Medical Mycology May 2007, 45, 279 282

Case Report

First Spanish case of onychomycosis caused by

Chaetomium globosum
CARMEN ASPIROZ*, JOSEPA GENÉ$, ANTONIO REZUSTA%, LUIS CHARLEZ§ & RICHARD C. SUMMERBELL’
*Microbiologı́a, Hospital Royo Villanova, Zaragoza, Spain, $Facultad de Medicina y Ciencias de la Salud, Unidad de
Microbiologı́a, Universidad Rovira i Virgili, Reus, Spain, %Microbiologı́a, Hospital Universitario Miguel Servet, Zaragoza, Spain,
§Dermatologı́a. Hospital Royo Villanova, Zaragoza, Spain, and ’Centraalbureau voor Schimmelcultures, Medical Mycology,
Utrecht, The Netherlands

Members of the fungal genus Chaetomium usually colonize cellulose-containing

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plant remains but on rare occasions may cause opportunistic mycoses and
cutaneous infection in otherwise healthy individuals. To our knowledge, there
have been only five credible descriptions of onychomycosis caused by members of
this genus and only two of these contained information on therapy. We describe the
first case of Chaetomium globosum onychomycosis recorded in Spain. The etiologic
significance of the fungus was confirmed by its repeated isolation at different times,
to the exclusion of dermatophytes. Clinically, the affected nails showed an excellent
response to terbinafine and complete cure appeared to have been attained.
For personal use only.

Keywords onychomycosis, Chaetomium globosum, toenail, Spain

Introduction Alternaria spp., black Scopulariopsis/Microascus species

Dermatophytes cause 80 90% of onychomycosis cases
(tinea unguium) in which Trichophyton rubrum and
Trichophyton interdigitale are the primary agents [1 3].
Yeasts have been implicated in 5 17% of onychomy-
coses, while non-dermatophytic filamentous fungi on
average cause 3 5% of cases. However, the latter group
may be involved in more cases of toenail infections in the
elderly [3 5]. The most frequent non-dermatophyte
agent of onychomycosis is Scopulariopsis brevicaulis,
but other moulds, such as albino strains of the recently
renamed [4] Neoscytalidium dimidiatum (formerly clas-
sified as a separate species, Scytalidium hyalinum ),
various Aspergillus species, certain species of Acre-
monium and Fusarium , and Onychocola canadensis
have been implicated [6,7]. Dematiaceous moulds in-
volved include N. dimidiatum (/Scytalidium dimidia-
tum, Nattrassia mangiferae, Hendersonula toruloidea ),
and Chaetomium globosum [6].
Chaetomium species have been reported as causal
agents of cerebral, pulmonary and disseminated infec-
tions of immunocompromised patients and intravenous
drug users, and have also been shown to infect nails of
otherwise healthy patients [8 13]. Members of this
genus have also been associated with indoor air quality
problems because of their allergenic potential [12].
C. globosum has been identified as the causal agent
of some cases of onychomycosis [10,14 17]. Chaeto-
mium spp. make up 0.3% of non-dermatophyte moulds
growing from nails of patients with an underlying
dermatophyte infection, but in these cases Chaetomium
spp. are considered to be nail surface contaminants of
no etiologic significance [18].
We report the first case of confirmed C. globosum
onychomycosis seen in Spain, which had a good clinical
response to terbinafine.

Received 11 July 2006; Accepted 7 December 2006 Case report

Correspondence: Carmen Aspiroz, Microbiologı́a, Hospital Royo
Villanova, Avenida San Gregorio, 30, 50015 Zaragoza, Spain. The patient, a 23-year-old white man who was other-
Fax: /34 976 466918. E-mail: caspiroz@ya.com wise healthy, had a four-year history of a repeatedly
– 2007 ISHAM DOI: 10.1080/13693780601164280
 280 Aspiroz et al.

agar (SDA, Oxoid, Basingstoke, Hampshire, UK)

yielded rapidly growing colonies after three days, which
appeared whitish at first but soon became dark grey
to brown. It should be emphasized [3] that the
two separate microscopic observations and cultures
(23 January 2004 and 6 February 2004) of the toenail
yielded identical mycological results. The count
of colonies in Sabouraud dextrose agar was 7 from
the first nail sample and 9 on SDA plates inoculated
with the second sample. However, at the same time
Mycobiotic and Taplin-DTM (dermatophyte test med-
ium, Oxoid, Basingstoke, Hampshire, UK) cultures
were negative. The organism recovered from both sets
of samples was identified as Chaetomium globosum
(Fig. 3) [19]. Living cultures of the case isolate were
Fig. 1 Great toenail. Subungual hyperkeratosis and a yellow brown
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deposited in the Faculty of Medicine, Reus, Spain, and

discoloration.
designated FMR 8583.
A third sample was taken while the patient was under
loosening nail (four episodes in four years: two treatment and a fourth sample was obtained after
spontaneous dehiscences and two surgical ablations).
He was an amateur football player and had a job that
required him to spend many hours on his feet. The
great toenail of his left foot showed subungual hyper-
keratotic thickening and yellow brown discoloration
(Fig. 1). All fingernails and the other nine toenails were
For personal use only.

normal and the surrounding skin was not affected. Toe

webs were normal, as were the feet. No indications of
tinea pedis were remarked by medical examiners or the
patient himself.
Samples of the nail and the fourth toe web space
were collected in the microbiology laboratory. On two
different occasions onychomycosis was diagnosed by
microscopic observation and culture. Hyaline, septate
filaments and irregular hyphae were seen in light
microscopy (Fig. 2). Culture on Sabouraud dextrose

Fig. 2 Potassium hydroxide mount of the infected nail showing Fig. 3 Chaetomium globosum (FMR 8583). Ascomata and ascos-
hyaline, septate filaments and irregular hyphae. pores.

– 2007 ISHAM, Medical Mycology, 45, 279 282


therapy. On these occasions (9 June 2004 and 23 July
2004), KOH preparations and cultures (SDA, Myco-
biotic and DTM) were negative.
In view of the laboratory results, the dermatologist
initiated a 12-week course of topical (spray) and oral
terbinafine therapy on 9 March 2004. At follow-up on
26 April 2004, the patient showed good clinical
progress and a decision was made to continue therapy
until the 12 week course was complete. On 9 June 2004,
the nail showed continued healing and finally, on 23
July 2004, the patient was seen with almost complete
clinical resolution. There was no evidence of fungal
relapse in a final follow-up examination in November
2004.
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Discussion
Chaetomium species are usually found in association
with cellulose-containing substrates such as wood,
straw and paper. They rarely cause disease in humans,
and reports of cutaneous infection have been particu-
larly sparse. To our knowledge, however, at least five
authors have reported Chaetomium onychomycosis
[10,1417]. Therapy was only documented in two of
these cases [15,16].
For personal use only.
Rippon stated that C. globosum was implicated in
three cases of onychomycosis from his clinic [17]. Costa
et al . [15] studied a 62-year-old woman with a
phaeohyphomycotic onychomycosis of the fingernails
caused by Chaetomium perpulchrum , a species currently
considered synonymous with Chaetomium brasiliense.
Naidu et al . [14] reported onychomycosis caused by
C. globosum in a patient from India. In the latter case,
the patient, a 26-year-old male, initially observed an
infection of the left index fingernail following minor
trauma. Later, the infection spread to the thumbnail,
and then to the third and fourth fingernails. No history
of underlying disease was found. Direct microscopic
examination of the nail sample in 40% KOH revealed
large numbers of light brown coloured hyphae bearing
thick-walled cells in chains [14], a type of presentation
seen in some cases of Chaetomium onychomycoses
[14 16] but not others [10, present case]. Stiller et al .
have suggested that Chaetomium species are variable in
the appearance in KOH mounts, as is Neoscytalidium
dimidiatum [10].
Since melanized filaments were not seen by direct
microscopy in specimens from our patient, we had to
methodically demonstrate through repeat microscopic
examinations and culturing that Chaetomium was the
cause of the onychomycosis. The repeated isolation in
culture from specimens taken on different dates was
particularly critical in confirming its etiologic role.
– 2007 ISHAM, Medical Mycology, 45, 279 282
First Spanish case of onychomycosis caused by C. globosum 281
In addition, the consistently heavy outgrowth seen in
both examinations strengthened our conclusion as to
the involvement of Chaetomium . As mentioned above,
successive microscopy and culture examination were
negative in two consecutive nail specimens obtained
in control visits after initiation of terbinafine. To the
best of our knowledge, ours is the first reported case of
infection caused by Chaetomium in the nails of
a patient in Spain, as well as the first report of clinical
success with terbinafine in a confirmed case of Chae-
tomium onychomycosis. Unfortunately, it was not
practical for us to conduct in vitro susceptibility test-
ing to terbinafine with the isolate recovered in this
case.
Full laboratory mycological diagnosis is justifiable to
optimize treatment as certain fungi are less responsive
than others to standard therapies. For example, toenail
infections caused by T. rubrum are well known to
respond differently than those caused by many non-
dermatophytes [20]. Cases of nail deformity similar in
appearance to onychomycosis and initially suspected as
such may be attributable exclusively to trauma, or less
frequently, to psoriasis, lichen planus, or peripheral
vascular disease. In such cases, negative laboratory
results are of considerable medical and economic value.
In the present case, the fact that the KOH was positive
and that C. globosum was repeatedly isolated, excludes
most differential diagnoses. In conclusion, we suggest
that KOH-positive, dystrophic nails that fail to yield
dermatophytic growth in cultures on selective media
(such as Dermatophyte Test Medium or Mycosel), and
that yield non-dermatophytic filamentous fungi, must
be studied with repeat specimens in order to asses the
value of isolates, their pathogenicity and their clinical
response to antifungal agents. Following this procedure
has allowed us to better understand the much-debated
category of etiologic agents encountered in atypical
onychomycoses.
Acknowledgements
This work was supported by a Fellowship from
CAI-CONAI Diputación General de Aragón, Spain.
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