A 33-year-old man seeks attention for his abnormal toenails, having already failed full treatment courses of both terbinafine and itraconazole. Review of systems reveals complaints of painful “eye irritation” as well as chronic low back pain severe enough to warrant daily ingestion of aspirin. What diagnoses in addition to onychomycosis would you consider given this picture?
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Case and photo courtesy of Ted Rosen, MD
While there are certainly treatment failures, onychomycosis (the presumptive diagnosis) usually responds to one or the other of the approved antifungal agents. Thus, alternative diagnostic considerations must be entertained. What disorders figure into your differential?
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