Comparison of Fungal Fluorescent Staining and ITS rDNA PCR-based Sequencing with Conventional Methods for Diagnosis of Onychomycosis

Accurate identification of fungal causes for onychomycosis is essential for proper treatment. Presently available laboratory methods show unreliable sensitivity; so there is a requirement for innovative detection techniques. The aim for this work was to assess the efficiencies of fluorescent staining and internal transcribed spacer (ITS) ribosomal DNA (rDNA) polymerase chain reaction (PCR)-based sequencing in comparison to conventional techniques for diagnosis of onychomycosis. Nail specimens obtained from 100 patients with clinically- diagnosed onychomycosis were analyzed. Nail scrapings or clippings were subjected to direct microscopic examination by KOH mount, culture by using Sabouraud's dextrose agar and histopathological examination with periodic-acid Schiff (PAS). Collected specimens were subsequently examined by fluorescent staining and PCR-based sequencing (30 specimens only) to compare the feasibility, sensitivity and diagnostic accuracy for these two methods. The most frequently isolated fungi were yeasts (39/76: 51.3%), dermatophytes (24/76; 31.6%) and non-dermatophyte molds (NDMs) (13/76; 17.1%). Mixed mycotic infections were recovered from 6% of the collected nail specimens. The positive detection rates were significantly different between KOH examinations (52%), nail plate histology (55%), fungal culture (70%) and fluorescent staining (80%). Considering fungal culture as the gold standard, the most sensitive technique was PCR (100%) followed by fluorescent staining (89%), PAS staining (69%) while the least sensitive technique was KOH mount (53%). Fluorescence staining can be used as a rapid and high-yield technique for identification of fungi in the specimens. PCR-based sequencing was highly sensitive and faster compared to culture. Whenever possible, it enables species identification with higher adequacy.