Scopulariopsis/Microascus isolation in lung transplant recipients: A report of three cases and a review of the literature

The current knowledge of invasive Scopulariopsis/Microascus infection in lung transplantation has been derived from only four case reports. Although these fungi are uncommon compared with Aspergillus, they are highly resistant to the current antifungal agents, and the mortality is extremely high. To explore the risk factors, clinical manifestations, notable diagnostic characteristics and outcomes of positive Scopulariopsis/Microascus isolation in lung transplantation patients. We included all cases with positive Scopulariopsis/Microascus isolation from lower respiratory tracts or bronchial mucosa biopsies in our lung transplantation centre. Proven cases from the literature were added. Positive isolation occurred in 2% (3/157) in our centre. Four cases from the literature were added. The mortality could be considered as high as 80%, once the two cases of colonisation were excluded. The average interval between transplantation and positive isolation was 106 (19‐131) days. A total of 57.1% of patients had experienced a combination of infection with Aspergillus or other fungi as well as long‐term azole antifungal agent treatment before the positive isolation, which may be possible risk factors. The combination of micafungin, posaconazole and terbinafine may be an effective treatment. The peak time of positive isolation was consistent with that of some opportunistic pathogens, and the possible risk factors were the infection of other fungi as well as prior long‐term azole antifungal administration. In addition to its high mortality, Scopulariopsis/Microascus was also highly resistant to common antifungal agents and the combination of two or three drugs for therapy was recommended.     

Treatment of disseminated onychomycosis due to Trichophyton rubrum with itraconazole under control of plasma levels

Successful treatment of a disseminated Trichophyton rubrum infection of the nails is reported. Under therapy with 50 mg/100 mg itraconazole daily total remission was achieved after 5 months (finger nails) and 6 months (toe nails) respectively. Plasma levels of itraconazole were determined twice a month to control the regularity of the treatment using HPLC.     

Onychomycosis Due to a Fungus of the Aspergillus versicolor Group

Summary:  A case of onychomycosis involving both big toe nails caused by a fungus of the Aspergillus versicolor group is described. The presence of hyaline hyphae and conidia in direct microscopy and the repeated isolation in culture of the fungus from the nails before and after extirpation, as well the histopathologic findings, are taken as demonstration of the fungal invasion of the nail tissue. After surgical treatment, the nails grew well and no further Aspergillus isolations were done.
Zusammenfassung:  Es wird ein durch einen Pilz aus der Aspergillus versicolor - Gruppe verursachter Fall beschrieben, der sowohl Zehen als auch Fingernägel betraf. Die Anwesenheit hyaliner Hyphen und Konidien im Nativpräparat und die wiederholte Isolierung von Pilzen der Aspergillus versicolor -Gruppe in Pilzkulturen von den Nägeln jeweils vor und nach der Exstirpation, wie auch die histopathologischen Befunde werden als Beweis für die Pilzinvasion in das Nagelgewebe betrachtet. Nach einer chirurgischen Behandlung wuchsen die Nägel gut, und weitere Aspergillus -Isolierungen erfolgten nicht.     

Candida ciferrii: clinical and microbiological features of an emerging pathogen

The authors report six cases of toenail onyxis due to an unusual yeast species, Candida ciferrii. For half of these cases, direct microscopical examination showed the presence of blastospores and pseudo-to-true mycelium, demonstrating the parasitic transition of the fungus. In light of the literature and of their own experience, the authors suggest that C. ciferrii could be an etiological agent of onychomycosis, particularly for elderly patients with extensive trophic disorders.     

Onychomycosis due to Ulocladium botrytis

A case of disto-lateral onychomycosis of the third toe of the right foot of a 45-year-old man is reported. The agent of infection was Ulocladium botrytis, a mycete not hitherto reported to infect humans. The patient underwent mycological examination consisting of direct microscope observation and culture of pathological material. Diagnosis was based on the macro- and microscopic characteristics of the colonies. Fragments of the latter were also examined by scanning electron microscope. Clinical and mycological recovery was achieved after 3 months of topical therapy with ciclopiroxolamine.     

Onychomycosis, Tinea Pedis and Tinea Manuum Caused by Non-Dermatophytic Filamentous Fungi Nicht-Dermatophyten-Fadenpilze als Erreger von Onychomykosen, Tinea pedis und Tinea manuum

Over 4000 cases of fungal nail, sole and palm infection recorded during a three-year study period were investigated to determine the prevalence and significance of etiologic agents other than dermatophytes and yeasts. Littman's oxgall agar, which permitted isolation of cycloheximide-sensitive species but restricted overgrowth by fast growing contaminants, was used to promote isolation of these disease agents. Non-dermatophytic filamentous fungi made up 2.3% of the confirmed etiologic agents obtained overall, and constituted 3.3% of the agents obtained from nail infections. The most common species were Scopulariopsis brevicaulis, Hendersonula toruloidea, and Aspergillus sydowii. Scytalidium hyalinum was recorded for the first time from Canada, and an instance of nail infection by Gymnascella dankaliensis was recorded. Only H. toruloidea and Sc. hyalinum caused palm and sole infections.     

Dystrophic onychomycosis due to Microsporum gypseum

A case of onychomycosis with nail dystrophy due to Microsporum gypseum in a healthy 35-year-old woman is described. The infection had a 2-year history, occurring in the site of a nail trauma sustained in a fall from a horse. Diagnosis was based on mycological examination (direct microscope observation and culture). Clinical and mycological recovery was achieved after local treatment with ciclopiroxolamine nail solution and pulsed systemic terbinafine therapy.     

Onychomycosis in a diabetic patient due to Trichophyton gallinae

A 67-year-old female suffering from diabetes mellitus type I revealed brownish-yellow discolouration, subungual hyperkeratosis, and onychodystrophy of several finger nails. Upon culturing of nail specimens, Trichophyton gallinae could be repeatedly identified on Sabouraud glucose agar. To our knowledge, this is the first report of a human infection caused by this species in Germany. T. gallinae is a zoophilic dermatophyte that primarily infects higher animals, but can also be transmitted to humans sporadically. Herein, clinical, diagnostic, and epidemiological aspects of this zoophilic dermatophyte are briefly reviewed.     

Contribution à L'Etude de la Sensibilité de Scopulariopsis brevicaulis (Bainier) aux Antifongiques

Résumé: 38 souches de Scopulariopsis brevicaulis isolées de prélèvements au niveau de lésions de la peau et des phanères sont testées comparativement à 3 souches de Scopulariopsis de référence, afin d'apprécier leur sensibilité aux antifongiques utilisés dans le traitement des mycoses. Sont envisagées en utilisant les techniques de la C. M. I. (concentration minimum inhibitrice) sur trois milieux solides (Sabouraud, YMA, Casitone) les sensibilités vis-à-vis: - des antibiotiques: Nystatine, Amphotéricine B, Pimaricine, Griséofulvine. - des dérivés imidazoles: Clotrimazole, Miconazole, Econazole, Isoconazole, Kétoconazole. - des antimétabolites: 5 FC - du Tolnaftate. Scopulariopsis brevicaulis possède généralement une grande résistance vis-à-vis des antifongiques. Parmi les antibiotiques testés la Griséofulvine et l'Amphotéricine semblent inefficaces (C. M. I. sup. à 1000 γ/ml) la Nystatine possède une certaine activité (50 γ/ml) la Pimaricine étant la plus active (5 γ/ml). Parmi les produits chimiques la 5 FC et le Tolnaftate n'ont pas d'action (C. M. I. sup. à 1000 γ/ ml); par contre, les dérivés imidazoles possèdent tous une efficacité certaine vis-à-vis de ce champignon dont le caractère pathogène est souvent discuté. Summary: 38 strains of Scopulariopsis brevicaulis isolated from lesions of the skin and from cutaneous appandages were tested against antimycotics in comparison to 3 strains (2 S. brevicaulis, 1 S. brumptii) taken from culture collections. Minimal inhibitory concentrations were determined on different solid media using the following antifungals: nystatine, amphotericine B, pimaricine, griseofulvin, clotrimazole, miconazole, econazole, isoconazole, ketoconazole, 5-flucytosine, tolnaftate. In general, S. brevicaulis showed remarkable resistance against the antifugal substances. Among the antibiotics, griseofulvin and amphotericin B were without effect (MIC > 1000 μg/ml). Nystatine had some inhibitory activity (MIC = 50 μg/ml) while pimaricine was the most active substance (MIC = 5 μg/ml). Among the antimycotic chemicals, flucytosine and tolnaftate were ineffective while all the imidazoles had some inhibitory activity against this fungus whose role as pathogen is often discussed.     

Fungi Causing Superficial Cutaneous Mycoses in the District of Cracow Part One: The Incidence of Dermatophytes

Summary: From January 1^st 1972 to December 31^st 1981 5363 patients living in Cracow and its environs were examined mycologically. Those patients were suspected of superficial cutaneous mycoses and were referred to the department of Mycology of the Institute of Microbiology (Medical Academy of Cracow). A total of 8545 samples were examined. 36% of the patients were males and 64% were females. Part one of the paper presents the spectrum of dermatophytes isolated from different regions of the skin, the nails and hair. In general, dermatophytes were cultured from 23% of the specimens. T. rubrum outnumbered T. mentagrophytes (13.7% and 8.87% respectively). Other species and genera of dermatophytes such as T. tonsurans, T. violaceum, T. verrucosum, E. floccosum and M. gypseum were found only sporadically. Dermatophytes were found most often in samples taken from the toe nails (39.6%) and the skin of the feet (38.9%), both in male patients. They were found extremely rarely in samples taken from the scalp and the beard (5.8%). Many authors have pointed out that it is important to review the mycological flora of human skin in certain areas of the world from time to time because this flora changes (2, 6, 10, 13). Zusammenfassung: Vom 1. Januar 1972 bis 31. Dezember 1981 wurden 5363 Patienten aus Krakau und dessen Umgebung mykologisch untersucht. Diese boten klinischen Anhalt für oberflächliche Mykosen der Haut Sie wurden an die Abteilung für Mykologie des Institutes für Mikrobiologie (Medizinische Akademie Krakau) überwiesen. Insgesamt wurden 8545 Proben untersucht 36% der Untersuchten waren Männer, 64% Frauen. Teil 1 der Arbeit bringt das Dermatophytenspektrum, welches aus verschiedenen Bereichen - der Haut, den Nägeln und den Haaren - isoliert wurde. Insgesamt wurden aus 23% der Proben Dermatophyten gezüchtet. T. rubrum übertraf T. mentagrophytes (Nachweis in 13,7 bzw. 8,87% der Fälle). Andere Dermatophytenarten und -gattungen wie T. tonsurans, T. violaceum, T. verrucosum, E. floccosum und M. gypseum wurden nur sporadisch nachgewiesen. Dermatophyten wurden am häufigsten aus Zehennägeln und Fußhaut bei Männern nachgewiesen (in 39,6 bzw. 38,9% der Fälle), am seltensten aus Proben der Kopf- und Bartregion.     

Ungual phaeohyphomycosis caused by Alternaria alternata

Summary. Phaeohyphomycoses are a heterogeneous group of rare mycotic infections caused by dematiaceous fungi. They are classified into four forms: superficial, cutaneous and corneal, subcutaneous, systemic. Alternaria species are ubiquitous fungi that are occasionally aetiological agents of pheohyphomycosis. A case of onychomycosis caused by Alternaria alternata treated with itraconazole is reported.
Zusammenfassung. Phaeohyphomykosen sind eine heterogene Gruppe seltener, durch Dematiaceae-Arten hervorgerufener Infektionen Man unterscheidet vier Formen: oberflächliche, kutane und corneale, subkutane, systemische. Die Alternaria -Arten sind allgegenwärtige Pilze, die gelegentlich Phaeohyphomykosen verursachen. Wir berichten über einen Fall von Onychomykose, durch Alternaria verursacht und mit Itraconazol behandelt.     

First isolation of Trichophyton raubitschekii (syn. T. rubrum) in Europe

Trichophyton raubitschekii is a rare dermatophyte which belongs to the Trichophyton rubrum species complex. Since 1981, only a few cases of dermatophytosis due to this anthropophilic causative agent were published. In this paper the authors report the first cases of Tinea corporis caused by Trichophyton raubitschekii (syn. T. rubrum) in Europe. The patients, one immigrant from Ghana and three from Cameroon, had typical lesions of tinea corporis. Four strains were isolated and characterized by conventional and molecular methods. On morphological and physiological grounds the isolates were identified as T. raubitschekii by the following phenotypical features: (1) velvety colony texture; (2) brown pigment; (3) abundant macroconidia and (4) positive urease activity. Molecular diagnostics were performed by single strand conformation polymorphism (SSCP) and sequence analysis of the ATPase9 intron of the mitochondrial (mt) DNA and the internal transcribed spacer (ITS) region of the rDNA, respectively. The ITS sequences and SSCP patterns of the ATPase9 intron were found to be identical among the four strains and also when compared to reference strains of T. rubrum. As shown in the present paper, T. raubitschekii is genetically identical to T. rubrum but differs in some phenotypical characteristics. Since misidentification with other dark-coloured dermatophyte variants is possible, medical mycologists should bear in mind the special morphological characteristics of T. raubitschekii (syn. T. rubrum) for future identifications.     

A human subcutaneous infection by Microascus ennothomasiorum sp. nov

A 60‐year‐old woman presented with a nodular granulomatous skin lesion on her right thumb. It had developed after inoculation of a splinter of wood. Because it was resistant to various therapies, the nodule was finally excised. Complete healing followed this surgery and a melanised filamentous fungus with scopulariopsis‐like morphology was recovered from the dermal tissue. Fitting with no known species, the fungus was subjected to extensive morphological, physiological and genetic investigations. It was characterised by resistance to cycloheximide, growth at 37°C, branched conidiophores with cylindrical annellides in brush‐like groups producing dark conidia in basipetal chains, and cleistothecia with ellipsoidal to slightly reniform ascospores. Genetically it clustered in a well‐supported clade together with Microascus (M.) brunneosporus, Microascus chinensis, Microascus intricatus, Microascus longicollis, Microascus micronesiensis and Microascus onychoides, but formed an independent branch distant from the other Microascus species. Based on its unique genetic characteristics and morphological findings, the isolate is proposed as a new species, Microascus ennothomasiorum. Morphologically it differs from its phylogenetically closest species by its branched conidiophores and ascomata with a peridium of textura intricata. Our observation once again emphasises that dermal granulomas can be caused by uncommon fungi; diagnostics should therefore include appropriate mycological investigations.     

Tinea faciei incognito due to Trichophyton rubrum as a result of autoinoculation from onychomycosis

The localisation of a dermatophytosis on the face is rare. Differential diagnoses include a broad range of dermatological disorders, e. g. contact dermatitis, psoriasis vulgaris, seborrhoeic dermatitis, demodicosis, and polymorphic photo eruptions. Two patients suffering from tinea faciei incognito caused by Trichophyton rubrum are presented. Diagnosis was based on mycological diagnostics of skin scrapings using Calcofluor preparation and cultivation of the causative dermatophyte. Both patients were suffering from tinea pedis and tinea unguium caused by the same dermatophyte species. An infection caused by Trichophyton rubrum of the face always occurs following autoinoculation from a pre-existing tinea pedis and tinea unguium of feet and toenails, sometimes of the fingernails.     

Performance of mycology and histopathology tests for the diagnosis of toenail onychomycosis due to filamentous fungi: Dermatophyte and non‐dermatophyte moulds

Improvement of laboratory diagnosis of onychomychosis is important so that adequate treatment can be safely implemented. To evaluate and compare the performance of mycological and histopathological examinations in onychomycoses caused by dermatophyte and non‐dermatophyte moulds. Patients with lateral/distal subungual onychomycosis in at least one hallux were enrolled in the protocol and assessed via mycological and histopathological tests. The isolation of filamentous fungi was considered the gold standard. Test performance was evaluated through sensitivity, specificity and positive and negative predictive values. A total of 212 patients were enrolled in the study. Direct microscopy (DM) was positive in 57.5% patients, and cultures in 34.4%. Among these patients, 23.3% were positive for dermatophytes, with Trichophyton rubrum the most frequently isolated, and 86.3% were positive for non‐dermatophytes, with Neoscytalidium dimidiatum predominance. Histopathology was positive in 41.0% samples. Direct microscopy showed better sensitivity for non‐dermatophyte moulds (P=.000) and nail clipping was more specific for dermatophyte (P=.018). Histopathology of the distal nail plate is a valuable complementary tool for the diagnosis of onychomycosis caused by dermatophytes and direct microscopy is especially useful for non‐dermatophyte molds.     

Clinico-Mycological Study of Dermatomycoses in Madras (India)

Summary: Three hundred and fifty clinically diagnosed cases of dermatomycoses from a referral hospital in Madras (India) were subjected to mycological investigation during 1980–1982. Skin scrapings and hair and nail clippings from the patients were examined by direct microscopy and culture. The data were analysed to correlate the fungal species with certain factors like age, sex, clinical types and occupation. Among the clinical types encountered, tinea corporis was the most predominant one followed by tinea cruris. The maximum isolates obtained in this study were T. mentagrophytes (96/195) and the pattern of incidence of fungal species was: T. mentagrophytes (49.23%) > Candida spp. (22.05%) > T. rubrum (153%) > E. floccosum (4.61%) = Microsporum spp. (4.61%) > T. violaceum (4.1%).
Zusammenfassung: 350 Paüenten mit dem klinischen Verdacht einer Dermatomykose wurden in den Jahren 1980 bis 1982 in einem Krankenhaus in Madras (Indien) mykologisch untersucht. Die Haut-, Haar- und Nagel-Proben wurden mikroskopisch und kulturell untersucht Bei der Auswertung wurden Alter, Geschlecht, Beruf und klinische Formen der Mykose berücksichtigt. Bei den letzteren erwies sich die Tinea corporis als die häufigste Form, ihr folgte die Tinea cruris. Der häufigste Erreger war bei dieser Untersuchung Trichophyton mentagrophytes (96 von 195). Im übrigen ergaben sich folgende Zahlen: T. mentagrophytes (49,23%) > Candida spp. (22,05%) > T. rubrum (15,3%) > E. floccosum (4,61%) = Microsporum spp. (4,61%) > T. violaceum (4,1%).     

Molecular identification and antifungal susceptibility of clinical fungal isolates from onychomycosis (uncommon and emerging species)

Onychomycosis is a common nail problem, accounting for up to 50% of all nail diseases. The aim of the present study was to determine the species distribution based on the restriction fragment length polymorphism and susceptibility patterns of the causative agents of onychomycosis. This cross‐sectional study was conducted on nail samples collected from 257 patients suspected of onychomycosis during 14 months. Fungal isolates were identified by polymerase chain reaction‐restriction fragment length polymorphisms (PCR‐RFLP) with the enzymes Msp I, Mva I, Alw I and sequencing. According to the results, out of the 257 patients participating in the study, onychomycosis was diagnosed in 180 (70.03%) cases, among which 51.1% were caused by non‐dermatophyte moulds (NDMs), 35% by yeast and 10.6% by dermatophytes. Numerous cryptic species recovered from onychomycosis for the first time. In the majority of cases, novel triazoles and imidazoles (ie, efinaconazole, luliconazole and lanoconazole) showed potent activity in comparison with other antifungal agents. The minimum inhibitory concentration (MIC) of luliconazole and lanoconazole ranged within 0.001 to >1 μg/mL and their geometric mean MICs were 0.0154 and 0.0309 μg/mL against all isolates, respectively. It seems that obtained data will be useful to improve the knowledge of researchers, clinicians and dermatologists about onychomycosis distribution, species diversity and adoption of appropriate treatment.     

Histopathological examination of nail clippings using PAS staining (HPE‐PAS): gold standard in diagnosis of Onychomycosis

Onychomycosis is fungal infection of one or more of the nail units. However, because fungi cause only about half of all nail dystrophies, the use of appropriate diagnostic techniques is important to ensure correct diagnosis and treatment. Aim of the present study was to compare direct microscopy, culture and HPE‐PAS for diagnosis of onychomycosis by evaluating their sensitivity and various other relevant statistical parameters. A prospective, hospital‐based, cross‐sectional study was conducted on 216 patients with a high degree of clinical suspicion of onychomycosis. Nail specimens were evaluated using three diagnostic methods, i.e. direct microscopy using 20% Potassium hydroxide (KOH) & 40% Di‐methyl‐suphoxide (DMSO), culture and histopathological examination using PAS stain (HPE‐PAS). Of 216 patients direct microscopy was positive in 138 (63.9%), culture in 147 (68%) and HPE‐PAS in 164 patients (76%). One hundred and seventy‐nine patients fitted into the criteria set for confirmed diagnosis of onychomycosis. Using this as a denominator; direct microscopy, culture and HPE‐PAS had sensitivities of 77.1%, 70% and 91.6% respectively. Also, HPE‐PAS showed the highest sensitivity of 94.7% in 19 cases with prediagnostic antimycotic treatment compared to direct microscopy (42.1%) or culture (57.9%). HPE‐PAS shows high sensitivity for diagnosis of onychomycosis and can be considered as a gold standard in the diagnosis of onychomycosis.