Tehran University Medical Journal

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Fungal infection of the nail, also known as onychomycosis, is a worldwide problem. It is estimated that onychomycosis constitutes 15-22 percent of all nail disorders. It is also known that 2-5 percent of the adult population in Europe have onychomycosis. This problem is quite common in the dermatology clinic of the countries in the Midle East, India and the Far East. The infection rates and types of fungi involved in onychomycosis vary with conditions such as age, sex, occupation, hygiene, foot wear and several environmental and climatic factors.
Methods and Materials: A retrospective study of nail infection was carried out in the section of Medical Mycology, Pasteur Institute of Iran from April 1993 to March 1999. Nineteen hundreds eighty five cases examined for toe and finger nail infections.
Results: Ranging in age were from 3 months to 84 years old. This study reports the causative agents of onychomycosis in the presented patients in the section of Medical Mycology, Pasteur Institute of Iran. The 1985 patients were examined for onychomycosis. Diagnosis was confirmed by demonstration of fungi in direct (K.OH 20 percent) and cultural examination. Onychomycosis were proven in 601 patients. Three hundreds fifty patients were females (59 percent). The fingernails were more commonly positive in females (73.5 percent) than males, while the toenail positivity rate in males was 69 percent. Among 601 isolated species, dermatophytes were 308 cases (51 percent) mainly from toenail were predominant. Candida SPP. Were isolated in 46 percent of the cases, especially from fingernails. Nondermatophytic molds were isolated only in 3 percent of the patients (18 cases). Most common isolated dermatophytes were Trichophyton rubrum (66.5 percent) and T. Mentagrophytes (24.6 percent). Other isolated dermatophytes were: violaceum, T. schoenleinii and Microsporum gypseum. Candida albicans were isolated in 40.9 percent of the yeast onychomycosis. Non- dermatophytyic molds were Aspergillos, Acromonium. Fusarium and Chrysosporium.
Conclusion: Onychomycosis represent 30 percent of all mycotic infections of the skin. Their promoting factors, clinical aspects and differential diagnosis have been reviewed. It is necessary to confirm the clinical diagnosis of onychomycosis by laboratory tests (direct microscopy and cultures).

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Background: Simple bone cyst is a common benign lesion in the proximal humerus, especially in prepubertal children. Up to 75 percent of patients with the bone cyst have a pathologic fracture and the most significant complication is recurrent pathologic fracture. Since the process of spontaneous healing of these fractures is rare, treatment is required. Ideal treatment for simple bone cyst should stabilize pathologic fractures, assist healing and provide a quick return to normal activity with reduced complication and recurrence.
Methods: In this descriptive case series study, 24 patients with simple bone cysts of the humerus were selected for retrograde flexible intramedullary nailing from the lateral cortex of the distal humerus, since 2000 to 2005 at Imam Khomeini Hospital, Tehran. The mean age of the patients was 14.4 years, ranging from 6-39 years. Results were evaluated by plain radiography using the classification system of Capanna et al.
Results: The mean duration of follow up for 23 of the patients was 31 (9-51) months. One patient with short-term of follow-up was excluded. Of these patients, 91.3% were healed either completely (65.2%) or with residual minor defect (26.1%). Only one cyst (4.3%) persisted with no response to treatment and one patient (4.3%) had a recurrence of the cyst. However, there was no instance of recurrent pathologic fracture among these patients.
Conclusion: This study shows that flexible intramedullary nailing is an effective treatment for humeral simple bone cysts that reduces the chance of complication, recurrence of cyst or pathologic fracture. This technique provides sufficient stability for quick return to normal activity.

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Background: Dental amalgam, a mixture of approximately 50% mercury with silver, tin, zinc and copper in varying ratios, is a major source of mercury pollution in the general population not occupationally exposed. The toxicity of mercury is enhanced because it is so readily absorbed, with around 90-100% of mercury vapor being absorbed through the oral mucosa. The aim of the current study is to examine the mercury levels in hair and nails in subjects with amalgam fillings.
Methods: For a sample of forty university students reporting infrequent fish consump-tion, with their only known exposure to mercury from amalgam fillings, mercury levels were measured in hair and nail samples using the LECO AMA 254 Advanced Mercury Analyzer (USA), according to the ASTM standard No. D-6722 test method.
Results: Mercury concentration in hair ranged from 0.09 to 3.11 mg/kg, and in nail from zero to 1.35 mg/kg. We found that subjects with five or more amalgam fillings had significantly higher levels in their hair than subjects with zero to 5 amalgam fillings (CI 95% P=0.003). However, the number of amalgam fillings had no effect on the mercury concentration in nails in these two groups (P=0.26). There was no significant difference between the levels of mercury of males and that of females tested (P=0.26 for nail and P=0.15 for hair).
Conclusion: The mercury amount in hair was 1.5 times as much as that of the nail samples, may be due to the differences in the chemical compounds, particularly those with sulfur, or the deposition of those compounds that would be affected by blood circulation during formation of hair and nails. Although the amounts of mercury found in this study were below the WHO maximum acceptable level of 6 mg/kg for mercury in human hair, the levels were sufficient to warrant the use of other dental materials such as composites in order to decrease the overall rate of exposure to mercury.

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Background: The etiologic role of Malassezia furfur in onychomycosis, because of its controversial keratinolytic ability, has not been proven. The most reported cases are distal subungual onychomycosis (DSO). In our knowledge no cases of proximal onychomycosis (PO) has been reported. For the first time we report proximal onychomycosis. This case report describes the isolation of Malassezia furfur from fingernails.
Case presentation: An Iranian 56- year- old women had been referred to mycology lab with hyperkeratosis in proximal regions of right hand nails and clinical diagnosis of onychomycosis without paronychia in May 2012. She used several medicines for her cardiac disease, mental illness, severe stress and blood glucose fluctuation diseases. Scraping and sampling from nail lesions were done, budding yeast cells with broadband connections were observed in 15% KOH wet mounts. Also, other differentiation tests, consist of staining with methylen blue, cultures and biochemical tests were done. In order to rejecting the probable etiologic role of any dermatophytic or non-dermatophytic fungi in this case, samples were collected from other parts of the body by scotch tape and scraping with scalpel blade too, but the results of direct microscopy and culture were negative. Finally, Malassezia furfur was identified as the causative agent of onychomycosis.
Conclusion: Despite failure to prove Malassezia furfur keratinolytic ability, it can be the etiologic agent of proximal onychomycosis that shows the aggressive properties of this species. Its clinical importance is the easier transmission to hospitalized patients and other people.

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Background: Mycosis fungoides (MF) is the commonest T-Cell lymphoma (CTCL) involving skin and its appendages to variable degrees. Nail involvement is one of multiple dermatologic manifestation of this disorder and could have negative impact on psychological status of patients and producing therapeutic challenge to physician. We aimed to evaluate prevalence and subtypes of nail involvement in MF patients attending dermatology clinic, Razi Hospital in Tehran, Iran. Methods: All patients having MF confirmed via histopathology, visiting Razi Hospital Dermatology Clinic, Phototherapy and follow-up on inpatient wards from 2010 to 2011, were included. Patients examined by dermatologist researcher focusing on nail changes and all detected nail changes including onycholysis, longitudinal ridges and 11 more other changes, recorded in appropriated questionnaires. Treatment regimen prescribed to the patients also recorded as well as clinical CTCL staging. Results: A total of 60 patients, including 28 (46.7%) males and 32 (53.3%) females entered the study. 18 patients (12 males and 6 females) had different nail changes including longitudinal ridging, leukonychia, pitting and nine more morphological changes in decrescendo order. Ten patients had smoking history including four patients with nail changes. The commonest used treatment was local bath Psoralen and UVA light therapy (PUVA). Overall nail involvement in our study was approximately 30%. There was no significant relationship between prevalence of nail changes, demographic and clinical specification of underlying CTCL disorder especially tumor stage. Also, no significant relationship between prevalence and type of nail involvement with prescribed therapeutic regimen was found. Conclusion: We found about 30% prevalence that is a little higher than previously shown. It seems that nail changes in CTCL have no relationship to CTCL staging or other specifications including demographic specifications.