Three cases of Nattrassia mangiferae (Scytalidium dimidiatum) infection in Singapore
Authors: Goon Anthony Teik‐Jin , Seow Chew‐Swee 
Published: March 2003

Case no. 1 A 70‐year‐old Indian man had lateral onycholysis of his left big toe since 1989. Nail scrapings from the left big toenail were negative three times in 1989 and 1990. Fungal cultures from the left big toenail were negative for dermatophyte and nondermatophyte molds in 1990. The condition did not respond to topical itraconazole 1% lotion (prepared by our pharmacy from itraconazole capsules), ketoconazle cream, tolnaftate lotion and nonstaining Castellani paint as well as oral itraconazole 100 mg daily for 4 weeks.

In 1993, there was distal onycholysis of the fingernails on the left thumb, left ring and index and right little fingers as well. Once again, the skin scrapings from the finger‐ and toenails were negative. The condition did not respond to topical tolnaftate lotion, clotrimazole 1% lotion, miconazole 1% lotion, thiabendazole 10% lotion and nonstaining Castellani paint.

In September 1999, both big toenails had crumbling nail plates and ragged distal edges. Nail scrapings showed the presence of mycelium and the fungal culture result was reported Scytalidium dimidiatum and Fusarium species. The Fusarium was thought to be a nonpathogenic coloniser. He was treated with oral griseofulvin, thiabendazole 10% lotion and nonstaining Castellani paint without much improvement.

He was last seen in January 2001. There was still destruction of the nail plate and separation of the nail plate from the nail bed.

Case no. 2 A 45‐year‐old Chinese man who worked as a clerk in a cosmetic company was first seen in July 1994 for scaly hyperkeratotic rashes on both soles for 10 years. He had tried using miconazole cream but the problem persisted. Skin scrapings revealed the presence of mycelium and fungal culture result war reported as Hendersonula toruloidea. He was born in Singapore and had never lived overseas.

The condition persisted despite 9 weeks of oral griseofulvin 250 mg twice daily and miconazole 2% cream, 3 months of 10% thiabendazole lotion, 2 weeks of oral thiabendazole 500 mg twice daily and ung Whitfield. He subsequently defaulted after the last visit in April 1995, when he was prescribed amorolfine cream.

He was seen again in July 1998 for acne vulgaris. His soles were still hyperkeratotic but skin scrapings were not taken. He defaulted again after 3 visits.

Case no. 3 A 33‐year‐old Indian man who had been working in a machine assembly line for 12 years presented with an itchy scaly rash on his feet for 3 years and on the hands for 1 year in November 1996. The rash was especially prominent on the toewebs and occasionally formed vesicles and became secondarily infected. He had been treated with antifungal creams, with the addition of oral antibiotics for episodes of secondary infection, but the skin condition deteriorated. He wore shoes at work and had been exposed to coolants for 3 years. There was no history of atopy or allergies.

On examination, there was maceration and scaling between the right second and third toes. Scaling was seen in the toewebs and near the thumbs bilaterally. The nails and groin were normal.

Skin scrapings were negative on the hands, but showed a few hyphae on the toewebs. Fungal cultures from the toewebs were negative but bacterial cultures of the toewebs grew Acinetobacter baumanii and Klebsiella species, both of which were sensitive to gentamicin. The diagnoses of secondarily infected tinea pedis and hand dermatitis were made.

The infection settled with oral cloxacillin and topical gentamicin cream but the skin of the hands and feet remained dry and fissured. He was then treated as for hand and foot dermatitis with moderately potent topical corticosteroids with minimal improvement. Repeated skin scrapings were negative in January and May 1997. He defaulted in September 1998.

He returned in March 2000 with an acute exacerbation of a dry itchy rash on his palms and soles. He was treated as for dermatitis with cephalexin and a tapering course of prednisolone with significant improvement. Due to the persistent rashs, a skin scraping of the feet was repeated in May 2000 and this showed the presence of mycelium. He was treated with a course of oral griseofulvin 250 mg twice daily for 4 weeks with no improvement. He was then treated empirically with oral terbinafine 250 mg daily for 3 weeks and miconazole 2% cream, as cultures were not available.

In June 2000 he had an infected exacerbation of his rash, which required treatment with oral cephalexin followed by oral cotrimoxazole. The skin scraping of the toewebs was negative and a diagnosis of acute dermatitis was made. He was given a tapering course of prednisolone with improvement. A patch test was negative.

In November 2000, he still had a rash on the palms and soles. The fungal culture result was reported as Scytalidum dimidiatum but fungal scrapes had not been done. He was treated with oral itraconazole 200 mg daily for 4 weeks, oral cloxacillin and miconazole 2% cream.