孢子丝菌病的临床表现诊疗与变迁

孢子丝菌病是由申克孢子丝菌复合体感染皮肤、皮下组织、黏膜和局部淋巴系统所引起的慢性感染性疾病。临床表现多样,皮损主要表现为慢性炎症性肉芽肿损害。自1898年报道第一例孢子丝菌病后,对孢子丝菌病的认识越来越深刻,包括孢子丝菌病原体的变迁及其诊断和治疗方法的改进。病原体从申克孢子丝菌单一菌种到目前孢子丝菌复合体的认识。诊断方法包括真菌学检查、组织病理检查、孢子丝菌素以及分子生物学诊断;治疗方法包括碘化钾、伊曲康唑、特比萘芬、两性霉素B口服以及物理和手术疗法等。     

孢子丝菌病38例临床分析

经真菌培养,涂片和病理检查而确诊３８例孢子丝菌病,其中皮肤淋巴管型２１例,皮肤限局型１７例。采用１０％碘化钾２－３个月治疗,达到临床治愈。     

特比萘芬治疗皮肤播散型孢子丝菌病1例

报告１例３１岁男性患者，全身多发结节７个月，经组织病理、真菌镜检和培养确诊为皮肤播散型孢子丝菌病。给予特比萘芬２５０ｍｇ／ｄ口服，２周后皮损开始好转，３个月达临床和真菌学痊愈。继续隔日２５０ｍｇ维持２个月，无复发迹象。治疗前后未见任何不良反应。特比萘芬能安全有效地治疗皮肤播散型孢子丝菌病，建议剂量采用２５０ｍｇ／ｄ，疗程应在３个月以上     

面部皮肤型孢子丝菌病72例临床分析

目的 报道面部皮肤型孢子丝菌病72例。方法 详细观察72例患者的皮损表现,逐一做真菌学检查,部分做病理检查。采用碘化钾、伊曲康唑、特比萘芬等联合疗法治疗。结果 颜面孢子丝菌病的皮损形态复杂,其中淋巴管型占9.72%,局限型占90.28%,有明确外伤史的26.4%。以碘化钾为基础的联合治疗,6~8周全部治愈。结论 皮损表现和真菌学检查是诊断孢子丝菌病的重要依据。颜面孢子丝菌病形态分布以局限型为主。基层误诊率高达16%。碘化钾为首选基础用药。     

黑龙江省502例孢子丝菌病患者临床分析

目的对黑龙江地区502例孢子丝菌病患者临床资料进行回顾性分析,探讨近年孢子丝菌病的发病特点,为今后防治孢子丝菌病提供有力依据。方法对2014年4月—2017年4月至哈尔滨医科大学第二附属医院就诊,经过临床表现、组织病理检查及真菌培养确诊为孢子丝菌病的502例患者进行回顾性分析。结果患者男女比例1:2,平均年龄49.7岁,以41～65岁人群最为多见。66.5%的患者在冬春两季发病,76.2%的患者为农民,37.8%的患者有明确外伤史。皮肤固定型占74.9%、皮肤淋巴管型24.9%、皮肤播散型0.2%。患者对碘化钾、特比萘芬治疗反应良好。结论孢子丝菌病在黑龙江地区发病率高,其流行病学特点与吉林省、辽宁省相似,但不同于其他国家。碘化钾、特比萘芬、伊曲康唑是其有效的治疗药物。     

用5-氟胞嘧啶治愈皮肤和骨的播散性孢子丝菌病：出现光敏并发症

作者报告一例皮肤及骨播散性孢子丝菌病患者,39岁、男性,1978年9月沿右前臂发生一串软的红色化脓性结节,曾用青霉素、红霉素治疗无效并渐累及臂、面部、躯干、小腿等部位.经真菌学及组织病理检查证实为孢子丝菌病.但用碘化钾治疗     

儿童皮肤型孢子丝菌病56例临床与病理分析

目的分析儿童孢子丝菌病的临床、病理特点,提高临床医生对本病的认识。方法对2006年1月-2010年12月经真菌培养确诊的56例儿童孢子丝菌病进行回顾分析。结果本组病例淋巴管型15例(26.78%),固定型41例(73.21%)。发病部位主要为面部(76.78%)。主要病理类型为混合细胞型肉芽肿(64.29%)。结论儿童孢子丝菌病并非少见,真菌培养是确诊的金标准,组织病理可提供诊断线索,斯皮仁诺口服治疗本病安全有效。     

皮肤固定型孢子丝菌病1例及其相关实验检查

患者男,50岁。左上臂皮肤溃疡2年。皮损组织病理示:炎性肉芽肿改变,PAS染色可见圆形孢子和星状体。皮损真菌培养阳性,菌种鉴定为球形孢子丝菌。确诊为皮肤固定型孢子丝菌病,给予患者口服伊曲康唑和特比萘芬联合治疗3个月,皮损部分改善。之后患者间断口服特比萘芬联合碘化钾治疗,一年半后复诊仍有局灶性皮损未愈。     

误诊为孢子丝菌病的带状结节性痒疹1例

患者男,41岁,右上肢、右胸壁结节6年余。曾于多家医院诊断为“孢子丝菌病”,给予口服及外用抗真菌药物治疗无效。通过皮损组织的真菌学及病理检查,确诊为带状结节性痒疹,给予局部糖皮质激素封闭,辅以抗组胺药、激素类软膏治疗后皮损逐渐消退。呈带状分布的结节性痒疹与局部淋巴管型孢子丝菌病在临床表现上具有一定的相似性,应注意加以鉴别。     

特比萘芬成功地治疗皮肤孢子丝菌病

孢子丝菌病是由申克氏孢子丝菌引起的。口服碘化钾和局部加热常被用于治疗固定型及皮肤淋巴管型孢子丝菌病而获得成功。最近报道一种新的口服抗真菌药特比萘芬治疗皮肤孢子丝菌病有效。该药属丙烯胺类,为高效、广谱的抗真菌制剂,抗菌谱包括皮肤癣菌、酵母菌和霉菌。作者用该药125mg每日1次治疗3例皮肤淋巴管型孢子丝菌病 获得成功。     

Evaluation of skin biopsies for fungal infections: role of routine fungal staining

Background: The diagnosis of cutaneous fungal infection is usually made on clinical examination of the lesion and direct microscopic examination of skin scrapings with potassium hydroxide. Histopathological examination is rarely required to confirm dermatophytic infections. There is often a discord between the clinical and histopathological findings and many times clinical appearance can have a poor histopathological correlation. Methods: This retrospective study was carried out on all skin biopsies received in a period of 1 year. The clinical details of all cases were retrieved and slides were reviewed. Routine fungal staining periodic acid‐Schiff (PAS) stain was performed in all cases. Results: Of 403 skin biopsies received in 1 year, material for further staining was available in 338. On re‐examining the slides stained with PAS stain, fungi were identified in 34 cases (10%), of which fungal infection had been suspected clinically in five cases. Conclusions: Use of routine stains like PAS can help to reach a correct diagnosis and initiate appropriate treatment. Fungal staining should be done in skin biopsies with non‐specific clinical details and microscopic findings for best patient management.     

Cutaneous sporotrichosis. Intermittent treatment (pulses) with itraconazole

Sporotrichosis is a subcutaneous and exceptionally deep mycosis caused by a dimorphic fungus, Sporothrix schenckii. Itraconazole is a triazole derivative leading to good results in the treatment of sporotrichosis. Patients with cutaneous sporotrichosis proven with mycological tests (direct examination and culture) were enrolled. All patients underwent laboratory tests (at baseline and on a monthly basis) and received oral itraconazole 400 mg/day for one week with a 3-week break (pulses); thereafter the drug was administered as pulses until clinical and mycological cure was achieved. Five patients with sporotrichosis were enrolled, 4 with cutaneous lymphangitic form and one with fixed cutaneous form. Clinical and mycological cure was achieved in 4/5 cases (80%), with a mean number of pulses of 3.5. No patient had side effects and no laboratory test abnormalities occurred. Intermittent or pulsed itraconazole was effective in treating cutaneous sporotrichosis. It may be considered as a new treatment choice that entails an important reduction in total medication use.     

A case of lymphangitic sporotrichosis occurring on both forearms with a published work review of cases of bilateral sporotrichosis in Japan

The patient, 56-year-old man who was working as a clerk and a farmer, presented with nodules that had appeared on the dorsa of both his hands 3 months earlier. At the first examination, there were multiple dark-red nodules scattered on the fingers, dorsa and wrists of both hands. The nodules were up to 3 cm in diameter and had crusts in the incenters. The patient was suspected to suffer from prurigo and was subsequently treated with topical steroid, but the nodules did not respond. Therefore, a skin biopsy and fungal culture were performed, and the patient was finally diagnosed as having bilateral multiple sporotrichosis. He was then successfully treated with local thermotherapy and oral potassium iodide. Bilaterally-distributed lymphangitic sporotrichosis is very rare and often difficult to diagnose. Careful attention is required to avoid misdiagnosis.     

20甲扁平苔藓11例临床分析

目的：了解11例20甲扁平苔癣的临床特点，以提高对该病的认识。方法：对11例20甲扁平苔癣患者的临床资料、真菌学和组织病理检查进行分析，并对相关文献进行复习。结果：11例患者中男6例，女5例，平均年龄27．9岁，均表现为20指趾甲全部受累，真菌镜检、培养均阴性，经组织病理检查明确诊断为甲扁平苔癣。结论：甲扁平苔癣好发年龄为青少年和40～60岁，无性别差异。单独发生于甲部，特别是20甲受累的扁平苔癣十分少见，容易误诊，确诊需要组织病理活检。     

甲真菌病甲板真菌镜检方法的探讨

目的探索一种操作简便、结果可靠的甲真菌病检验方法。方法对341例拟诊甲真菌病的患者分别采用KOH直接镜检法和浸软法进行病损指、趾甲的真菌镜检。取病损指、趾甲末端标本少许放入标本小碗中,加入10%的KOH后加盖浸泡至病甲标本完全浸透软化呈蛋白胨状,取标本放在载玻片上并将标本压平、压薄呈云雾状或毛玻璃状,在普通光学显微镜下检查真菌成分。结果KOH直接镜检法和浸软法的真菌检出率分别为34.90%和100.00%。结论浸软法真菌镜检是一种适合临床的、检出率较高的甲真菌病诊断方法。     

Proposal of a histopathological predictive rule for the differential diagnosis between American tegumentary leishmaniasis and sporotrichosis skin lesions

Background American tegumentary leishmaniasis (ATL) and sporotrichosis exhibit similar histopathology and low frequencies of microorganism detection. Objectives This study seeks to identify microscopic alterations that can distinguish between these diseases. Methods Haematoxylin and eosin stained slides of 171 ATL and 97 sporotrichosis samples from active cutaneous lesions were examined for histopathological alterations. The lesions were diagnosed by isolating the agent (which was not visible) in culture. An intuitive diagnosis was assigned to each slide. The strength of the association between the histopathological findings and the diagnosis was estimated by an odds ratio, and each finding was graded according to a regression model. A score was assigned to each sample based on the histopathological findings. A study of the interobserver reliability was performed by calculating kappa coefficients of the histopathological findings and intuitive diagnoses. Results The markers ‘macrophage concentration’, ‘tuberculoid granuloma’ and ‘extracellular matrix degeneration’ were associated with ATL. ‘Suppurative granuloma’, ‘stellate granuloma’, ‘different types of giant cells’, ‘granulomas in granulation tissue’ and ‘abscess outside the granuloma’ were associated with a diagnosis of sporotrichosis. ‘Macrophage concentration’ and ‘suppurative granuloma’ had the highest (substantial and almost perfect, respectively) reliability. The regression model score indicated 92·0% accuracy. The intuitive diagnosis had 82·5% diagnostic accuracy and substantial reliability. Conclusions Taking into account the clinical and epidemiological context, some histopathological alterations might be useful for the differential diagnosis between ATL and sporotrichosis cutaneous lesions in cases in which the aetiological agent is not visible.     

Sporotrichosis

Sporotrichosis is a chronic fungal infection that most commonly involves the skin and lymphatics. It is classified into five forms: classic lymphocutaneous, fixed cutaneous, disseminated cutaneous, primary pulmonary, and systemic sporotrichosis. Its diagnosis is established by fungal culture or by direct immunofluorescence. Safe effective therapy for cutaneous sporotrichosis exists in the form of oral potassium iodide and local heat therapy. However, itraconazole, one of the newer triazole antimycotic agents, appears quite effective against Sporothrix schenckii and may provide a means of reducing both the length of therapy and the relapse rate. Systemic sporotrichosis, although still rare, is becoming more common, especially in immunosuppressed patients. Because of multisystem involvement, both diagnosis and management of patients with systemic sporotrichosis are difficult. Serologic antibody tests such as the slide latex agglutination test are useful to confirm the diagnosis and to determine the effectiveness of antifungal therapy. Intravenous amphotericin B is still considered the drug of choice for systemic sporotrichosis, but the search for a less toxic agent continues. Also, combination drug therapy and surgical intervention are necessary for some patients with extracutaneous sporotrichosis.     

White sponge nevus: A condition not always clinically suspected

White sponge nevus (WSN) is an uncommon benign inherited disorder characterized by white and diffuse painless lesions in oral, esophageal, or genital mucosa. The lesions may develop at birth or later in childhood or adolescence, with careful clinical examination being sufficient for diagnosis in most cases. However, microscopic analysis may be necessary particularly in adults in which other whitish oral lesions may be clinically suspected. Dermatologists, dentists, and pathologists should consider WSN when evaluating multiple white oral lesions, thus preventing unnecessary treatments. Herein, we report four additional cases of WSN with emphasis on its clinical and histopathological features.     

Histologische Diagnose der Onychomykose

It is mandatory to establish a firm diagnosis before starting systemic antimycotic therapy because of potential side effects and relatively high therapy costs. Direct microscopy and fungal culture are the most widely employed diagnostic tools. Not infrequently, a strong clinical suspicion cannot be proven by even repeated direct microscopic examinations and fungal cultures. In these cases histologic examination is a simple alternative. We identified 32 cases of histopathologically proven onychomycosis; of the 29 where a fungal culture was performed, only 14 (48 %) were positive. Direct microscopy was performed only in 12 cases since most had repeatedly negative direct microscopy results before being referred to us; 5 cases (42 %) were positive. Histopathology for onychomycosis has several advantages in addition to its sensitivity – particularly in difficult to diagnose cases: lack of the danger of contamination, a permanent preparation with the possibility to demonstrate fungal invasion of the nail organ and to identify other or concomitant nail disorders, simplicity of the procedure; quicker results as compared to fungal culture. Exact specification of the fungus is not possible with histology. Even though histological examination is not mentioned in the current guidelines for onychomycosis of the German Dermatological Society, it should be kept in mind as a simple but sensitive diagnostic tool.