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Epidermophyton. Onychomycosis is an infection in which fungal organisms invade the nail bed and is the most common nail disorder. It accounts for nearly 50% of all nail problems. Its prevalence in the general population ranges from 2% to 14%. This infection causes progressive changes in the color, structure, and texture of the nail. It rarely resolves spontaneously, and, even with treatment, it may take months to years to clear. Figures 8-115 and 8-116 show examples of distal and lateral subungual onychomycosis, the most common form of nail infection, caused by Trichophyton rubrum. Onychomycosis results in inflammation of the nail bed, which promotes hyperkeratosis of the nail bed epithelium and thickening. This may cause a lifting up of the nail plate, as shown in Figure 8-117.

On September 11, 2001, the country and world changed. As a result of the events of that day and the events afterwards, everyone must be aware of the possibility of terrorist activity. Health-care workers must be alert to illness patterns caused by possible acts of terrorism. If you suspect an incident of biologic, chemical, or radiologic terrorism, contact your local state

Figure 8-114 Cutaneous manifestations of -

acquired immunodeficiency syndrome (AIDS). Figure 8-115 Subungual onychomycosis.

Figure 8-114 Cutaneous manifestations of -

acquired immunodeficiency syndrome (AIDS). Figure 8-115 Subungual onychomycosis.

Figure 8-116 Subungual onychomycosis.

department of health immediately, as well as the Hotline for the Bioterrorism Preparedness and Response Program of the Centers for Disease Control and Prevention at 770-488-7100 or at www.cdc.gov.

Several of the biologic agents that have been associated with possible terrorist attacks have dermatologic signs;they are anthrax, smallpox, and plague.

Anthrax (from the Greek anthrax, meaning ''coal'') is a disease caused by the spore-forming Bacillus anthracis. Anthrax occurs in three forms: cutaneous (95%), inhalational (5%), and gastrointestinal and oropharyngeal (extremely rare). In the most common cutaneous form, typically, several days after exposure, a raised, inflamed, painless, pruritic papule appears within 1 day. The papule enlarges to approximately 1 to 3 cm, and vesicles may develop around the lesion (Fig. 8-118). Extensive edema of the area is common (Fig. 8-119). Adjacent lymph nodes become swollen and may become tender. The vesicles enlarge and rupture to form an ulcer, with the formation of a tough, adherent, black scab, or eschar, which forms in the center of the developing lesion (Fig. 8-120). In 1 to 2 weeks, the lesion dries with the separation of the eschar, leaving a permanent scar. The mortality rate ranges from 20% if the disease is untreated to very low if treated.

Figure 8-119 Anthrax. Note the early lesion and marked edema.
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