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4851 Northshore Lane, Suite B North Little Rock, AR 72118 Phone: 501.225.1400 Fax : 501.225.1401

advanced pathology solutions

PATIENT INFORMATION

COLLECTED

Name:

RECEIVED

10/31/2016 11/02/2016 11/03/2016

REPORTED DOB: Gender:

MRN/CHART#

Age :

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Referring Physician :

Accession#:

FINAL DIAGNOSIS

I A.

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FINAL MICROSCOPIC DIAGNOSIS: A. NAIL PLATE AND NAIL BED DERIVED KERATIN, CURETTINGS: - Onychomycosis. - Extensive (3+) fungal hyphae identified (superficially) within the nail matrix on PAS stain and GMS special stains. - Fontana Masson stain negative for melanin pigment in fungal organism. Theodore Chang, MD Electronic Signature, 11/03/2016 02:14 PM COMMENTS

Fungal elements with features most characteristic of dermatophytes (T. rubrum / T. mentragrophytes / E. floccosum), are demonstrated with the use of a periodic acid-Schiff (PAS) reaction and Gomori methenamine silver (GMS) stain. Studies show that T. rubrum is the offending organism in the vast majority of such cases. Budding yeast forms are not present making Candida! onychomycosis less likely. The absence of stainable melanin pigment argues against filamentous saprophytic molds. Approximately 90% of lower extremity onychomycosis can be attributed to dermatophytes. Efinaconazole topical solution, 10% (Jublia) is indicated for the topical treatment of onychomycosis (tinea unguium) of the toenail(s) due to Trichophyton rubrum and Trichophyton mentagrophytes 1 with daily application for 48 weeks. Terbinafine is FDA approved for treatment of toenail onychomycosis: 250 mg daily 12 weeks (continuous) or 500 mg daily for 1 week per month for 3 months (pulse). Terbinafine is fungicidal against dermatophytes, non-dermatophyte molds and C. parapsilosis. Continuous dosing has been shown to be more effective but requires monitoring of liver function tests2 • Refractory cases of onychomycosis and cases caused by non-dermatophyte molds may benefit from Fluconazole 150-200 mg/week for 9 months or ltraconzaole, 200 mg twice daily for 1 week for 3-4 months (or 200 mg daily for 12 weeks). Both of these agents also require liver function test monitoring3 • Terbinafine is a category B drug while itraconazole and fluconazole are in pregnancy category C . Use of all these drugs should be avoided in pregnancy. All oral antifungals are excreted in breast milk and therefore contraindicated in lactating mothers. Evidence pertaining to the effectiveness of laser therapy in the treatment of onychomycosis is emerging; further studies are needed to adequately evaluate this therapy4; however, laser and

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4851 Northshore Lane, Suite B North Little Rock, AR 72118 Phone: 501.225.1400 Fax: 501.225. 1401

advanced pathology solutions

photodynamic therapy may have the potential to treat onychomycosis locally without adverse systemic effects 6 • Strategies to improve cure rate in onychomycosis include combination/sequential therapy, surgical avulsion in addition to oral/topical therapy, discarding/resting old shoes, and treatment of affected contacts 5 • References: 1. Westerberg DP, Voyack MJ. Onychomycosis: Current trends in diagnosis and treatment. Am Fam Physician. 2013;88(11 ):762-770 2. Warshaw EM , Fett DD et al. Pulse versus continuous terbinafine for onychomycosis: a randomized, double-blind, controlled trial. J Am Acad Dermatol. 2005 Oct;53(4):578-84. 3. Ellis DH, Watson AB et al. Non-dermatophytes in onychomycosis of the toenails. J. Dermatol. 1997 PR. 136(4)490-3. 4. Bristow IR. The effectiveness of lasers in the treatment of onychomycosis: a systematic review. J Foot Ankle Res. 201 ; 7:34 . 5. Singa A , Khanna D. Onychomycosis: Diagnosis and management. IJDVL 2011. 77 (6)659-672. 6. Becker C, Bershow A. Lasers and photodynamic therapy in the treatment of onychomycosis: a review of the literature. J. Dermatol, 2013 19(9). GROSS DESCRIPTION

A. The specimen is received in a dry container labeled with the patient's name and designated "nails." It contains multiple pieces of tan nail that measure from <1x<1x<1 to 10x2x1 mm. The specimen is decalcified and processed in a single cassette. MICROSCOPIC DESCRIPTION

Complete microscopic examination is performed. The findings are included in the diagnosis rendered . Specimen A is evaluated with PAS and GMS stains for fungal organisms as well as a Fontana Masson stain for melanin pigment.

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88304 88311 88312 88313 CLINICIAN :

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