Supplementary Material for: Green nail syndrome treated with ozenoxacin: two case reports

Green nail syndrome (GNS) is a persistent greenish pigmentation of the nail plate, originally described in 1944 by Goldman and Fox, due to Pseudomonas aeruginosa infection. Recently, pulmonary co-infection of P. aeruginosa and Achromobacter spp. have been described in patients with cystic fibrosis. Achromobacter xylosoxidans is a multidrug-resistant (MDR) pathogen involved in lung and soft tissue skin infections. Both Achromobacter xylosoxidans and P. aeruginosa are mainly found in humid environments or in water. There are no recognized co-infections due to P. aeruginosa and A. xylosoxidans in the skin and appendages. We describe two cases of GNS, the first due to P. aeruginosa associated with Achromobacter xylosoxidans; the other due to MDR P. aeruginosa, both successfully treated with topical ozenoxacin 1% cream daily for 12 weeks. The clinical management of GNS can be confusing, especially when the bacterial culture result is inconsistent or when non-Pseudomonas bacteria are isolated. In our case, due to the co-infection of P. aeruginosa and Achromobacter spp., local treatment with ozenoxacin - the first nonfluorinated quinolone - could be a safe and effective treatment in case of MDR nail infections. Further studies are required to evaluate clinical isolation from nail infections and the co-presence of P. aeruginosa and A. xylosoxidans.绿甲综合征（Green nail syndrome, GNS）是一种持续存在的甲板绿色色素沉着，最早由Goldman与Fox于1944年报道，其致病原因为铜绿假单胞菌（Pseudomonas aeruginosa）感染所致。近期有研究在囊性纤维化患者中报道了铜绿假单胞菌与无色杆菌属（Achromobacter spp.）的肺部合并感染。木糖氧化无色杆菌（Achromobacter xylosoxidans）是一种可引发肺部与软组织皮肤感染的多重耐药（MDR）病原体。铜绿假单胞菌与木糖氧化无色杆菌均主要分布于潮湿环境或水体中。目前尚无关于皮肤及其附属器合并铜绿假单胞菌与木糖氧化无色杆菌感染的公认报道。本文报道2例绿甲综合征病例：1例为铜绿假单胞菌合并木糖氧化无色杆菌感染，另1例为多重耐药铜绿假单胞菌感染；2例均通过每日外用1%奥泽沙星乳膏治疗12周后获得临床痊愈。绿甲综合征的临床诊疗常存在挑战，尤其当细菌培养结果不符，或分离出非假单胞菌属细菌时。针对本次研究中合并铜绿假单胞菌与无色杆菌属感染的病例，采用首个非氟化喹诺酮类药物奥泽沙星进行局部治疗，有望成为多重耐药甲部感染的安全有效治疗方案。未来仍需开展进一步研究，以明确甲部感染的临床病原菌分离情况，以及铜绿假单胞菌与木糖氧化无色杆菌的共感染现状。