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5865 N Michigan Rd
Indianapolis, IN 46228
Phone: (317) 255-3579
Fax: (317 255-3530)
Ed Rivera, MD
Skin Solutions
Columbus, IN

Dear Ed:

In reference to ]                 07-1746, right thumbnail:

I have reviewed her case carefully and found fungal spores some unusually larger than others in the nail matrix epithelium. The presence of different spore forms goes along with the clinical history that this patient has been previously treated with antifungal medication. The presence of fungal spores in this area causes irritation with subsequent development of a dystrophic nail.

According to my sources(encl.) this type of fungal infection may not be sencitive to first line antifungal medication but may requre second line treatment such as itraconazole. A fungal culture with sensitivity may be helpful.

Lastly, even though you indicated that this patient does not have mucocutaneous candidiasis, I belive it would be worthwhile to check for cell mediated immune deficiency: A CBC with diff to check for diabetes and perhaps a potassium as a screening test for Addison`s disease.

You will receive the original letter and references with the courier on Friday.

Best regards,

Pieter Wiersema, MD