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Modified PAS stain: A new diagnostic method for onychomycosis
Examen directo teñido con PAS: un nuevo método diagnóstico de la onicomicosis
Tamar Hajara,
, Ramon Fernández-Martínezb, Gabriela Moreno-Coutiñob, Elsa Vásquez del Mercadob, Roberto Arenasc
Corresponding author
a Dermatology Resident, General Hospital “Dr. Manuel Gea González”, Clazada de Tlalpan 4800, Sección XVI, CP 14080 México City, Mexico
b Mycology Section Attending Physician, General Hospital “Dr. Manuel Gea González”, Clazada de Tlalpan 4800, Sección XVI, CP 14080 México City, Mexico
c Head of the Mycology Section, General Hospital “Dr. Manuel Gea González”, Clazada de Tlalpan 4800, Sección XVI, CP 14080 México City, Mexico
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The sample is obtained by scraping the subungueal hyperkeratotic area of the affected nail, placed on a slide with KOH/CB and then observed with light microscopy (10× and 40×).<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6,14</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The rest of the scales are placed in a Sabouraud with cycloheximide medium for culture. This procedure is considered the gold standard for species identification.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">5,15,16</span></a> The most widely used diagnostic methods are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Other available diagnostic methods are biopsies in different variants such as nail clipping, nail plate punch or keratin biopsy, where the collected samples are processed in the same way as skin samples, and stained with PAS. These are excellent methods but not easy to perform.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Diagnostic accuracy is important because oral antimycotic treatment is lengthy, expensive and significant drug interactions can occur. The currently employed methods do not offer enough specificity and sensitivity for the diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">7,15</span></a> The objective of this study was to create a new method for the diagnosis of onychomycosis, and compare its sensitivity and specificity with those of the current methods.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Materials and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">We designed a new diagnostic procedure that consists of taking a sample obtained by scraping the subungueal hyperkeratotic area of the affected nail, fixating it on a slide with nitrocellulose–toluene–formaldehyde (transparent nail polish), and then staining the sample with PAS (M-PAS) in the histology department. PAS stain was performed in the usual manner: the slides were oxidized in 0.5% periodic acid solution for 5<span class="elsevierStyleHsp" style=""></span>min, rinsed in distilled water, placed in Schiff reagent for 15<span class="elsevierStyleHsp" style=""></span>min, washed in lukewarm tap water for 5<span class="elsevierStyleHsp" style=""></span>min, counterstained in hematoxylin for 1<span class="elsevierStyleHsp" style=""></span>min, washed in tap water for 5<span class="elsevierStyleHsp" style=""></span>min, and finally coverslipped using a synthetic mounting medium.</p><p id="par0035" class="elsevierStylePara elsevierViewall">These slides were observed in light microscopy at 10×, 20× and 100× by an experienced mycologist that was blinded to the results obtained in the routine tests, KOH/CB and culture.</p><p id="par0040" class="elsevierStylePara elsevierViewall">We considered as inclusion criteria samples of patients that had the enough material for the three studies (M-PAS, KOH/CB, and culture), with clinical suspicion of onychomycosis that were referred to the mycology section of our hospital for a routine workup for onychomycosis diagnosis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The exclusion criteria included those patients that had received topical or systemic treatment 1 or 3 months before taking the sample, respectively, and those with other ungueal diagnoses such as lichen planus, psoriasis, or traumatic dystrophy.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The elimination criteria were the loss of a sample during any of the proceedings involved.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Every culture was performed on BBL Mycosel Agar (Becton Dickinson and Company, Sparks, MD, USA), and incubated up to 4 weeks. If a colony developed, the macroscopic and microscopic characteristics were analyzed to determine the fungal species. We considered a positive result when fungal structures were identified.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The KOH/CB test was accomplished in the usual manner. This test was considered positive when fungal structures such as hyphae or spores were visualized.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The M-PAS stain exam was performed as follows: (i) the slide was properly marked with an identification number; (ii) nitrocellulose–toluene–formaldehyde was applied to the slide, in a enough amount for the scale to adhere; (iii) part of the subungueal hyperkeratotic sample was placed on top of the nitrocellulose–toluene–formaldehyde; (iv) after the sample had dried (about 5<span class="elsevierStyleHsp" style=""></span>min) it was sent to the histopathology department for PAS staining; (v) the sample was considered positive if hyphae or spores were observed.</p><p id="par0070" class="elsevierStylePara elsevierViewall">For the evaluation of the sensitivity and specificity, we considered culture together with KOH/CB as the gold standard for comparison, based on the fact that these two methods are sensitive and specific when performed in combination and evaluated by trained personnel. Moreover, these are the two methods we use as routine diagnostic tests for onychomycosis.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The diagnosis of onychomycosis was made when one or more of the three diagnostic tests were positive.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">We included 192 samples of patients with clinical suspicion of onychomycosis. All of them underwent the three diagnostic methods. One hundred and fifty-two (79.2%) were positive in at least one of the tests.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In the slides with M-PAS, fungal structures were shown in 143 samples out of the 152 that were positive (94%) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Nine samples were false negative with the PAS stain (5.9%), but resulted positive with KOH/CB. In the slides studied with KOH/CB we found 113 positive samples out of 152 (73.8%). Thirty-nine false negative samples with KOH/CB (25.6%) were exclusively positive with the PAS stain (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Sensitivity and specificity were estimated in 92.5% and 55.55%, respectively. We obtained 35 positive cultures from the 152 positive cases (23%). <span class="elsevierStyleItalic">Trichophyton rubrum</span> was the etiologic agent in 77% of the isolates (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">In the pursuit of simplifying the diagnosis we created a new procedure that is a combination of the existing techniques for the observation of fungal structures. This procedure proved to have a high sensitivity and feasibility, as well as low cost. The good cost–benefit of this diagnostic test is confirmed with the fact that the approximate cost of this diagnostic method is less than 1 US dollar.</p><p id="par0095" class="elsevierStylePara elsevierViewall">We found that M-PAS has a sensitivity of 92.5% and a specificity of 55.55%, whereas KOH/CB has 75% sensitivity and 72% specificity.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> The low specificity of our procedure is due to the false negative results in the KOH/CB group.</p><p id="par0100" class="elsevierStylePara elsevierViewall">This technique allowed us to make the diagnosis in 39 cases (25.6%) that were false negative with the routine diagnostic tests. Therefore, we consider that these findings are of great benefit for those patients and represent a new feasible option for routine diagnosis.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Onychomycosis is a common condition in the medical practice<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> and although the clinical picture can be very suggestive of the diagnosis, this should be confirmed by any of the routine methods before starting any treatment, particularly if it will be systemic, since antimycotic drugs can have adverse effects, possible drug interactions and are expensive.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> The routine methods used in our hospital for the diagnosis of onychomycosis are KOH/CB, that has a reported sensitivity between 75 and 80%,<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8,15</span></a> and culture, that has a low sensitivity for the identification of dermatophytes, and usually have false negative results in up to 60% of the cases.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">13,14</span></a> The high frequency of false negative results made us conceive a new diagnostic procedure that would be easy, fast, low-cost and with high sensitivity. Multiple studies report that when the routine methods are negative but the clinical picture is suggestive, a histological analysis either by a punch biopsy or nail-clipping specimens stained with PAS are indicated because this is a reliable method with a high reported sensitivity 80.8–92%<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8,15</span></a> However, it is technically demanding, invasive and can have morbidity if performed by inexperienced personnel, is time consuming and more expensive than the routine tests.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The keratin biopsy described by Chang et al. is a technique in which the subungueal hyperkeratosis is analyzed in the same way a skin biopsy is, and better results are reported (97% of positivity) when compared with a PAS stained nail clipping biopsy.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3,9,10,13</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The limitations for our diagnostic procedure are that this method requires a histopathology department, a qualified histology technician, and a trained observer. The quality of the sample will also determine the sensitivity and specificity of the test.</p><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion, our recommendation is to perform this test only when the routine methods are negative and the clinical picture is highly suggestive.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Financial disclosure</span><p id="par0130" class="elsevierStylePara elsevierViewall">This work was funded by the first place award of the <span class="elsevierStyleGrantSponsor" id="gs1">Foundation La Roche Posay Latin-America</span> for researcher dermatologists.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">All authors agree that no conflict of interest exists for the publication of this paper.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres600213" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Aims" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec614539" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres600214" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec614538" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Materials and methods" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Results" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Financial disclosure" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 9 => array:2 [ "identificador" => "xack202153" "titulo" => "Acknowledgments" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-06-13" "fechaAceptado" => "2014-10-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec614539" "palabras" => array:3 [ 0 => "Mycology" 1 => "Diagnosis" 2 => "Onychomycosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec614538" "palabras" => array:3 [ 0 => "Micología" 1 => "Diagnóstico" 2 => "Onicomicosis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Onychomycosis is the most common nail disease and represents around 50% of nail disorders. Accurate diagnosis with adequate evidence is ideal before starting any treatment. Current diagnostic methods offer low specificity and sensitivity.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Aims</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To create a new method for the diagnosis of onychomycosis, and to compare its sensitivity and specificity with the existing methods.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">One hundred and ninety-two samples with clinical suspicion of onychomycosis were included and underwent modified PAS stain (M-PAS), KOH/chlorazol black (KOH/CB) and culture testing. Sensitivity, specificity, positive and negative predictive values were calculated.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In 152 out of 192 samples (79.2%) fungi structures were found in at least one of the three tests performed, and the patients were diagnosed with onychomycosis; 40 samples out of 192 (20.8%) were negative. Using M-PAS, filaments and/or spores were seen in 143 samples from the 152 positive (94%); 39 of them were negative to KOH/CB and positive to M-PAS (25.6%). With KOH/CB, filaments and/or spores were seen in 113 cases from the 152 positive samples (73.8% of the onychomycosis cases). Thirty-five cultures were positive, of which 77% were identified as <span class="elsevierStyleItalic">Trichophyton rubrum</span>; 117 onychomycosis cases were diagnosed despite the negative culture (76.9%). M-PAS showed 92.5% sensitivity and 55.55% specificity, a 67.5% positive predictive value and a 81.6% negative productive value.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">This procedure, a combination of the existing methods to diagnose onychomycosis, KOH/CB together with a nail clipping biopsy, proved to have high sensitivity, as well as being rapid, easy, inexpensive and readily available in most hospital settings. M-PAS allowed us to diagnose 39 cases (25.6% of the cases of onychomycosis) that were false negative using only KOH/CB and culture.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Aims" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La onicomicosis es la enfermedad más común de las uñas y representa un 50% del total de las enfermedades que afectan a esta parte del cuerpo. Antes de iniciar un tratamiento, es muy recomendable contar con un diagnóstico preciso y pruebas suficientes. En la actualidad, los métodos diagnósticos ofrecen una sensibilidad y especificidad bajas.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Crear un nuevo método de diagnóstico de la onicomicosis y comparar su sensibilidad y especificidad con los métodos diagnósticos existentes.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Métodos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se recogieron ciento noventa y dos muestras con sospecha clínica de onicomicosis en las que se aplicaron las pruebas de examen directo con KOH/Negro de clorazol (KOH/CB), cultivo y examen directo teñido con PAS (M-PAS). Se calcularon la sensibilidad, la especificidad, y los valores predictivos positivo y negativo.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">En 152 de las 192 muestras (79,2%) se hallaron estructuras micóticas en una de las tres pruebas realizadas como mínimo, y se diagnosticó onicomicosis en dichos pacientes; 40 de las 192 muestras (20,8%) dieron resultados negativos. Mediante M-PAS, se observaron filamentos o esporas en 143 de las 152 muestras (94%); 39 de ellas resultaron negativas con KOH/CB y positivas con M-PAS (25,6%). En el caso de KOH/CB, se observaron filamentos o esporas en 113 de las 152 muestras, (73,8% de los casos de onicomicosis). Treinta y cinco cultivos dieron resultados positivos, conel 77% de los aislamientos obtenidos identificados como <span class="elsevierStyleItalic">Trichophyton rubrum</span>; se diagnosticaron 117 casos de onicomicosis a pesar de los resultados negativos en el cultivo (76,9%). La sensibilidad de M-PAS fue del 92,5%, la especificidad del 55,55%, y los valores predictivos positivo y negativo de 67,5% y 81,6%, respectivamente.</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Este procedimiento, una fusión de métodos ya existentes para el diagnóstico de la onicomicosis, que aplica KOH/CB junto con una biopsia de fragmentos de uña, mostró una gran sensibilidad. Es además un método rápido, fácil, económico y disponible en la mayoría de los ámbitos hospitalarios. M-PAS permitió diagnosticar 39 casos (25,6% de los pacientes con onicomicosis) con resultados falsos negativos al utilizar únicamente KOH/CB y cultivo.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 490 "Ancho" => 1400 "Tamanyo" => 168637 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Fungal hyphae with PAS stain: A (10×) and B (100×).</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">NA, not available.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sensitivity (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Specificity (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">KOH/CB<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8,15</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75–80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Culture<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">15,16</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">82 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Nail clipping biopsy<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8,15,16</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80–92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Nail plate punch biopsy<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Keratin biopsy<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NA \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab982061.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Comparison of traditional diagnostic methods.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">KOH/CB+ \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">KOH/CB- \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">PAS + \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">104 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">143 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">PAS − \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">113 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">192 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab982063.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Sensitivity and specificity.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Etiologic agents \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Number of patients (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Trichophyton rubrum</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (74.28%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">T. rubrum</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">+</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Candida</span> sp. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2.85%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Trichophyton mentagrophytes</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (5.71%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Candida</span> spp. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (17.14%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab982062.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Etiologic agents.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Micologia medica ilustrada" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R. Arenas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "edicion" => "3cera edicion ed." "fecha" => "2008" "editorial" => "McGraw Hill" "editorialLocalizacion" => "Mexico" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0090" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Las onicomicosis. Aspectos clínicos, epidemiológicos, micológicos y terapéuticos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 67 | 13 | 80 |
| 2024 September | 83 | 16 | 99 |
| 2024 August | 99 | 33 | 132 |
| 2024 July | 122 | 13 | 135 |
| 2024 June | 129 | 8 | 137 |
| 2024 May | 131 | 10 | 141 |
| 2024 April | 129 | 11 | 140 |
| 2024 March | 132 | 6 | 138 |
| 2024 February | 108 | 7 | 115 |
| 2024 January | 125 | 10 | 135 |
| 2023 December | 97 | 5 | 102 |
| 2023 November | 105 | 6 | 111 |
| 2023 October | 99 | 11 | 110 |
| 2023 September | 87 | 8 | 95 |
| 2023 August | 75 | 6 | 81 |
| 2023 July | 63 | 7 | 70 |
| 2023 June | 58 | 6 | 64 |
| 2023 May | 81 | 11 | 92 |
| 2023 April | 86 | 3 | 89 |
| 2023 March | 77 | 16 | 93 |
| 2023 February | 85 | 9 | 94 |
| 2023 January | 66 | 7 | 73 |
| 2022 December | 75 | 9 | 84 |
| 2022 November | 114 | 17 | 131 |
| 2022 October | 76 | 18 | 94 |
| 2022 September | 93 | 10 | 103 |
| 2022 August | 76 | 18 | 94 |
| 2022 July | 59 | 11 | 70 |
| 2022 June | 50 | 7 | 57 |
| 2022 May | 67 | 20 | 87 |
| 2022 April | 85 | 23 | 108 |
| 2022 March | 83 | 13 | 96 |
| 2022 February | 64 | 12 | 76 |
| 2022 January | 106 | 14 | 120 |
| 2021 December | 87 | 25 | 112 |
| 2021 November | 88 | 10 | 98 |
| 2021 October | 93 | 19 | 112 |
| 2021 September | 149 | 22 | 171 |
| 2021 August | 82 | 14 | 96 |
| 2021 July | 49 | 14 | 63 |
| 2021 June | 48 | 9 | 57 |
| 2021 May | 59 | 8 | 67 |
| 2021 April | 290 | 37 | 327 |
| 2021 March | 95 | 11 | 106 |
| 2021 February | 80 | 11 | 91 |
| 2021 January | 78 | 17 | 95 |
| 2020 December | 58 | 17 | 75 |
| 2020 November | 56 | 23 | 79 |
| 2020 October | 42 | 14 | 56 |
| 2020 September | 42 | 17 | 59 |
| 2020 August | 68 | 13 | 81 |
| 2020 July | 47 | 9 | 56 |
| 2020 June | 47 | 16 | 63 |
| 2020 May | 57 | 13 | 70 |
| 2020 April | 76 | 10 | 86 |
| 2020 March | 75 | 15 | 90 |
| 2020 February | 73 | 17 | 90 |
| 2020 January | 64 | 24 | 88 |
| 2019 December | 71 | 18 | 89 |
| 2019 November | 54 | 34 | 88 |
| 2019 October | 64 | 13 | 77 |
| 2019 September | 72 | 18 | 90 |
| 2019 August | 57 | 24 | 81 |
| 2019 July | 63 | 21 | 84 |
| 2019 June | 96 | 24 | 120 |
| 2019 May | 172 | 56 | 228 |
| 2019 April | 118 | 9 | 127 |
| 2019 March | 36 | 11 | 47 |
| 2019 February | 45 | 13 | 58 |
| 2019 January | 36 | 3 | 39 |
| 2018 December | 46 | 14 | 60 |
| 2018 November | 49 | 8 | 57 |
| 2018 October | 49 | 13 | 62 |
| 2018 September | 29 | 4 | 33 |
| 2018 August | 25 | 2 | 27 |
| 2018 July | 19 | 5 | 24 |
| 2018 June | 28 | 1 | 29 |
| 2018 May | 19 | 10 | 29 |
| 2018 April | 22 | 3 | 25 |
| 2018 March | 13 | 4 | 17 |
| 2018 February | 12 | 0 | 12 |
| 2018 January | 12 | 3 | 15 |
| 2017 December | 15 | 2 | 17 |
| 2017 November | 17 | 5 | 22 |
| 2017 October | 22 | 4 | 26 |
| 2017 September | 11 | 12 | 23 |
| 2017 August | 13 | 22 | 35 |
| 2017 July | 16 | 27 | 43 |
| 2017 June | 24 | 26 | 50 |
| 2017 May | 35 | 7 | 42 |
| 2017 April | 18 | 13 | 31 |
| 2017 March | 18 | 40 | 58 |
| 2017 February | 28 | 5 | 33 |
| 2017 January | 23 | 10 | 33 |
| 2016 December | 40 | 9 | 49 |
| 2016 November | 25 | 13 | 38 |
| 2016 October | 41 | 17 | 58 |
| 2016 September | 44 | 8 | 52 |
| 2016 August | 33 | 5 | 38 |
| 2016 July | 27 | 15 | 42 |
| 2016 April | 0 | 1 | 1 |
| 2016 March | 0 | 1 | 1 |
| 2016 February | 3 | 2 | 5 |
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