Tinea capitis outbreak among paediatric refugee population,an evolving healthcare challenge

Outbreaks of tinea capitis (TC) represent a major medical and economic burden. Population migrations have become a phenomenon of increasing relevance for medical conditions management. Given the recent massive arrival of immigrants, we sought to determine epidemiologic trends for TC among paediatric populations at the Tel Aviv Medical Center. We conducted a retrospective study of all TC cases diagnosed between 2010 and 2014 in a paediatric dermatology unit of a tertiary medical centre, serving as a referral centre for the paediatric refugee population from the great Tel Aviv area. Epidemiologic, clinical and treatment data including effectiveness and safety were reviewed. In all, 145 children met the inclusion criteria. Trend analyses showed increases in TC rates over the study period. Incidence rates were higher in boys than in girls. Children of African origin had the highest TC incidence rates as compared with other ethnic groups. Trichophyton violaceum and Microsporum audouinii were the predominant causative organisms. Treatment with griseofulvin was satisfactory in all cases. There was a significant increase in TC incidence rates in the Tel Aviv area over the study period. TV and MA were the predominant organisms. These trends may be a result of poor living conditions and crowded school premises.     

Screening for asymptomatic scalp carriage in household contacts of patients with tinea capitis during 1997–2011: a retrospective hospital‐based study

For anthropophilic tinea capitis (TC), household spread and asymptomatic scalp carriage (ASC) is considered an important route of transmission and incomplete clearance. To investigate ASC in household contacts of patients diagnosed with TC in a tertiary hospital in Athens, Greece, we retrospectively reviewed the medical files of household contacts that were screened for ASC from 1997 to 2011. Only 34 household contacts of 15 index cases agreed to come for screening. Thirty‐three (97%) household contacts were asymptomatic scalp carriers. The most commonly isolated species was Trichophyton violaceum (59%). There was a statistically significant association of ASC with the isolated dermatophyte species (T. violaceum, P‐value: 0.029), and with the age of younger than 16 years old (P‐value: 0.005), while there was no association with gender (P‐value: 0.672). A small number of household contacts accepted to proceed for screening. ASC was found in nearly all screened household contacts and was associated with T. violaceum and younger age. The low number of household contacts that accepted screening may reflect the ignorance of the general population about the possibility of ASC among household contacts in case of a patient with TC.     

Inflammatory tinea capitis mimicking dissecting cellulitis in a postpubertal male: a case report and review of the literature

Tinea capitis in postpubertal patients is unusual and may be misdiagnosed as dissecting cellulitis. We report a case of a healthy 19‐year‐old Hispanic male presenting with a 2‐month history of a large, painful subcutaneous boggy plaque on the scalp with patchy alopecia, erythematous papules, cysts and pustules. Although initially diagnosed as dissecting cellulitis, potassium hydroxide evaluation (KOH preparation) of the hair from the affected region was positive. A punch biopsy of the scalp demonstrated endothrix consistent with tinea capitis, but with a brisk, deep mixed inflammatory infiltrate as can be seen with chronic dissecting cellulitis. Fungal culture revealed Trichophyton tonsurans, and a diagnosis of inflammatory tinea capitis was made. The patient was treated over the course of 17 months with multiple systemic and topical antifungal medications, with slow, but demonstrable clinical and histopathological improvement. A rare diagnosis in adults, clinicians should have a high index of suspicion for this condition in an adult with an inflammatory scalp disorder not classic for dissecting cellulitis or with a recalcitrant dissecting cellulitis. Prompt, appropriate diagnosis and treatment is necessary to prevent the long‐term complications of scarring alopecia.     

Dermatophytosis and immunovirological status of HIV‐infected and AIDS patients from Sao Paulo city,Brazil

Over the past decades, more people became infected with human immunodeficiency virus (HIV) and developed acquired immunodeficiency syndrome (AIDS). Because of that the incidence of fungal infections rose dramatically. It happened because this virus can modify the course of fungal diseases, leading to altered clinical pictures. The aim of this study was to evaluate epidemiological and biological aspects of dermatophytosis in HIV‐positive and AIDS patients living in the city of São Paulo, Brazil. A total of 84 (44 HIV‐positive and 40 AIDS) patients were enrolled in this study. The patients were tested for dermatophyte infections, as well as for the CD4⁺/CD8⁺ and HIV viral load counts. Tinea unguium was most frequently observed in AIDS patients, whereas Tinea pedis was mostly observed in HIV‐positive patients. The most frequent dermatophyte species was Trichophyton rubrum. CD4⁺ counts and CD4⁺/CD8⁺ ratios were not associated with a higher risk for dermatophytosis. On the other hand, viral load higher than 100 000 copies/ml was associated with a higher frequency of dermatophytosis. The results suggest to that although dermatophytosis is common in HIV‐positive and AIDS patients, the degree of immunosuppression does not seems to correlate with increased risk of this fungal infection. In addition, high viral load as a predictive risk factor for dermatophyte infection should be subject of further evaluations.     

A herbal antifungal formulation of Thymus serpillum,Origanum vulgare and Rosmarinus officinalis for treating ovine dermatophytosis due to Trichophyton mentagrophytes

A number of herbal products with anti‐inflammatory, antiseptic and antimycotic properties are available for dermatological usage. The successful treatment of 13 sheep affected by ringworm due to Trichophyton mentagrophytes with a mixture consisting of essential oils (EOs) of Thymus serpillum 2%, Origanum vulgare 5% and Rosmarinus officinalis 5% in sweet almond (Prunus dulcis) oil. The effectiveness of EOs and of the major components of the mixture (thymol, carvacrol, 1,8 cineole, α‐pinene, p‐cymene, γ‐terpinene) against the fungal clinical isolate was evaluated by a microdilution test. Thirteen animals were topically administered with the mixture twice daily for 15 days. The other sheep were administered with a conventional treatment (seven animals) or left untreated (two animals). Minimum inhibitory concentration (MIC) values were 0.1% for T. serpillum, 0.5% for O. vulgare, 2.5% for I. verum and 5% for both R. officinalis and C. limon. Thymol and carvacrol showed MICs of 0.125% and 0.0625%. A clinical and aetiological cure was obtained at the end of each treatment regimen in only the treated animals. Specific antimycotic drugs licenced for food‐producing sheep are not available within the European Community. The mixture tested here appeared to be a versatile tool for limiting fungal growth.     

An outbreak of Arthroderma vanbreuseghemii dermatophytosis at a veterinary school associated with an infected horse

We report a case of an outbreak of inflammatory dermatophytoses caused by Arthroderma vanbreuseghemii (formally Trichophyton mentagrophytes pro parte) that involved an infected horse, the owner and at least 20 students, staff and stablemen at a veterinary school in Bern (Switzerland) that presented highly inflammatory dermatitis of the body and the face. Transmission from human to human was also recorded as one patient was the partner of an infected person. Both the phenotypic characteristics and ITS sequence of the dermatophytes isolated from the horse and patients were identical, consistent with the conclusion that the fungus originated from the horse. Three infected persons had not been in direct contact with the horse. Although direct transmission from human to human cannot be ruled out, fomites were most likely the source of infection for these three patients. Inspection of the literature at the end of the nineteenth and beginning of the twentieth century revealed that this dermatophyte was frequently transmitted from horses to humans in contact with horses (stablemen, coachmen, carters and artillery soldiers). The rarity of the present case report at the present time is likely related to the transformation of civilisation from the nineteenth century to nowadays in Europe with the change of horse husbandry. In addition, the inadequate immune response of the horse and the high number of people in contact with it at the equine clinic may explain the exceptional aspect of this case report.     

Onychomycosis secondary to onychomadesis: an underdiagnosed manifestation

Onychomycosis is a rare nail disorder in early childhood, while onychomadesis is a periodic idiopathic, non‐inflammatory disease that affects the nail matrix and is common in children especially in those who suffer from viral infections. In this study, we investigated recent cases of onychomycosis subsequent to periods of onychomadesis in children. Sixteen young children (six males, 10 females) with a mean age of 36.5 months were diagnosed with onychomadesis, and 13 of the patients had a history of viral infection prior to nail changes. Direct microscopy of nail scaling was positive in 11 cases (68.8%), and culture was positive in the same number of cases. Four Candida species were isolated: Candida glabrata was the most frequent, found in eight cases (72.7%), while C. albicans, C. parapsilosis and C. tropicalis, each were encountered in a single case. All children were treated successfully with or without topical bifonazole therapy.     

Invasive infections due to Saprochaete and Geotrichum species: Report of 23 cases from the FungiScope Registry

Saprochaete and Geotrichum spp. are rare emerging fungi causing invasive fungal diseases in immunosuppressed patients and scarce evidence is available for treatment decisions. Among 505 cases of rare IFD from the FungiScope^? registry, we identified 23 cases of invasive infections caused by these fungi reported from 10 countries over a 12‐year period. All cases were adults and previous chemotherapy with associated neutropenia was the most common co‐morbidity. Fungaemia was confirmed in 14 (61%) cases and deep organ involvement included lungs, liver, spleen, central nervous system and kidneys. Fungi were S. capitata (n=14), S. clavata (n=5), G. candidum (n=2) and Geotrichum spp. (n=2). Susceptibility was tested in 16 (70%) isolates. All S. capitata and S. clavata isolates with the exception of one S. capitata (MIC 4 mg/L) isolate had MICs>32 mg/L for caspofungin. For micafungin and anidulafungin, MICs varied between 0.25 and >32 mg/L. One case was diagnosed postmortem, 22 patients received targeted treatment, with voriconazole as the most frequent first line drug. Overall mortality was 65% (n=15). Initial echinocandin treatment was associated with worse outcome at day 30 when compared to treatment with other antifungals (amphotericin B ± flucytosine, voriconazole, fluconazole and itraconazole) (P=.036). Echinocandins are not an option for these infections.     

Tinea corporis purpurica and onychomycosis caused by Trichophyton violaceum

We report two cases of tinea corporis purpurica of the legs, presumably caused by self‐inoculation of the mycete from the toenails, in two elderly women (80 and 78 years). Trichophyton violaceum was isolated from the skin and nails. Histological examination of a biopsy specimen from the leg lesions confirmed the diagnosis. The source of infection was an Ethiopian carer who had tinea capitis in the first case, and was undiagnosed in the second patient. Cases of purpuric variants of tinea corporis are rare and this is the first report of probable self‐inoculation of T. violaceum from onychomycosis.     

Itraconazole in chronic cavitary pulmonary aspergillosis: a randomised controlled trial and systematic review of literature

Patients with aspergilloma can be safely managed with supportive therapy in absence of massive haemoptysis. We hypothesised that chronic cavitary pulmonary aspergillosis (CCPA) could also be managed on similar grounds. The aim of this prospective, randomised controlled trial was to evaluate the efficacy and safety of itraconazole in CCPA. Consecutive patients of CCPA with presence of chronic pulmonary/systemic symptoms; and pulmonary cavities; and presence of Aspergillus (immunological or microbiological) were randomised to receive either supportive treatment alone or itraconazole 400 mg daily for 6 months plus supportive therapy. Response was assessed clinically, radiologically and overall after 6 months therapy. A total of 31 patients (mean age, 37 years) were randomised to itraconazole (n = 17) or the control (n = 14) group. The number of patients showing overall response was significantly higher in the itraconazole group (76.5%) vs. the control (35.7%) group (P = 0.02). The numbers of patients demonstrating clinical or radiological response were also significantly higher in the itraconazole group (P = 0.016 and 0.01 respectively). Adverse events were noted in eight patients in the itraconazole group, however, none was serious or led to discontinuation of the study drug. Itraconazole was found to be superior to standard supportive treatment alone in stabilising cases of CCPA. (clinicaltrials.gov; NCT01259336).     

Case of dermatophyte abscess caused by Trichophyton rubrum: a case report and review of the literature

A 54‐year‐old Japanese man without apparent immunosuppression presented with nodules with purulent drainage on the right lower leg. He had ringworm of the right leg and tinea unguium. A biopsy specimen of the nodule showed intradermal abscesses with fungal elements, and Trichophyton rubrum was cultured from both the pus and the biopsy specimen. Treatment with oral terbinafine resolved the nodules. Dermatophyte abscess is a rare, deep and invasive dermatophytosis, which is often associated with immunocompromised conditions. We provide a review of the literature including Japanese cases.     

High dermatophyte contamination levels in hairdressing salons of a West African suburban community

Tinea capitis is a dermatophyte infection of scalp is commonly spread by currently infected patients, asymptomatic carriers or by fomites, such as hairdressing tools. However, studies on the risk factors of Tinea capitis remain scarce. The aim of this study was to evaluate the dermatophytes contamination level of the hairdressing tools to which hairdressing salon customers are exposed in Sirakoro‐Méguétana, a suburb of Bamako, the capital city of Mali. A total of 41 hairdressing tools were sampled in five hairdressing salons. Two anthropophilic dermatophytes species, Microsporum audouinii (53.3%) and Trichophyton soudanense (46.7%), were cultured from 30 (73.2%) samples. This first study, addressing hairdressing salons dermatophyte contamination, revealed a strikingly high contamination of hairdressing tools with dermatophyte propagules, which exposes hairdressing salons customers to an important dermatophytosis risk. The sterilisation of hairdressing tools is central to preventing dermatophytoses spreading. Appropriate community information and hairdressers training should be implemented in this view.     

Subcutaneous phaeohyphomycosis caused by Exophiala spinifera in a European patient with lymphoma: a rare occurrence case report and literature review

Exophiala spinifera is a dematiaceous fungus responsible for rare skin infections presenting as phaeohyphomycosis or chromoblastomycosis which has been primarily reported in tropical and subtropical areas (Asia, South and North America). We report the first case of E. spinifera phaeohyphomycosis in a European patient. The phaeohyphomycosis was limited to the skin, involving the finger of an immunocompromised patient presenting with a large B‐cell lymphoma treated by R‐mini‐CHOP regimen. Remission was initially achieved by surgical excision; however, a local subcutaneous relapse required treatment with itraconazole. We performed a literature review of the 32 previously published cases of E. spinifera phaeohyphomycosis highlighting its clinical phenotype: disseminated infection with extracutaneous involvement and poor prognosis were reported in young patients, of whom some were recently associated with CARD9 mutations, whereas cases in older immunocompromised patients were limited to the skin and showed better prognosis. There is currently no standard treatment for E. spinifera phaeohyphomycosis; however, itraconazole, alone or in combination, allowed partial or complete response in 16 out of 20 cases.     

Natural coniferous resin lacquer in treatment of toenail onychomycosis: an observational study

In in vitro tests, natural coniferous resin from the Norway spruce (Picea abies) is strongly antifungal. In this observational study, we tested the clinical effectiveness of a lacquer composed of spruce resin for topical treatment of onychomycosis. Thirty‐seven patients with clinical diagnosis of onychomycosis were enrolled into the study. All patients used topical resin lacquer treatment daily for 9 months. A mycological culture and potassium hydroxide (KOH) stain were done from nail samples in the beginning and in the end of the study. Treatment was considered effective, if a mycological culture was negative and there was an apparent clinical cure. At study entry, 20 patients (20/37; 54%; 95% CI: 38–70) had a positive mycological culture and/or positive KOH stain for dermatophytes. At study end, the result of 13 patients was negative (13/19; 68%; 95% CI: 48–89). In one case (1/14; 7%; 95% CI: 0–21) the mycological culture was initially negative, but it turned positive during the study period. By 14 compliant patients (14/32; 44%; 95% CI: 27–61), resin lacquer treatment was considered clinically effective: complete healing took place in three cases (9%) and partial healing in 11 cases (85%). The results indicate some evidence of clinical efficacy of the natural coniferous resin used for topical treatment of onychomycosis.     

Trichophyton mentagrophytes and T interdigitale genotypes are associated with particular geographic areas and clinical manifestations

The fungi Trichophyton mentagrophytes and T interdigitale account for significant amount of dermatophytosis cases worldwide. These two dermatophytes form a species complex and have a number of ribosomal internal transcribed spacer (ITS) region genotypes, allowing simultaneous species identification and strain typing. Our aim was to describe the geographic distribution of T mentagrophytes/T interdigitale ITS region genotypes and find an association between the genotypes and clinical presentations of respective infections. We performed rDNA ITS region sequencing in 397 Iranian T mentagrophytes/T interdigitale isolates and analysed all available in GenBank entries with sequences of this kind. For the study, 515 clinical annotations were available. Statistical analysis was performed by chi‐squared test and Spearman rank correlation analysis. A total of 971 sequences belonged to genotypes with at least 10 geographic annotations and were classified on the basis of exclusive occurrence in a particular region or high relative contribution to a regional sample. We discerned Asian and Oceanian (“ KU496915 ” Type V, “ KT192500 ” Type VIII, “ KU315316 ”), European (“ FM986750 ” Type III, “ MF926358 ” Type III*, “ KT285210 ” Type VI) and cosmopolitan (“ FM986691 ” Type I, “ JX122216 ” Type II, “ KP132819 ” Type II* and “ AF170453 ” Type XXIV) genotypes. There was statistically significant difference in the ITS genotype distribution between different affected body sites. Trichophyton mentagrophytes “ KT192500 ” Type VIII correlated with tinea cruris, T mentagrophytes “ KU496915 ” Type V correlated with tinea corporis, T interdigitale “ JX122216 ” Type II correlated with tinea pedis and onychomycosis. Trichophyton mentagrophytes and T interdigitale genotypes can be associated with distinct geographic locations and particular clinical presentations.     

Mucormycosis in Iran: a systematic review

Fungi in the order Mucorales cause acute, invasive and frequently fatal infections in susceptible patients. This study aimed to perform a systematic review of all reported mucormycosis cases during the last 25 years in Iran. After a comprehensive literature search, we identified 98 cases in Iran from 1990–2015. The mean patient age was 39.8 ± 19.2 years. Diabetes was the most common underlying condition (47.9%), and 22.4% of the patients underwent solid organ or bone marrow transplantation. The most common clinical forms of mucormycosis were rhinocerebral (48.9%), pulmonary (9.2%) and cutaneous (9.2%). Eight cases of disseminated disease were identified. Overall mortality in the identified cases was 40.8%, with the highest mortality rate in patients diagnosed with disseminated infection (75%). The mortality rate in rhinocerebral infection patients was significantly lower (45.8%). Rhinocerebral infection was the most common clinical manifestation in diabetes patients (72.9%). Patients were diagnosed using various methods including histopathology (85.7%), microscopy (12.3%) and culture (2.0%). Rhizopus species were the most prevalent (51.7%), followed by Mucor species (17.2%). Sixty‐nine patients were treated with a combination of surgery and antifungal therapy (resulting survival rate, 66.7%). Owing to the high mortality rate of advanced mucormycosis, early diagnosis and treatment may significantly improve survival rates. Therefore, increased monitoring and awareness of this life‐threatening disease is critical.     

Thirty‐six cases of epidemic infections due to Trichophyton violaceum in Siena,Italy

Trichophyton violaceum is an anthropophilous dermatophyte endemic to parts of Africa and Asia, sporadic in Europe. It is an emerging pathogen in Italy due to immigration. We report 36 cases of infections due to T. violaceum, diagnosed in the last 5 years by mycological examination. The source of contagion was 13 children adopted from orphanages.     

Clinical signs,therapy and zoonotic risk of pet guinea pigs with dermatophytosis

Systematic studies about pet guinea pigs with dermatophytosis are rare. The aim of this study was to evaluate clinical signs, therapy and zoonotic risk of pet guinea pigs with dermatophytosis. Questionnaires from both owners (n = 74) of pet guinea pigs with dermatophytosis and their veterinarians (n = 101) were analysed regarding clinical signs, therapy and data pertinent to zoonotic potential. Trichophyton (T.) mentagrophytes was found in 97% of cases. In the weeks preceding the onset of the clinical signs, a new guinea pig joined the household in 43% of cases. One third of the affected guinea pigs had lived in the household for less than 3 months. Predominant clinical signs were alopecia (83%), scaling (73%) and crusting (70%). The most commonly affected body site was the head (75%). In approximately one quarter of the cases humans showed clinical signs of dermatophytosis, in half the households, only children were affected. Skin lesions were seen most often on the face, the neck and the arms. Pet guinea pigs carrying dermatophytes must be considered a serious zoonotic risk for their owners, especially for children. A major risk factor for dermatophytosis seems to be a recent acquisition of a new guinea pig.     

Detection of dermatophytes in human nail and skin dust produced during podiatric treatments in people without typical clinical signs of mycoses

Pedicures are the most common cosmetic foot treatment. Many pedicurists and podiatrists suffer from respiratory infections and diseases such as asthma, sinusitis, chronic cough and bronchitis. Skin and nail dust may play an important role in the development of occupational diseases and the transmission of mycosis to other clients. To examine the presence of dermatophytes in nail and skin dust produced during podiatric treatments of people without typical symptoms of mycosis and to assess the epidemiological hazards of tinea pedis for podiatrists as well as other clients. Seventy‐seven samples underwent direct microscopy and culture. The results of direct microscopy were positive in 28/77 samples (36.36%) and doubtful in 3/77 (3.9%). Fungi were cultured from 36/77 samples (46.75%), including 8/77 (10.3%) positive for dermatophytes (Trichophyton rubrum‐6 isolates and Trichophyton mentagrophytes‐2). Material collected during podiatric treatments is potentially infected by pathogenic fungi; thus, there is a need to protect both workers who perform such treatments, as well as other clients, to prevent the transmission of pathogens in the Salon environment. Exposure to this occupational hazard may increase not only the risk of respiratory infections but also increase asthmatic or allergic reactions to Trichophyton.