Pseudomonas aeruginosa and Burkholderia cepacia complex co-infection in green nail syndrome: a case report

Green nail syndrome (GNS) is classically characterized by a triad of green nail discoloration, paronychia, and onycholysis. Although <i>Pseudomonas aeruginosa</i> (<i>P. aeruginosa</i>) is the primary etiologic agent, infections involving co-pathogens are uncommon and pose considerable diagnostic and therapeutic challenges due to the absence of standardized management guidelines. We herein report a rare case of GNS caused by a co-infection with <i>P. aeruginosa</i> and the <i>Burkholderia cepacia</i> complex (BCC) in a woman with a history of manicures and frequent domestic exposure to water and detergents. The diagnosis was confirmed through bacterial culture and antimicrobial susceptibility testing. Targeted therapy involving a combination of oral and topical levofloxacin, guided by the antimicrobial susceptibility profile, resulted in the successful resolution of the infection. This case underscores the critical importance of microbiological identification for guiding effective treatment of non-classical GNS and demonstrates the efficacy of tailored antibiotic regimens in managing complex co-infections.