It
was my first day shadowing the clinical director of a local clinic. Since this was my first experience my main
focus was just not to say anything too obviously ignorant. So when the doctor turns to me to give me the
patient’s information before we see them and says, “looks like we’ve got one
with chronic onychomycosis and will be needing surgical removal,” my mind began
to spin as this is a general internal medicine clinic. What kind of surgery could we be doing and what
was that word he just said? Was that
even English?
We
enter the patient’s room and let me tell you, onychomycosis is the euphemism
for toenail fungus. The patient had been
trying oral antifungals for several months and the fungus was still invading
the nail bed. In otherwise healthy
individuals this type of fungal infection is more unsightly and a nuisance than
anything but for those with diabetes or serious immune deficiencies it can lead
to other complications. After explaining
the treatment options to the patient I was able to watch my first surgical
procedure. The physician actually removed
the nail completely then used an acidic chemical on the cuticle to prevent nail
regrowth as well as applied a topical antifungal to the nail bed.
After
leaving the patient’s room I had many questions. The primary question being, why is it that
hard to treat a toenail infection, and suddenly the newly formed immunology
student kicked in. Obviously we have learned that the immune system has
specific cells that can identify fungal antigens, however the toenail is not
easily flooded by blood flow making it difficult for an immune response to
occur or for antifungal medications to access.
This is usually why oral medications can take months to be effective and
why treatment is usually needed in general.
Recently
there has been four laser systems approved by the FDA to treat onychomycosis
and may prove to be a substantial advantage over pharmacotherapy (Gupta &
Simpson 429). None the less, for my
first shadowing experience it was great to have
a patient that allowed me to have something to blog about!
Gupta,
A., & Simpson, F. “Newly Approved
Laser Systems for Onychomycosis.”
Journal of the American
Podiatric Medical Association. 2012: 102: 428-429.
Herranz,
P., Garcia, J., De Lucas, R., Gonzalex, J., Pena, J., Diaz, R., & Casado,
M.
“Toenail onychomycosis in patients with acquired immune
deficiency syndrome: treatment with terbinafine.” British founuil of
Denmitolo. 1997: 137: 577-580.
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I had the same kind of experience. Some doctors just think you're on the same level and you are a deer in the headlights when they say a complicated procedure. Then your physiology knowledge kicks in, and you kind of get an idea of what language their speaking. On a complete opposite note, I once had a serious nail infection, and at first they thought it was a fungal infection. I was so freaked out when they told me the procedure to rip out my fingernail, thank the lord they figured out it was a staph. I'll take prescriptions over getting body parts ripped out of me any day.
ReplyDeleteI could certainly see the lack of blood flow being an issue, but I do believe that we have skin surface defenses to fungal infections. I wonder if there are less on the toe-nail bed because the nail is there to cover it and when exposed we become more susceptible? I only suggest this because I have heard of more fungal infections in toe-nail beds than any other location on the body.
ReplyDeleteAlso after looking into the immune response to fungal infection, I found that the primary responder is cell-mediated immunity (T-cell, particularly Th1) as opposed to humoral immunity (b-cell/antibodies). I wonder why this is. Any suggestions?
Off the top of my head, I wonder whether big tough fungus requires something big and mean like M1 macrophages attracted by Th1, not dainty little neutrophils?
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