Trichophyton Tonsurans Induced Recurrent Onychomadesis in a Very Young Infant

Abstract: Onychomadesis, or nail shedding, is rarely seen in children and can be due to stress, systemic illnesses, trauma, and drug therapy or may be idiopathic. Fungal infection of the nail is only rarely reported as a cause of onychomadesis. We present here a case of Trichophyton tonsurans–induced onychomycosis and resultant onychomadesis in a 9‐month‐old boy with onset of lesions at 2 weeks of life.     

Deep (subcutaneous) dermatophyte infection presenting with unilateral lymphoedema

An unusual presentation of a common infection is described in a 17-year-old girl who had a 14-year history of chronic Trichophyton rubrum affecting both feet. This has persisted despite adequate systemic therapy with griscofulvin and ketoconale and had recently become more extensive with lymphatic spread to a secondary site of infection on her knee. She was not atopic but had depressed cell-mediated immunity with reduced lymphocyte transformation in autologous serum. She had antibodies to Trichophyton rubnum and defective fungal killing by neutrophils. She responded well to itrazole and, over the 12-month period of treatment, her cell-mediated and phagocytic function returned to normal.     

Impetigo‐Like Tinea Faciei Around the Nostrils Caused by Arthroderma vanbreuseghemii Identified Using Polymerase Chain Reaction–Based Sequencing of Crusts

We report a case of Arthroderma vanbreuseghemii (a teleomorph of Trichophyton interdigitale) infection around the nostrils in a 3‐year‐old girl. The culture was negative, so the pathogenic agent was identified using polymerase chain reaction–based sequencing of the crusts taken from the lesion on the nostril. Treatment with oral itraconazole and topical 1% naftifine/0.25% ketoconazole cream after a topical wash with ketoconazole shampoo was effective.     

Dermatophyte infections mimicking other skin diseases: a 154-person case survey of tinea atypica in the district of Cagliari (Italy)

Background Although usually simple, the diagnosis of dermatophyte infection is sometimes neglected. An observational study has been realized to evaluate the role of corticosteroid exposure (tinea incognito) and of other primary characteristics of the dermatophytosis that from onset mimic other diseases and mislead an unexperienced physician. Materials and methods Between 1990 and 2009, all cases of atypical dermatophytosis mimicking other skin diseases were collected from the more general number of dermatophyte infections diagnosed at the Dermatology Department of Cagliari University, Italy. Results One‐hundred and fifty‐four cases (71 male/83 female, 2–81 years old) were studied, with a median of 7 cases/year. The most observed clinical forms were those mimicking impetigo, eczematous dermatitis, lupus erythematosus, polymorphous light eruption, psoriasis, and rosacea. The identified dermatophytes were: Microsporum canis (70 cases), Trichophyton rubrum (43 cases), Trichophyton mentagrophytes var. mentagrophytes (29 cases), Trichophyton mentagrophytes var. interdigitale (six cases), Microsporum gypseum (three cases), Epidermophyton floccosum (two cases), and Trichophyton verrucosum (one case). Diagnostic difficulties are discussed, with special attention to the origin of the pathomorphosis. Conclusions In our experience, clinical atypia is not a mere consequence of corticosteroid therapy but present at the very onset of the illness, due to the variable dermatophyte invasive capacity, the site of invasion, physiological individual, and/or acquired condition, such as excessive washing or sun exposure. Therefore, we suggest using the term “tinea atypica” rather than “tinea incognito” to include all forms of dermatophytosis that do not present the classic features for both primary and secondary pathomorphosis.     

Simple identification of Trichophyton tonsurans by chlamydospore‐like structures produced in culture media

Trichophyton tonsurans is known to be the causative agent of a worldwide epidemic of dermatophytoses among contact sports practitioners, and is spreading among the general population of Japan. Prompt and simple identification of T. tonsurans in diagnostic laboratories is crucial to control infection. The present study evaluated the availability of observation of chlamydospore‐like structures grown in culture media as a characteristic for identification of T. tonsurans. Twenty‐five strains of T. tonsurans and five strains each of Trichophyton verrucosum, Trichophyton rubrum and Trichophyton mentagrophytes were inoculated on Mycosel agar plates and inoculated Petri dishes were observed by light microscopy from the reverse side. Twenty‐three of 25 T. tonsurans strains showed chlamydospore‐like structures within 5 days, and all strains at day 8. The numbers of chlamydospore‐like structures were very abundant in most strains. The majority of strains of other species showed no chlamydospore‐like structures, or very few when present. Positive for chlamydospore‐like structures among 15 strains other than T. tonsurans was one strain at day 5 and six strains at day 8. As for the identification of T. tonsurans, presence of chlamydospore‐like structures showed 92.0% sensitivity (23/25) and 93.3% specificity (14/15) at day 5, and 100% sensitivity (25/25) and 60.0% specificity (9/15) at day 8. Electron microscopic findings suggest chlamydospore‐like structures are not true chlamydospores but are produced by inflation of actively growing hyphae by developing vacuoles in cells. In conclusion, observation of development of chlamydospore‐like structures in culture media is the simplest method for identification of T. tonsurans.     

Clinical and Laboratory Characteristics of a Tinea Capitis Outbreak Among Novice Buddhist Monks

Sixty novice Buddhist monks with tinea capitis confirmed according to clinical presentation and mycological laboratory finding were included in this study. Mixed‐type clinical presentation was observed in approximately half of all cases, together with scarring alopecia (95%) and superficial fungal skin infection at locations other than the scalp (43.3%). The major isolated organism was Trichophyton violaceum, and mixed‐organism infection was found in 27 cases (45%). Slow‐onset presentation and an extensive area of infection were significantly associated with mixed‐type clinical presentation.     

Trichophyton erinacei kerion barbae from a hedgehog with direct osculatory transfer to another person

We describe a case of kerion tinea barbae infection due to Trichophyton erinacei in a 37‐year‐old man. The infection had also been transferred to his partner by direct contact from kissing. T. erinacei is a zoophilic dermatophyte occasionally harboured by the hedgehog (Erinaceus europaeus). There are few reports of human infection in the literature, and it rarely causes a kerion. There is only one previous report of tinea barbae occurrence due to T. erinacei. This case highlights the possibility of one of the more unusual fungal infections that can be acquired in the UK, and highlights the necessity of asking specific questions to identify possible sources of infection.     

Laser treatment of onychomycosis: an in vitro pilot study

Background: Laser treatment of onychomycosis is the object of considerable interest. Laser therapy could be a safe and cost‐effective treatment modality without the disadvantages of drugs. Some studies have described the inhibitory effects of lasers on the growth of fungal colonies. We therefore examined the effects of various laser wavelengths, which have previously shown inhibitory potential, on the fungal isolate Trichophyton rubrum. Patients and Methods: Isolates of fungal colonies were placed clockwise on culture plates. Each culture plate was irradiated on one half with one of the following treatment regimens: 1064 nm‐Q‐switched Nd:YAG laser at 4 J/cm² and 8 J/cm²; 532 nm‐Q‐switched Nd:YAG laser at 8 J/cm²; 1064 nm‐long‐pulsed Nd:YAG laser at 45 J/cm² or 100 J/cm². The other half remained untreated. Standardized photographs were taken and areas of treated and untreated colonies were compared for growth inhibition. Results: There was no inhibition of fungal growth in any of the treated plates. Differences in size between treated and untreated colonies were not significant (p > 0.10). Conclusions: In this in vitro study Nd:YAG laser treatment of Trichophyton rubrum colonies failed to inhibit fungal growth. Nevertheless there might be an effectiveness in vivo which has to be clarified by clinical studies.     

Disseminated dermal Trichophyton rubrum infection – an expression of dermatophyte dimorphism?

We present a case of disseminated dermal infection caused by Trichophyton rubrum (T. rubrum). This rare variant of dermatophytosis has an atypical clinical and histopathological presentation and occurs exclusively in immunosuppressed patients. The large, broad, pleomorphic hyphae with scattered budding arthrospores in this variant of T. rubrum infection are unusual and may represent expression of dermatophyte dimorphism previously described in vitro. Lillis JV, Dawson ES, Chang R, White Jr CR. Disseminated dermal Trichophyton rubrum infection—an expression of dermatophyte dimorphism?     

Trichophyton mentagrophytes var. nodulare–Ein seltener Fußpilzerreger auf dem Vormarsch?

Background: The spectrum of organisms causing dermatophytoses is changing continuously. Patients/Methods: Two strains of Trichophyton mentagrophytes var. nodulare are characterized mycologically; both were isolated for the first time in our laboratory within the past 2 years from patients with tinea pedis. Results: Distinctive features of Trichophyton mentagrophytes var. nodulare are a bright yellow‐orange pigmentation of the thallus, a marked exudation of pigment, and the development of nodular bodies. Trichophyton mentagrophytes var. nodulare is an anthropophilic variety of Trichophyton mentagrophytes causing tinea and onychomycosis. Conclusions: Trichophyton mentagrophytes var. nodulare has been found only very rarely in Germany and is relatively unknown. An increased awareness of this dermatophyte is needed in order to track its possible spread.     

Evaluation of the association of superficial dermatophytosis and athletic activities with special reference to its prevention and control

Objective This study was conducted to evaluate the association of superficial mycosis and athletic activities with special references to its prevention and control in Tehran. Participating in various kinds of sports can lead to direct and indirect exposures to and transmission of micro‐organisms between athletes and also passive observers. Methods A retrospective study of superficial fungal infections in athletes was carried out during the period of March 2002 to December 2006 on 656 mycological proven cases of dermatophytosis found in athletes in Tehran. Mycologic examination consisted of culturing of pathologic material followed by direct microscopic observation. Mycologic cultures were carried out on Sabouraud Chloramphenicol Agar, Sabouraud Chloramphenicol and Cyclohexamide Agar, and Dermatophyte Agar incubated at 25 °C for at least 28 d. Diagnosis was based on macroscopic and microscopic characteristics of the colonies. Results A total of 1075 athletes, from 201 institutions, suspected of cutaneous fungal infections were examined and 656 (61%) were found to be positive for fungal infections. The fungal isolates comprised Trichophyton tonsurans (56%), Epidermophyton floccosum (11.8%), Trichophyton mentagrophytes (8.9%), Trichophyton rubrum (8.3%), Trichophyton verrucosum (3.9%), Trichophyton violaceum (3.3%), Microsporum canis (2.5%), and Malassezia spp. (5.3%). The distribution of lesions on the body in decreasing order was as follows: trunk, groin, hair and scalp, sole, toe webs, finger nails, and toe nails. Fungal infections were more commonly seen in wrestlers and individuals that participate in aerobics. Conclusion The results suggest that athletic activity seems to be a predisposing factor, especially for fungal infections. Guidelines are provided regarding measures to prevent transmission of infectious diseases in athletic settings, including hygiene, infection control practices, and education of officials, coaches, trainers, and sports participants.     

Tinea capitis in adults in Tunisia

Objective To determine the pattern of infectious agents causing tinea capitis (TC) in adult patients in adult patients in Tunisia. Methods From January 1990 to December 2005, we retrospectively collected all cases of adult TC, confirmed by the mycological examination. Results Sixty patients (18 male, 42 female) with a mean age of 34.5 years were diagnosed as having adult TC among a total number of 1137 cases of TC (5.27%). Clinical features were polymorphic and diagnosis was made on mycological examination. Culture identified Trichophyton violaceum in 36 cases (60%), Microsporum canis in 12 cases (20%), Trichophyton schoenleini in 7 cases (12%), Trichophyton verrucosum in two cases (3.5%), and Trichophyton mentagrophytes and Trichophyton rubrum in one case (each 1.77%). Culture was negative in one case. Treatment consisted of administration of Griseofulvin at the dose of 20–25 mg/kg/d during 6–8 weeks associated with antifungal topics. A complete recovery was noted in 55 cases and relapse occurred in two patients. A scary alopecia was observed in one patient and two patients were lost to follow‐up. Conclusion Trichophyton violaceum remains the most common etiological agent of adult TC in Tunisia. Microsporum canis is rising rapidly most notably due to the high frequency of asymptomatic carriage by domestic animals.     

Refractory Trichophyton rubrum Infection in Lamellar Ichthyosis

A 10‐month‐old boy with congenital lamellar ichthyosis presented with a chronic Trichophyton rubrum infection. There was no history of atopy or immunosuppression, and examination revealed high total immunoglobulin E (IgE) with a positive specific IgE for T. rubrum. Multiple treatments with fluconazole were necessary to control the infection. T. rubrum is present worldwide and is responsible for the vast majority of chronic dermatophytosis. Lamellar ichthyosis is a risk factor for chronic dermatophytosis because of excessive keratin and the barrier defect. A delayed‐type hypersensitivity reaction to T. rubrum is associated with cure, whereas immediate hypersensitivity and IgE are not protective and may lead to chronic infection. Atopy and the Th2 profile therefore seem to be associated with chronic dermatophytosis. The association between ichthyosis and atopy is well documented. T. rubrum also has an interesting ability to evade immunity, which helps explain the chronic infection. Finally, in ichthyosis, it is likely that fluconazole has difficulty penetrating the acanthotic stratum corneum, which explains treatment failure. We report this case to alert clinicians to the possible association between lamellar ichthyosis and chronic dermatophytosis and to report the difficulties of management.     

Tioconazole nail solution—an open study of its efficacy in onychomycosis

In view of the problems encountered in the treatment of onychomycosis with orally administered antifungal drugs, alternative forms of therapy arc needed. Tioconazole (28%) nail solution is a new topical preparation for use on infected nails. In this study 27 patients received treatment with tioconazole (28%) for up to 12 months. Six patients (22%) achieved complete clinical remission and were free of infection at follow-up, 3 months after therapy. They included infections caused by Trichophyton rubruni (4), Hendersonula toruloidea (1) and Acremonium (1). Apart from the latter, all infections responding to treatment were in the finger nails, even though three patients had active infection in the toe nails as well which did not respond to therapy. Significant improvements were recorded in a further 11 patients. They did not, however, achieve complete clinical and mycological recovery. The results indicate that cures of onychomycosis are possible after topical therapy, and further methods of using this form of treatment such as combined surgical and topical therapy are discussed.     

Nail sampling in onychomycosis: comparative study of curettage from three sites of the infected nail

Background: Onychomycosis is a common problem.Obtaining accurate laboratory test results before treatment is important in clinical practice since the treatment of onychomycosis requires expensive oral antifungal therapy with potentially serious side‐effects. The purpose of this study was to compare results of curettage technique of nail sampling in the diagnosis of onychomycosis from three different sites of the affected nail to establish the best location of sampling. Patients and Methods: We evaluated 194 patients suffering from distal and lateral subungual onychomycosis (DLSO) and lateral subungual onychomycosis (LSO) using curettage technique. KOH examination and fungal culture were used for detection and identification of fungal infection. Results: The culture sensitivity improves significantly as the location of the sample is more proximal. Trichophyton rubrum was by far the most common pathogen detected from all sampling sites. Conclusions: We found that the culture sensitivity improved as the location of the sample was more proximal. More types of pathogens were detected in samples taken from proximal parts of the affected nails.     

Onychomycosis in Cameroon: a clinical and epidemiological study among dermatological patients

Background  There are currently no studies on epidemiology and clinical aspects of nail fungal infections in the general population of Cameroon. Patients and methods  Two series of patients observed at a hospital dermatological service of Yaoundé and in a volunteer service of Douala were evaluated. All the patients, regardless of the reason for the consultation, were examined by an expert dermatologist to discover signs of onychomycosis. Patients with suspected nail lesions underwent mycological examination according to the standard techniques. Results  Among 590 subjects (317 males and 273 females), aged 16–83 years, onychomycosis was mycologically confirmed in 52 cases (8.8%). The infection was most common in the fifth decade. Fingernails were affected in 12 cases, toenails in 30 cases, and both fingernails and toenails in 10 cases. Dermatophytes were isolated in 57.7% of cases, the most common species being Trichophyton rubrum (16 cases) and Trichophyton violaceum (eight cases). Non‐dermatophytic mould, including Aspergillus spp., Fusarium spp., and Neoscytalidium dimidiatum, was found in 10 cases. Onychomycosis was more common in patients from low social‐economic classes. Conclusions  This is the first investigation dealing with onychomycosis in Cameroon. These data may be useful for future research and in the development of preventive and educational strategies.     

Mating type gene for isolates of Trichophyton mentagrophytes from guinea pigs

Trichophyton mentagrophytes were isolated from 19 of 20 guinea pigs in a children's corner of a zoo. The nucleotide sequence identity of the internal transcribed spacer region among 19 guinea pig isolates was 99%, including the reference strain of animal type 3 of T. mentagrophytes. The genomic DNA of all isolates were investigated for the mating (MAT) gene by specific polymerase chain reaction. The alpha‐box gene was detected in all 19 isolates, while the high‐mobility‐group (HMG) gene was detected in only one of 19 isolates. Therefore, the guinea pig population harbored at least 2 MAT types of Arthroderma vanbreuseghemii. The T. mentagrophytes that was prevalent in this population may constitute a constant source of infection for persons coming into contact with guinea pigs.     

A twenty-year survey of dermatophytoses in Braga, Portugal

Background Modifications in social habits together with the increase of emigration have contributed not only to increased dermatophytoses but also to an altered etiology. During the last few years, Braga has suffered a radical change from a rural to a cosmopolitan life‐style. Methods A statistical study of dermatophytoses and the etiology of their causative agents was performed by a retrospective survey carried out among patients of Hospital de São Marcos, Braga, Portugal, from 1983–2002. In this study, a total of 10 003 patients were analyzed. Results Over this period the frequency of dermatophytoses, as defined by the recovery of a dermatophyte in culture, was found to be 23.6%, whereas nondermatophytic infections accounted for 7.0%. Analysis of the clinical forms and the isolated fungi supports that the dermatophyte species have a predilection for certain body areas (P ≤ 0.01). Age is a very important factor regarding the occurrence of dermatophytoses (P ≤ 0.0001), with a correlation between increasing age and infection, positive for Trichophyton rubrum and negative for Microsporum canis. Overall the gender of the patients is not an association factor for the development of dermatophytoses; however, significant differences were detected in the distribution of some etiologic agents (P ≤ 0.05). Conclusions The results showed the main etiologic agent of dermatophytoses to be Trichophyton rubrum (37.4%). Moreover, dermatophytoses are both decreasing and showing a new profile in Braga, and a pronounced decrease of Trichophyton megninii was observed throughout the study.     

Specific detection of Trichophyton rubrum and Trichophyton interdigitale based on loop‐mediated isothermal amplification (LAMP) from onychomycosis specimens

In diagnosing onychomycosis, diseases with similar features must be excluded by demonstrating the presence of fungal infection and identifying the fungal species. However, fungal culture of onychomycosis‐derived samples usually takes many weeks to yield species identification results, and is associated with a low successful culture rate. Loop‐mediated isothermal amplification (LAMP) is a highly sensitive and specific molecular biological method that can amplify DNA at a constant temperature, allowing for a simpler testing procedure, shorter detection time and less cost than conventional techniques including quantitative polymerase chain reaction. We have developed a new LAMP method specifically to detect Trichophyton rubrum (T. rubrum) and Trichophyton interdigitale (T. interdigitale), major causative dermatophytes for onychomycosis, and analyzed the correlation between LAMP results and those of the existing fungal culture method for the detection and identification of Trichophyton species from onychomycosis‐derived samples. The results showed that all 59 specimens in which T. rubrum or T. interdigitale was identified by fungal culture also tested positive by LAMP, giving a 100% positivity concordance rate between the two methods. Moreover, all 55 and four specimens in which T. rubrum and T. interdigitale were identified by fungal culture, respectively, also tested positive for each species by LAMP, again giving a 100% species‐identification concordance rate. The high correlation demonstrated between LAMP and fungal culture results in detection and identification of Trichophyton species from onychomycosis‐derived samples suggests high reliability of LAMP as a promising, alternative mycological detection and identification technique which can serve as an alternative to the fungal culture method.     

Dermatophytosis and Sjögren–Larsson syndrome: Foe or friend?

We report the patchy normalization of lamellar ichthyotic skin in Sjögren–Larsson syndrome (SLS) following a cutaneous Trichophyton rubrum infection. The dermatophytosis was pruritic and pustular, requiring treatment which was followed by the return of the lamellar ichthyosis. We discuss the possible mechanism of this clinical observation, which in turn may direct future therapy for difficult to treat ichthyotic skin seen in conditions such as SLS.