produced by the atrophic skeletal muscles in a similar manner to some immune-mediated skeletal myopathies.1 CONCLUSIONS: Patients with amyotrophic lateral sclerosis may have persistent elevations of cardiac specific troponins without acute coronary syndrome. This is important to recognize when evaluating patients with ALS when admitted to the ICU to avoid unnecessary invasive procedures, which could have significant morbidity, prolong hospital stay and increase costs.

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