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Pseudomonas Aeruginosa

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Sources from my proposal or sources I intend on using in the stub Green Nail Syndrome

Green Nail Syndrome (aka Chromonychia) is a bacterial nail infection that leads to the nail becoming discoloured and green in appearance (AOCD, 2019; Anderson & Regula, 2017;Chiriac et al., 2015;Clark & Davison, 2006).

It is most commonly caused by the bacteria “Pseudomonas Aeruginosa” (AOCD, 2019; Anderson & Regula, 2017; Chiriac et al., 2015; Matsuura et al., 2017), which thrives in moist conditions(Anderson & Regula, 2017). Green Nail Syndrome is linked to regular submergence of one’s hands in water, detergents and soils(Chiriac et al., 2015). There are several activities and injuries that are linked to predisposition in contracting the condition.

Table of contents

1.      Symptoms

2.      Diagnosis

3.      Causes

3.1 Predispositions

3.2 Bacteria

                 4. Treatment

                                   4.1 Medical Treatment

                                   4.2 Alternative Treatment

                                   4.3 Prevention

                 5. Patient Management and Prognosis

6. Case Studies and Data

1.    Symptoms

The most common symptom of Green Nail Syndrome is the discolouration of the infected nail as it turns a dark green colour, due to the bacteria secreting the green pigments Pyoverdin and Pyocyanin (AOCD, 2019; Anderson & Regula, 2017; Clark & Davison, 2006). The patient can also suffer from tenderness surrounding the infected nail along with redness and swelling (AOCD, 2019).

2.    Diagnosis

Diagnosis can typically be made from a physical examination of the nail. If necessary, a gram stain (Anderson & Regula, 2017) or bacteriological culture of nail scrapings (Anderson & Regula, 2017; Matsuura et al., 2017) can be performed in order to identify the presence of bacteria.

There are shortcomings however in conducting a culture because the infection can be present a distance from the nail site, and as a result return a false negative result (Anderson & Regula, 2017). A sample of infected nail can be submerged in distilled water to perform a pigment solubility test, within 24 hours the liquid will turn blue green in colour indicating the presence of Pseudomonas Aeruginosa (Anderson & Regula, 2017).

3.    Causes

Green Nail Syndrome is caused by exposing the nail to the bacterial organism, which leads to opportunistic infection (Anderson & Regula, 2017). These bacteria are typically found in water sources and soil. They grow and multiply rapidly in moist environments such as sinks, swimming pools and sponges (AOCD, 2019).

The seal between the nail and finger acts as a physical barrier to prevent this kind of infection, however hyperhydration or destruction of the epidermis can impair the barrier, allowing the colonization of the bacteria (Anderson & Regula, 2017).

It is possible for a patient to transfer Green Nail Syndrome from an infected nail to a non-infected nail via self-inoculation, in transferring the bacteria to a new infection site. (Anderson & Regula, 2017)

3.1  Predispositions

Those working in jobs requiring them to have their hands submerged in water or soil for prolonged periods of time on a regular basis (Anderson & Regula, 2017; Clark & Davison, 2006). These include housewives, dishwashers, bakers, barbers, medical personnel (Clark & Davison, 2006) and farmers. Patients in hospital for non-related issues have contracted the infection, indicating that Green Nail Syndrome can be a hospital acquired infection (Anderson & Regula, 2017).

The elderly (Chiriac et al., 2015) and people who have suffered trauma to a finger or nail are predisposed to contracting Green Nail Syndrome. Patients who are already suffering with nail diseases such as onycholysis and onychotillomania (Bardeli & Hengge, 2009) are at higher risk of contracting Green Nail Syndrome.

Predisposition to Green Nail Syndrome has also been linked to manicures, heat, dermatitis, ulcerations. Occlusions and excess sweating (Anderson & Regula, 2017). Higher risk of contracting the infection is also linked to soccer players and military personnel due to the prolonged periods of time in which they exercise while wear tight fitting shoes (AOCD, 2019) as well as immunosuppressed persons and those with weakened epidermis barrier.

3.2  Bacteria

Pseudomonas Aeruginosa (Anderson & Regula, 2017; Clark & Davison, 2006) species of bacteria are the most common causes of Green Nail Syndrome. Nail scrapings have identified Aspergillus (Anderson & Regula, 2017), Candida (Anderson & Regula, 2017; Clark & Davison, 2006) and Klebsiella Pneumoniae (Bardeli & Hengge, 2009) species present at the infected nail site. It is unsure whether these are causative organisms or simply coinfections alongside Pseudomonas Aeruginosa (Anderson & Regula, 2017).

4.    Treatment

Treatment for Green Nail Syndrome varies greatly depending on the severity of the infection and the length of time it has been present. There are many medically approved options when a patient is treated by a medical professional. For persons who are unable to seek medical help there are also alternative treatments that have been trialled successfully (Anderson & Regula, 2017).

4.1  Medical Treatment

There are several medical treatment options, depending on the severity of the infection and how long it has been present. The least invasive treatment includes soaking the nail in alcohol and regularly trimming the nail back (Clark & Davison, 2006), to dry out the area and prevent bacterial colonisation (Matsuura et al., 2017). Moderate cases of Green Nail Syndrome are prescribed topical antibiotics (silver sulfadiazine, gentamicin, ciprofloxacin, bacitracin and polymyxin B)(Matsuura et al., 2017) or oral antibiotics (ciprofloxacin) (Adigun, 2019; AOCD, 2019; Bardeli & Hengge, 2009; Matsuura et al., 2017), antiseptic creams (Adigun, 2019), tobramycin eye drops have also been reported to be effective. In severe cases, surgical removal of the infected nail may be required (Adigun, 2019; AOCD, 2019; Matsuura et al., 2017). The patient should always avoid further trauma to the infected nail regardless of the stage of treatment they received (AOCD, 2019).

4.2   Alternative treatments

Some at-home treatments have been successfully trialled in treating mild cases of Green Nail Syndrome. Soaking the nails in vinegar or a chlorine bleach solution (diluted with water 1:4) at regular intervals can be used when medical help is not accessible to the patient (AOCD, 2019).

4.3   Prevention

Preventative measures should be implemented by those who are most at risk of contracting Green Nail Syndrome due to their predisposition or lifestyle/workplace choices. Wearing waterproof gloves or gum boots can be effective in preventing prolonged exposure of the nails to water (Anderson & Regula, 2017). Avoiding trauma that could lead to the destruction of the epidermis seal is on the nails is a priority in preventing green nail syndrome recurrences (Anderson & Regula, 2017).

5.    Patient Management and Recovery

In mild to moderate cases, where the infection clears with minimal medical intervention, the patient should ensure the nail is kept clean and dry and avoid hyperhydration. Humid climates could lead to a longer recovery than dry climes due to inability to expose the site to very dry air (Anderson & Regula, 2017). In cases where surgery is necessary, patients should follow their medical professional’s post-surgery advice.

6.    Cases/Medical Data

Green Nail Syndrome can be misdiagnosed with Aspergillus infections, Malignant melanoma, Subungual hematomas (Clark & Davison, 2006). The use of green dye, paint or chemical lacquers can also lead to confusion (Clark & Davison, 2006).

There have been cases where a Basel Cell Carcinoma has been present in conjunction with Green Nail Syndrome (Anderson & Regula, 2017).

Medical professionals with Green Nail Syndrome have been reported to have transferred the infection to patients in hospitals (Anderson & Regula, 2017).

References:

Adigun, C., (2019). Green Nail Syndrome. NJ, USA: Merck and Co. Available at: https://www.msdmanuals.com/en-au/home/skin-disorders/nail-disorders/green-nail-syndrome

American Osteopathic College of Dermatology. (2019). Green Nail Syndrome. Available at: https://cdn.ymaws.com/www.aocd.org/resource/resmgr/patientresources/1/GREEN_NAIL_SYNDROME.pdf

Anderson, B. and Regula, C., (2017). Green Nail Syndrome: GNS, Pseudomonas Nail Infection, Chloronychia, Green Striped Nails, Chromonychia. Dermatology Advisor. Available at: <https://www.dermatologyadvisor.com/home/decision-support-in-medicine/dermatology/green-nail-syndrome-gns-pseudomonas-nail-infection-chloronychia-green-striped-nails-chromonychia/>

Bardeli, V., & Hengge, U. (2009). Green Nails: Images in Clinical Medicine. The New England Journal of Medicine. Available at: https://www.nejm.org/doi/pdf/10.1056/NEJMicm0706497

Chiriac, A., et al. (2015). Chloronychia: Green nail syndrome caused by Pseudomonas aeruginosa in elderly persons. Clinical Intervention Aging.

https://doi.org/10.2147/CIA.S75525

Clark, K., & Davison, L. (2006). Green Nail Syndrome. NJ, USA: MJH Healthcare holdings LLC. Available at: https://www.patientcareonline.com/infection/green-nail-syndrome

Matsuura, H., et al. (2017). Green nail syndrome:  An International Journal of Medicine. https://doi.org/10.1093/qjmed/hcx114

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