Pseudomonas infection of nail: Green nail syndrome secondary to onychomycosis

A 21-year-old female presented with a 3-month history of slowly progressive greenish-black discoloration of right middle fingernail and left ring fingernail, with distolateral onycholysis of both middle fingernails and left ring fingernail with proximal nontender paronychia of both middle fingernails [Figure 1]. There was mild pus discharge from undersurface of left middle fingernail as well.

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Figure 1:

Proximal greenish-black discoloration, distolateral onycholysis, and proximal paronychia seen over (a) both middle fingernails and left ring fingernail. (b) Close-up view of right middle fingernail. (c) Close-up view of left middle and ring fingernail. (d) Mild pus discharge from undersurface of left middle fingernail.

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Direct mycologic examination of nail scrapings was positive for fungal elements and bacteriologic examination of nail scrapings revealed Pseudomonas aeruginosa infection. She was prescribed itraconazole 200 mg/day 7 days per month for 2 months for fungal infection and oral ciprofloxacin 500 mg/day for 3 weeks for pseudomonas coverage. There was significant improvement on follow-up.

P. aeruginosa is the most common pathogen causing bacterial nail infections.^[1] Treatment options include topical gentamicin for 1-3 months or oral ciprofloxacin for 2-3 weeks.