Need reassurance – or redirection

A case posted to the IDS forum

age: 70 years, sex: m, location: acral

Clinical history: Gent seen a month ago and I’ve been pondering since. Am confident there is hemorrhage – no h/o trauma or tight shoes. Clipped “black” residue off free nail edge – hemoccult negative x 3. MicroHutchinson’s negative. What concerns me is that I can’t be sure this is ONLY blood, no underlying matrix melanoma.

Diagnosis: Hemorrhage – could this be hemorrhage associated with matrix melanoma?

Question: Does this gent need his matrix evaluated? Would nail removal and histology of the nail be helpful? How would you proceed? Thanks in advance.

cotm.2014.04.b cotm.2014.04.a

Comments:

Burns John: Agree with probable subungal hemorrhage. Would follow for the next 8 weeks and if you can’t see the tail end of this then would get more involved. Thx for the case.

Sergeev Yury: it could be a hemorrhage or bacterial or fungal (mold) contamination. try to get the material from the proximal part of the nail plate

Muir James: The nail is thickened and shows areas of superficial white onychomycosis. Haemoccult is the wrong test. Get your scalpel/clippers and pare out the black nail. Get as much as you can. Submit it for histology dry i.e. not in formalin. Ring your pathologist and explain what you are looking for. They should be able to look at it and say if it is blood or not. Also submit some of the scraped white area for fungal culture. The most likely thing is that this is a dystrophic nail secondary to age and fungal infection plus some haemorrhage. Could it be what you are worried about? Sure but I guess that is true of every sub ungual bleed. The trouble here is that this will take forever to grow out. At least if we can confirm if this is blood that will be reassuring.

Sergeev Yury: http://www.skinmaster.ru/536/Aspergillez_kak_oslozhnenie_dermatofitnogo_onikhomikoza/1791 case of contamination with Asp. niger. p.s.: there is a button on the top totranslate in english

Fox Gary: re: Hemoccult – thought I’d read that here(!) as a tip. Guess not. I’m convinced there is blood there, and no doubt onychomycosis. No need to treat asymptomatic onychomycosis in my view. My issue is 25% of nail matrix melanomas supposedly show hemorrhage, and onychomycosis is common and often incidental. So, if I pare to the point of pigmentation and send the dry flakes to path, and path “proves” blood, I’ve proved blood. Is that any more reassuring that there isn’t a matrix melanoma than just the clinical, which shows blood?

Baker Ron: Good point Gary. You don’t really prove much unless you go for the matrix. In my experience 70 year old men don’t care much about onychodystrophy or onychomycosis and don’t really want a nail like this physically attacked or treated with medication, as the nail does not cause them any pain or trouble except being a bit harder to clip and keep tidy. So I am with JB, I would simply observe, and would be willing to observe for quite a long time as long as the black area is not widening. But we don’t get sued for malpractice in NZ. Excellent pictures by the way.

Burns John: I hate this problem. My previous path, who I had great respect for, told me that staining nail clippings for melanin was relatively unpredictable and he didn’t recommend it. However, if it is positive then my concern would go up and if cost is not an issue this might be worth a try.

Baker Ron: Thanks for the reference Yury, I only just properly noticed it now, and read it. In that case the black did not go proximally right to the cuticle, but Gary’s case here could also be Aspergillus niger complicating a fungal nail. In which case the black will not move distally and may even widen with time, prompting action eventually, so Gary maybe you should go on a fishing expedition now for Aspergillus? Click on the US flag at the top to read it in English if you haven’t already.

Burns John: Semin Cutan Med Surg 29:148-158 2010. ” Pigmented onycho- mycosis, especially black superficial onychomycosis, is often the result of nondermatophyte dematiaceous molds, such as Scytalidium.35,36 This also produces true melanonychia in a manner of speaking. The microorganisms stain with Fontana stain, as their cell walls contain melanin (Fig.10). As this diagnosis cannot be made without the nail plate, in any case of melanonychia in which nail matrix or bed biopsy is performed, the nail plate should always be submitted as well.”

Fox Gary: Thank you all. Just like releasing a subungual hematoma, has anyone ever used battery cautery to “burn through” nail to obtain a longitudinal section for submission? I guess just getting out the old nail elevator, nail splitter, etc, and doing it the old fangled way is best.

Fox Gary: I’ve talked with the podiatrists down the hall who do toe matrix biopsies. They’ll bx, submit nail, section of matrix, and just give him a thinner toenail.

Fox Gary: Dx: Onychomycosis. The fungus exhibits uniform melanin pigmentation f its cell walls, and therefore likely represents a non-dermatophyte organism. While tissue culture would be required to classify this precisely, considerations could include Aspergillus niger or an environmental dematiaceous fungus….no increase in melanocytes within the nail matrix…

Baker Ron: But no blood reported, and Aspergillus niger will produce black….gold star for Yury!

 

Diagnosis: Onychomycosis – no melanocytic lesion

See also: Piraccini BM1, Balestri R, Starace M, Rech G Nail digital dermoscopy (onychoscopy) in the diagnosis of onychomycosis.

J Eur Acad Dermatol Venereol. 2013 Apr;27(4):509-13. doi: 10.1111/j.1468-3083.2011.04323.x. Epub 2011 Nov 1.