短帚霉对小鼠致病性的实验研究

目的研究短帚霉的致病性,探讨系统性真菌病的发病机制。方法给不同免疫状态的小鼠经皮下、腹腔、静脉途径注射短帚霉菌悬液,对处死及自然死亡小鼠各脏器进行组织病理检查和逆培养,观察小鼠生存率。结果正常皮下组和免疫抑制皮下组仅在接种部位出现脓肿,不引起播散性损害;不同免疫状态的腹腔组和静脉组小鼠早期就出现各脏器的播散感染。组织病理学和逆培养均阳性。免疫抑制组小鼠有自然死亡。结论短帚霉是一种毒性较强的条件致病菌。     

Onychomycosis due to Scopulariopsis brevicaulis: clinical features and response to systemic antifungals

Summary Six cases of Scopulariopsis onychomycosis, including four patients with onychomycosis exclusively caused by Scopulariopsis brevicaulis and two patients with a mixed nail infection (S. brevicaulis + Tricophyton rubrum and S. brevicaulis + T. interdigitale), are reported. Four patients presented with a typical distal subungual onychomycosis characterized by subungual hyperkeratosis and onycholysis of the distal nail plate. In two patients. Scopulariopsis infection produced a total dystrophic onychomycosis associated with painful periungual inflammation. Three patients were treated with four pulses of itraconazole. 400 mg daily for 1 week a month, and three patients with terbinafine, 250 mg daily for 4 months. The mycological examination 8 months after discontinuation of treatment showed that one patient was mycologically cured whereas the remaining five patients still carried S. brevicaulis in their nails. The clinical examination at the end of the follow-up period showed a complete cure of the nail abnormalities in only one patient.     

短帚霉对小鼠致病性实验研究

目的 研究短帚霉的致病性,探讨系统性真菌病的发病机制。方法 给不同免疫状态的小鼠注射短帚霉菌悬液,对处死及自然死亡小鼠各脏器进行组织病理检查和逆培养。结果 在接种后早期即发生各脏器侵袭,免疫受损组小鼠坏死组织出现早,脾内多形核白细胞减少。结论 短帚霉是一种毒性较强的条件致病菌,真菌穿透宿主细胞的能力在感染的进程中起关键作用。多形核巨细胞在感染早期免疫应答中起重要作用。     

Histopathologic evidence of the nondermatophytic mould Scopulariopsis brevicaulis masking the presence of dermatophytes in a toenail infection

Nondermatophytic toenail infection with Scopulariopsis brevicaulis is rare, but may occur often in association with dermatophytes. We report a case of an 84-year-old man who presented with onychomycosis of the big toenail. Histopathologic examination of the avulsed nail showed evidence of S. brevicaulis coinfection with a dermatophyte, despite negative mycology results for the latter. Our case underscores the importance of histopathologic examination of nail specimens as an additional invaluable tool in the diagnosis of onychomycosis, as it may unmask false-negative mycology findings.     

ONYCHOMYCOSIS CAUSED BY SCOPULARIOPSIS BREVICAULIS

A case of toe nail infection due to Scopulariopsis brevicaulis is described. This organism is recognized as a possible nail pathogen and it has been found as a harmless contaminant in healthy and abnormal nails. The article endeavours to provide convincing evidence of a pathogenic role for S. brevicaulis in the case described.     

Ketoconazole and onychomycosis

We have treated 48 cases of onychomycosis (of which 37 were caused by dermatophytes, 10 by yeasts and one by Scopulariopsis brevicaulis) with 200 mg ketoconazole daily. We obtained recovery in 65 p. 100 of the cases of onyxis caused by dermatophytes and in 80 p. 100 of the cases of onychomycosis due to Candida. The one patient presenting an infection with Scopulariopsis brevicaulis recovered in 13 months. The average duration necessary to obtain complete recovery was 6 1/2 months for onychomycosis of the hands due to dermatophytes and 12 1/2 months for those of the feet. Perionyxis due to Candida needed 2 months of treatment with this drug, however 6 months of treatment were necessary to obtain recovery for onycholysis due to Candida. Biological tests remained normal and the side-effects were minimal and essentially gastrointestinal in our study. Ketoconazole is an effective treatment for onychomycosis: it is active against the different mycotic agents infecting nails and well tolerated by the patient. Several minor effects such as itching, nausea, headache and more serious reactions such as erythrodermia and hepatitis have been reported. Regular control and biological tests are therefore necessary. Patients with other diseases should avoid the use of ketoconazole for treatment of onychomycosis.     

Cutaneous 'ringworm' lesions of Scopulariopsis brevicaulis

Scopulariopsis brevicaulis is a saprophytic fungus which is occasionally isolated as an apparent cause of toenail fungal infection, and which rarely has been reported as a cause of deep fungal granuloma. We report a case of skin infection with this organism, which was proved by culture of a pure isolate. The skin lesions had an annular ringworm appearance with pustules, they occurred initially at a site of minor injury, and they responded to treatment with terbinafine and itraconazole.     

Microsporum ferrugineum infection with unusual clinical features

Unusual skin manifestations of a dermatophyte infection in a 30-year-old female were reported. These included a remarkable peripheral hyperkeratosis with central yellowish pus. The pinkish papillomatous lesions were covered with thick crusts. They gave off a foul smell. Abundant fungus elements were present in the crusts and keratotic layer. The trichophytin skin test was positive. Immunologic test results revealed that the patient had hypergammaglobulinemia with hypoalbuminemia. However, she had no edema or immunologic abnormalities. The skin lesions were successfully treated with topical miconazole cream, oral griseofulvin, and topical sulconazole cream. The etiologic agent was identified as Microsporum ferrugineum Ota 1922. It seemed to us that the unusual skin manifestation were induced by her immunological response to fungal and bacterial infection due to a long history of Candida granuloma.     

Imiquimod for restoring local immunity in a renal transplant patient with persistent keratoacanthoma

Keratoacanthoma (KA), a cutaneous neoplasm histologically resembling squamous cell carcinoma, is characterized by rapid growth and common spontaneous regression. The regression depends on an individual's immune response. We are reporting a case of a 53-year-old man who presented with an ulcerated tumor, which had arisen as a nodular lesion 9 months earlier. This was localized on the the left thumb. The patient had undergone a kidney transplant after severe glomerulonephritis. Following the operation, he was treated with systemic immunosuppressive drugs and developed multiple non-melanoma skin cancers. The histology examination of biopsy specimens was consistent with keratoacanthoma and showed low-density chronic inflammatory cells. Our patient refused surgical excision, so we prescribed imiquimod 5 percent cream once daily for 5 days a week. After 6 weeks of treatment the lesion had regressed completely, yielding an excellent cosmetic result. Continued resolution was documented 3 years after treatment. The patient had no signs of graft rejection related to the imiquimod treatment.     

Onychocola canadensis Sigler bei Onychomykose

Moulds or non-dermatophyte moulds (NDM) are being increasingly isolated as causative agent of onychomycoses. Known causes of a NDM-OM are Scopulariopsis brevicaulis, Fusarium, Aspergillus, Acremonium, Neoscytalidium dimidiatum, Arthrographis kalrae, and Chaetomium. In this article, 5 patients with suspected nail infection due to Onychocola canadensis are reported for the first time in Germany. Systemic antifungal agents are not considered to be effective in NDM onychomycosis. In individual cases, however, terbinafine seems to be effective in Onychocola canadensis infection of the nails. Treatment of choice represents, however, nontraumatic nail avulsion using 40?% urea ointment followed by antifungal nail lacquer with ciclopirox olamine or amorolfine.     

Systematic review of nondermatophyte mold onychomycosis: diagnosis, clinical types, epidemiology, and treatment

Nondermatophyte mold (NDM) onychomycosis is difficult to diagnose given that NDMs are common contaminants of the nails and of the mycology laboratory. Diagnostic criteria and definition of cure are inconsistent between studies, which may affect the quality of published data. We identified 6 major criteria used in the literature: identification of the NDM in the nail by microscopy (using potassium hydroxide preparation), isolation in culture, repeated isolation in culture, inoculum counting, failure to isolate a dermatophyte in culture, and histology. Most studies used 3 or more of these (range = 1-5). We recommend using at least 3 of the criteria to rule out contamination; these should include potassium hydroxide preparation for direct microscopy and isolation of the organism in culture. We review geographic distribution and clinical presentations associated with different NDMs. The treatment with the greatest quantity of data and highest reported cure rates is terbinafine, for the treatment of Scopulariopsis brevicaulis and Aspergillus species infections. Topicals such as ciclopirox nail lacquer may also be effective (data originating from Scopulariopsis brevicaulis and Acremonium species infections), especially when combined with chemical or surgical avulsion of the nail. We recommend that future studies use (and clearly indicate) at least 3 of the main criteria for diagnosis, and report the clinical type of onychomycosis and the isolated organism. When evaluating different treatments, we suggest that authors clearly define their efficacy outcomes.     

Onychomycosis in graft versus host disease

Graft versus host disease is associated with a myriad of cutaneous signs and few nail manifestations. A case of documented chronic graft versus host disease with the initial cutaneous presentation of white superficial onychomycosis is presented. The patient developed a lichenoid eruption in an unusual distribution and a reticulated hyperpigmentation of the face. Culture of the nails was positive for Trichophyton rubrum, an uncommon cause of white superficial onychomycosis, this being the third known reported case. Histopathologic examination revealed fungal elements in the superficial nail plate with an absence of fungus in the ventral aspect of the nail plate. A summary of cutaneous skin and nail manifestations in graft versus host disease is presented.     

T-cell signet-ring cell proliferation in the skin simulating true histiocytic lymphoma

We report the case of a solitary ulcerating lesion on the elbow of a 32-year-old man. Routine histopathological examination strongly suggested a histiocytic malignancy. However, electron-microscopical, enzyme-cytochemical, and immunological studies revealed that the "tumor" cells were T lymphocytes with an unusual (Leu 1+, Leu 3a+, Leu 4+, Leu 5b+, OKT4+, HLA-DR+, Ki-1+, Leu MI+) immunological phenotype and an even more uncommon morphology characterized by the development of giant multivesicular bodies giving some cells a signet-ring cell appearance, and autophagocytosis. The lesion healed spontaneously, notwithstanding its malignant histology.     

Evaluation of a polymerase chain reaction-restriction fragment length polymorphism assay for dermatophyte and nondermatophyte identification in onychomycosis

Background  Dermatophytes are the main cause of onychomycoses, but various nondermatophyte filamentous fungi are often isolated from abnormal nails. The correct identification of the aetiological agent of nail infections is necessary in order to recommend appropriate treatment.
Objective  To evaluate a rapid polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay based on 28S rDNA for fungal identification in nails on a large number of samples in comparison with cultures.
Methods  Infectious fungi were analysed using PCR-RFLP in 410 nail samples in which fungal elements were observed in situ by direct mycological examination (positive samples). The results were compared with those previously obtained by culture of fungi on Sabouraud agar from the same nail samples.
Results  PCR-RFLP identification of fungi in nails allowed validation of the results obtained in culture when Trichophyton spp . grew from infected samples. In addition, nondermatophyte filamentous fungi could be identified with certainty as the infectious agents in onychomycosis, and discriminated from dermatophytes as well as from transient contaminants. The specificity of the culture results relative to PCR-RFLP appeared to be 81%, 71%, 52% and 63% when Fusarium spp., Scopulariopsis brevicaulis , Aspergillus spp. and Candida spp., respectively, grew on Sabouraud agar. It was also possible to identify the infectious agent when direct nail mycological examination showed fungal elements, but negative results were obtained from fungal culture.
Conclusions  Improved sensitivity for the detection of fungi in nails was obtained using the PCR-RFLP assay. Rapid and reliable molecular identification of the infectious fungus can be used routinely and presents several important advantages compared with culture in expediting the choice of appropriate antifungal therapy.     

Drugs and Wells' syndrome: a possible causal relationship?

In April 1997, a 28‐year‐old woman presented with a 3‐day history of multiple papules and vesicles on the fingers and wrist of her right hand. She reported that she had been taking nonsteroidal anti‐inflammatory drugs containing tenoxicam and diclofenac sodium, and had no history of an insect bite. The medical history also included pruritic erythema on her trunk 1 month before her initial visit, and oral tenoxicam and diclofenac sodium treatment for ankle arthralgia 2 days before the skin lesions appeared. At that time, her dermatologist had told her that the skin lesions might be due to an insect bite and were secondarily infected. She took amoxicillin for the lesions, and during the following days developed bullous lesions on her hands and feet. The patient was diagnosed with ‘‘drug reaction’' at another hospital based on a histopathologic examination of the affected skin. Treatment with topical corticosteroids and oral antihistamines was ineffective. Physical examination revealed a few crusted, erythematous, papular lesions on the dorsal aspects of the patient's feet, bullous lesions on her right wrist, and vesiculopapules on her fingers. She had no fever or other abnormal clinical findings. Laboratory studies showed a white blood cell count of 6000/mL with 16.5% eosinophils. A bacterial culture of the content of one of the bullous lesions was negative. The results of stool tests for parasites and ova were negative. Clinical and laboratory findings were in line with the diagnosis of drug reaction. The patient was advised not to take nonsteroidal anti‐inflammatory drugs. The skin lesions resolved rapidly on treatment with wet compresses of Burow's solution and oral prednisolone (40 mg/day). The dose of prednisolone was gradually reduced, and was discontinued after 3 weeks. The patient was readmitted in July 1997 for an indurated, erythematous plaque on her left foot, a lesion that resembled cellulitis. Her history at that time included the initiation of amoxicillin treatment for a gingival abscess 2 days before the skin lesion appeared. The lesion regressed after amoxicillin was discontinued and the patient received an intramuscular injection of triamcinolone acetonide. Several months later, in October 1997, she developed a similar cellulitis‐like lesion on her right ankle. This time there was no history of drug intake. We obtained a skin biopsy from the lesion, and histopathology revealed an intense eosinophilic infiltrate in the dermis and extending into the subcutaneous tissue. Flame figures were abundant ( Fig. 1 ). We also observed edema and erythrocyte extravasation in the dermis. Based on these features and her history, a diagnosis of Wells' syndrome was made. The skin lesion resolved spontaneously, and she has experienced no lesion recurrence since.

Figure 1 Open in figure viewer PowerPoint A characteristic ‘‘flame figure’' (hematoxylin and eosin stain; original magnification, × 230)     

Treatment of nondermatophyte mold and Candida onychomycosis

Mold onychomycosis often can be clinically suspected because of the presence of periungual inflammation. Treatment with systemic antifungals is very effective in onychomycosis caused by Aspergillus sp. Scopulariopsis brevicaulis and Fusarium sp. infection are difficult to eradicate and treatment with systemic antifungals should always be associated with topical treatment with nail lacquers. Candida onychomycosis is always a sign of immunodepression. Systemic treatment with itraconazole or fluconazole is usually effective, but relapses are very common.     

Cutaneous Bipolaris spicifera infection

Bipolaris spicifera is a dematiaceous fungus that has rarely been reported to cause cutaneous infection in humans. A patient with leukemia was examined for a non-healing ulcer on her leg that developed following minor trauma. Histopathologic study revealed groups of nonpigmented, septate fungal hyphae located predominantly in the necrotic ulcer base. Cultures of a biopsy specimen yielded colonies that were gray to black with a black reverse. Microscopic examination revealed dematiaceous, straight, oblong conidia consistent with B spicifera. The ulcer was successfully treated with surgical excision, skin graft, and amphotericin B.     

TINEA CAPITIS IN SAUDI ARABIA

Background. Tinea capitis is a dermatophyte infection of the scalp, eyebrows, and eyelashes caused by species of Microsporum and Trichophyton. The purpose of this study was to discover the incidence and causal agents of tinea capitis in Saudi Arabia. Methods. Hair roots, skin scrapings, and pus swabs were collected from patients clincially diagnosed with tinea capitis and were processed for fungus. Results. Of 372 patients with tinea capitis investigated in Saudi Arabia, 240 were found to be positive by direct microscopic examination, and the causal agent was isolated from 237 patients. Tinea capitis accounted for 47.7% of all superficial mycoses, and 97% of it occurred in children below 15 years of age. Inflammatory lesions were found in 35% of cases, and 10 of them presented with kerion celsi. Favus-type lesion was found in one. Microsporum canis was the most common etiologic agent, responsible for 82.3% of the infections. Trichophyton violaceum was the next most common agent (13.9%), followed by M. audouini (2.2%); T. mertagrophytes, T. rubrum, T. verrucosum, and T. simii were isolated from one patient each. This is the first report of T. simii infection in a Saudi man. Conclusions. Although none of the patients owned pets, the predominance of M. canis may be explained by the large number of cats in the neighborhood. The disappearance of favus due to T. schoenleinii may be due to improved socio-economic conditions. Our results agreed with two previous reports.     

Tuberculosis verrucosa cutis associated with tuberculous lymphadenitis

A 34-year-old man presented with a large cutaneous lesion on his left thigh that had started as a small papule when he was 13 years of age. The lesion had enlarged slowly over the last 21 years. The patient had received bacillus Calmette-Guérin (BCG) vaccination in childhood. The family history was significant for tuberculosis. Clinical examination revealed a large, purplish-red, indurated plaque measuring 30 x 29 cm on the left thigh, extending to the buttock area. The edges of the lesion had a serpiginous contour with an involuted center (Fig. 1). A left inguinal lymph node was palpated. Chest X-ray and blood cell count were normal. No other focus of disease was identified. Laboratory testing for human immunodeficiency virus (HIV) infection was negative. Purified protein derivative (PPD) intradermal injection disclosed a 19-mm skin induration. Both the cutaneous lesion and the inguinal lymph node were biopsied. Histopathologic sections of the skin fragment showed epidermal hyperkeratosis, neovascular proliferation, and a dense dermal lymphocytic infiltrate. The histopathology of the lymph node demonstrated few granulomas with focal areas of central necrosis. Staining for fungus was negative. Ziehl-Neelsen staining was negative on both the skin and lymph node specimens. Culture for fungus and Leishmania sp. was negative. Tissue culture on Lowenstein-Jensen medium from skin and lymph node was positive for Mycobacterium colonies after 5 and 7 weeks, respectively. Multidrug therapy was instituted with rifampin 600 mg/day, isoniazid 400 mg/day, and pyrazinamide 2 g/day for 2 months, and then rifampin 600 mg/day and isoniazid 400 mg/day alone for the next 4 months. An excellent response was obtained at the end of treatment (Fig. 2).     

Pseudoepitheliomatous hyperplasia - an unusual reaction following tattoo: report of a case and review of the literature

A 59-year-old woman presented with an itchy and uncomfortable raised lesion at a tattoo site (Fig. 1) on the lateral aspect of the left leg, just above the ankle. The tattoo had been placed 2 years before her presentation and the tattoo site was sun exposed. Immediately after she had the tattoo, she noticed redness of the skin. After a week, a pruritic and red scaly nodule developed that continued to gradually enlarge until her presentation. The patient had tried topical vitamin A and D ointment with no relief. The patient also had tattoos on the arms without any noticeable skin changes. The patient reported that the tattoo procedure on her leg was more painful than that on her arms, and was performed by a different (and perhaps inexperienced) tattoo artist. The original tattoo contained red, green, and yellow pigments. A diagnosis of tattoo granuloma was considered; squamous cell carcinoma and fungal infection were included in the differential diagnosis. A punch biopsy was performed, followed by complete surgical excision of the lesion with a split-thickness skin graft from the right thigh. The skin excision specimen showed a 3 x 2.5-cm granular and pitted pink lesion with well-demarcated, somewhat irregular borders. The lesion was raised 0.5 cm above the skin surface. The lesion was present in the center of the original tattoo. Portions of the original tattoo with green and blue-green pigmentation were visible on either side of the lesion. No satellite lesions were identified. Microscopically, the raised lesion demonstrated striking pseudoepitheliomatous hyperplasia, with irregular acanthosis of the epidermis and follicular infundibula, hyperkeratosis, and parakeratosis (Fig. 2). Follicular plugging was present with keratin-filled cystic spaces. There was a brisk mononuclear inflammatory infiltrate in the dermis, composed primarily of lymphocytes, with admixed plasma cells and histiocytes. Giant cells were occasionally identified. Dermal pigment deposition was noted both within the lesion and in the surrounding skin, corresponding to the original tattoo. Variable dermal fibrosis was noted, with thick collagen bundles in some areas. There was no evidence of epidermal keratinocytic atypia, dyskeratosis, or increased suprabasal mitotic activity. Special stains (periodic acid-Schiff and acid-fast) for microorganisms were negative.