Short duration treatment with terbinafine for tinea capitis caused by Trichophyton or Microsporum species. The Study Group

Thirty-five patients with mycologically proven scalp infections were enrolled in a randomized, double-blind clinical trial with oral terbinafine (dose adjusted according to patient weight) for either 1 or 2 weeks. Patients were observed for 12 weeks; after 4 weeks, non-responders were offered an additional 4 weeks of treatment followed by a second observation period. The causative organisms were Microsporum canis (n = 12), Trichophyton tonsurans (n = 12) and other Trichophyton spp. (n = 11). The Trichophyton infections were treated effectively in five of nine (56%) patients treated for 1 week and 12 of 14 (86%) patients treated for 2 weeks. Three of the non-responders were treated for an additional 4 weeks, and one responded. In the Microsporum group only one of seven patients treated for 1 week and none of five treated for 2 weeks responded. However, treatment was effective in four of six (66%) patients treated for an additional 4 weeks. Mild to moderate adverse events believed to be drug related occurred in four patients in each of the two groups. Terbinafine is well tolerated, and requires 2 weeks of treatment in most patients with Trichophyton scalp infections and 4 weeks or more in Microsporum scalp infections, to achieve a successful clinical and mycological response.     

Signature polymorphisms in the internal transcribed spacer region relevant for the differentiation of zoophilic and anthropophilic strains of Trichophyton interdigitale and other species of T. mentagrophytes sensu lato

Background Dermatophytes are the main cause of superficial mycoses in humans and animals. Molecular research has given useful insights into the phylogeny and taxonomy of the dermatophytes to overcome the difficulties with conventional diagnostics. Objectives The Trichophyton mentagrophytes complex consists of anthropophilic as well as zoophilic species. Although several molecular markers have been developed for the differentiation of strains belonging to T. mentagrophytes sensu lato, correct identification still remains problematic, especially concerning the delineation of anthropophilic and zoophilic strains of T. interdigitale. This differentiation is not academic but is essential for selection of the correct antimycotic therapy to treat infected patients. Methods One hundred and thirty isolates identified by morphological characteristics as T. mentagrophytes sensu lato were investigated using restriction fragment length polymorphism (RFLP) and sequence analysis of the polymerase chain reaction‐amplified internal transcribed spacer (ITS) region of the rDNA. Results Species of this complex produced individual RFLP patterns obtained by the restriction enzyme MvaI. Subsequent sequence analysis of the ITS1, 5.8S and ITS2 region of all strains, but of T. interdigitale in particular, revealed single unique polymorphisms in anthropophilic and zoophilic strains. Conclusions Signature polymorphisms were observed to be useful for the differentiation of these strains and epidemiological data showed a host specificity among zoophilic strains of T. interdigitale/Arthroderma vanbreuseghemii compared with A. benhamiae as well as characteristic clinical pictures in humans when caused by zoophilic or anthropophilic strains. The delineation is relevant because it helps in determining the correct treatment and provides clues regarding the source of the infection.     

Detection and identification of Trichophyton tonsurans from clinical isolates and hairbrush samples by loop‐mediated isothermal amplification system

Since the 1990s, there have been reports of the spread of dermatophytosis caused by Trichophyton tonsurans among contact sports athletes in several countries, including Japan. This study was performed to develop a loop‐mediated isothermal amplification (LAMP) system for rapid and accurate detection and identification of T. tonsurans from clinical isolates or hairbrush samples for diagnosis and to prevent the spread of infection. A specific primer set was prepared by comparing the whole genome sequence of T. tonsurans with those of six other closely related dermatophytes. After confirming the sensitivity and specificity of this system, LAMP assay was performed using 37 clinical samples obtained from three healthy volunteers and 24 judo athletes. A total of 155 fungal isolates (56 strains of various standard fungi, 96 identified T. tonsurans isolates, three hairbrush‐cultured isolates from judo athletes) and 37 hairbrush samples (34 samples from 24 judo athletes, and three samples from three healthy volunteers) were used for culture and LAMP assay, respectively. The assay showed no cross‐reactivity to standard strains other than T. tonsurans. The detection limit was 100 copies of DNA template per tube. All of the 96 T. tonsurans isolates were amplified, and all samples from healthy volunteers showed negative results. Four of the 34 hairbrush samples obtained from judo athletes showed positive results in LAMP assay, and two of the four were positive in both culture and LAMP assay. We developed a rapid LAMP system with high specificity and sensitivity for diagnosis of T. tonsurans infection.     

Screening for asymptomatic carriage of Trichophyton tonsurans in household contacts of patients with tinea capitis: results of 209 patients from South London

BACKGROUND: There is currently an epidemic of tinea capitis in urban areas of developed countries caused by Trichophyton tonsurans. Recurrence or re-infection with dermatophyte is not uncommon after adequate oral treatment. Asymptomatic carriers who are household contacts may partly explain this observation by forming a reservoir for infection. PATIENTS/METHODS: Two-hundred and nine household contacts of patients with tinea capitis were examined and screened for asymptomatic carriage of dermatophyte. RESULTS: Only 7.2% had clinically evident disease yet 44.5% had silent fungal carriage on the scalp. Children under 16 years were much more likely to be carriers than adults (P < 0.001) and males were less likely than females to be affected (P < 0.01). CONCLUSION: This evidence poses questions about factors relevant in transmission of dermatophytes. The authors propose that all household contacts of patients with tinea capitis should be offered screening to eradicate a potential reservoir of infection.     

A case of black dot ringworm attributable to Trichophyton violaceum: a simple method for identifying macroconidia and microconidia formation by Fungi-Tape and MycoPerm-Blue

An 85-year-old Japanese woman sought a dermatologic consultation for evaluation of a walnut-sized alopecia with pityroid desquamation in the parietal region of her scalp. She had been admitted to a nursing home about three months earlier, and, at that time, a thumb-tip-sized, scaly alopecia was noted. Several hairs at the site were eroded in a black dot. Direct KOH microscopy of affected hair showed large spore endothrix infection. To isolate macro- and microconidia for fungal identification, we incubated the affected hair and scales and obtained giant colonies in a special enriched medium. Using Fungi-tape and MycoPerm-Blue, we were able to collect and identify Trichophyton violaceum macro- and microconidia from the white, powdery, fluffy colony that slowly developed after about six weeks of growth on enriched medium. Over the past 20 years, only about 20 cases of tinea capitis caused by T. violaceum have been reported in Japan, and macroconidia have been identified in only 4 cases, including this one.     

从包皮龟头炎患者皮损处分离鉴定马拉色菌

目的：了解马拉色菌属各菌种在包皮龟头炎皮损处的构成及其在发病中的作用。方法：从患处取材直接镜检查见马拉色菌孢子和(或)菌丝的包皮龟头炎患者作为研究对象。用胶带法取材后分别接种在含菜子油的培养基及无放线菌酮的沙堡培养基分离菌种。依据生理生化和形念学特点及转种到科玛嘉显色培养基和米粉吐温80琼脂培养结果鉴定出马拉色菌和(或)念珠菌。结果：81例患者中有57例(70．37％)培养并鉴定出马拉色菌(共60株)，其中糠秕马拉色菌20株(33．33％），合轴马拉色菌18株(30．00％)，钝形马拉色菌17株(28．33％)，球形马拉色菌5株(8．33％)。有37例同时分离到念珠菌(其中72．97％为白念珠菌）。44例仅检出马拉色菌的患者中有23例接受抗真菌治疗。结论：糠秕马拉色菌、合轴马拉色菌、钝形马拉色菌是包皮龟头炎患者皮损处的主要菌种；马拉色菌可能单独或与念珠菌协同引起包皮龟头炎。     

Trichophyton rubrum invasion of human hair apparatus in tinea capitis and tinea barbae: light- and electron microscopic study

Summary We have previously reported morphological changes ofTrichophyton violaceum andMicrosporum canis in hair apparatuses in tinea capitis. To investigate the morphology ofTrichophyton rubrum in the human hair apparatus, two cases of tinea capitis and one case of tinea barbae were examined by light- and electron microscopy. The fungal elements, which were located in the lower keratogenous zone, showed non-septate hyphae in the outer part of the hair cortex. With the upward development of the hair layers, some hyphae invaded the keratinized hair cuticle and keratinized inner root sheath and were transformed into arthrospores. Some hyphae remaining in the hair cortex were also transformed into arthrospores, while other hyphae in the hair cortex did not survive, but degenerated. InT. rubrum hair infection, there is a distinct relationship between the morphological changes of the fungi and the hair cell differentiation as seen inT. violaceum andM. canis infections. However,T. rubrum displays unique morphological changes, which are different from those ofT. violaceum andM. canis, in hair apparatuses.     

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.     

Thoroughness of skin examination by melanoma patients: Influence of age, sex and partner

The aim of this study was to determine the thoroughness of deliberate skin examination by people with a history of melanoma. Patients were randomized into one of two conditions: either to receive the brief educational and skills training intervention alone or as a couple with their spouse or cohabiting partner. Subjects recorded concerning lesions on body maps. At the 4-month visit, a total body skin examination was performed by a dermatologist blinded to the subjects' condition and to their recorded responses. The skin surface was divided according to the region's visibility during skin self-examination and sexual connotations: visible/not sexually sensitive, non-visible/not sexually sensitive and sexually sensitive. The primary point of comparison was missed lesions, defined as the difference between lesions recorded by the subjects and their partners and those recorded by the dermatologist. Among 130 participants, 56 subjects reported partner assistance while performing SSE. Participants missed more lesions in sexually sensitive areas than in the other regions. With the increasing age of the patient, the number of missed lesions in non-visible/not sexually sensitive and sexually sensitive areas decreased. Male patients assisted by female partners missed fewer lesions in all three regions than female patients assisted by male partners. In easily visible areas, male patients missed significantly fewer lesions than female patients ( P  = 0.01). Older couples performed more thorough partner-assisted skin examinations in non-visible and sexually sensitive areas than younger couples. Male patients who were assisted by female partners performed more thorough partner-assisted skin examinations than female patients assisted by male partners.     

Epinephrine‐supplemented local anesthetics for ear and nose surgery: Clinical use without complications in more than 10,000 surgical procedures

Introduction: Local anesthetics supplemented with epinephrine are generally regarded as contraindicated for surgical procedures involving the fingers, toes, penis, outer ear and the tip of the nose [ 1 ], but epinephrine is essential if automated tumescence local anesthesia (Auto‐TLA) is used. Materials and methods: Infiltration anesthesia supplemented with 1 : 200,000 epinephrine was used from 1985 – 1997 in our department, while Auto‐TLA supplemented with 1 : 1.000,000 epinephrine was introduced in 1997 for all surgical procedures involving the ear or nose. During this period, 10,201 patients underwent surgery at these locations. In addition, dermal blood flow was analyzed by acral photoplethysmography (APPG) and laser Doppler flowmetry (LDF) in the right ear lobe of five normal volunteers and during epinephrine supplemented Auto‐TLA. Results: Epinephrine‐induced complications were not observed in a single patient. Cosmetic skin flap surgery was performed in 4,953 of these patients. Even in patients with extended surgical procedures that took up to one to two hours and that included extensive skin flaps or skin grafts, we observed no increase in complications when compared to procedures performed either under general anesthesia or local anesthesia without epinephrine supplementation. Measuring blood perfusion of the earlobe showed a 69 % reduction of LDF and a 42 % reduction of arterial inflow (APPG) immediately following anesthesia. Conclusion: Epinephrine supplementation of local anesthetics does not block blood perfusion in the ear and did not induce organ, tissue or flap necrosis. Local anesthesia with epinephrine supplementation is therefore safe for acral areas such as the ear or nose. Despite the relatively small influence on blood perfusion, epinephrine supplementation results in a relatively bloodless operating field and longer effectiveness of local anesthesia. The relative absence of blood in the operating field of the ear and nose significantly reduces the duration of surgery and increases the healing rate, as less electrocautery is needed.     

Awareness and early detection of cutaneous melanoma: an analysis of factors related to delay in treatment

Factors associated with the detection of cutaneous melanomas and reasons for delay in diagnosis were investigated in 429 patients with histologically proven melanoma operated on between January 1993 and June 1996. Patients were interviewed using a standardized questionnaire. In 25% of patients, treatment was delayed for more than 1 year from the time they first noticed a suspicious pigmented lesion. Melanoma was detected by the patients themselves in 67% of women and 45% of men. The three predominant clinical symptoms of melanoma were change in colour (darker), increase in size and increase in elevation of a pigmented lesion. The role of sun exposure and of naevi as risk factors for melanoma, as well as the potential benefit of early treatment, were known by 87%, 66% and 82% of the patients, respectively. However, melanoma awareness had no impact on the time period between first observation of skin changes and treatment. Among the factors associated with delay in melanoma diagnosis, an initial incorrect diagnosis as a benign lesion by the physician first visited (in 18% of all cases) had the highest significance. Patients detecting their lesions themselves were treated significantly later than patients in whom others had remarked on changes in a naevus. Furthermore, melanomas of the head and neck were treated later than melanomas at other body sites. Further efforts to educate both the public and the medical profession are essential to ensure earlier treatment for cutaneous melanomas.     

In vitro phototoxicity of new quinolones: production of active oxygen species and photosensitized lipid peroxidation

To elucidate photosensitization potentials of new quinolone antibacterial agents, production of active oxygen species and peroxidation of squalene after ultraviolet A exposure were investigated. Production of singlet oxygen and/or hydrogen peroxide was estimated by bleaching of p-nitroso-N,N-dimethylaniline. Lomefloxacin showed the greatest ability to produce active oxygen species, and this ability was reduced by the addition of the singlet oxygen quencher sodium azide. Ciprofloxacin and fleroxacin also had strong activity. Photosensitized peroxidation of squalene was evaluated by measurement of thiobarbituric acid-reactive substances. Lomefloxacin was the strongest sensitizer, followed by fleroxacin and ciprofloxacin. These results suggest that certain new quinolones are involved in phototoxicity via the mechanism of active oxygen species.     

A Novel Approach for Full-Thickness Defect of the Nasal Alar Rim: Primary Closure of the Defect and Reduction of the Contralateral Normal Ala for Symmetry

In full-thickness defects of the nasal alar rim, to achieve projection and maintain airway patency, cartilage graft is frequently needed. However, cartilage graft presents a challenge in considerations such as appropriate donor site, skeletal shape and size, and healing of the donor area. To avoid these demerits, we tried primary closure of alar rim defects by also making the contralateral normal ala smaller. We treated two patients who had a full-thickness nasal alar defect after tumor excision. Cartilage graft was considered for the reconstruction. However, their alar rims were overly curved and their nostril openings were large. To utilize their nasal shape, we did primary closure of the defect rather than cartilage graft, and then downsized the contralateral nasal ala by means of wedge resection to make the alae symmetric. Both patients were satisfied with their aesthetic results, which showed a smaller nostril and nearly straight alar rims. Moreover, functionally, there was no discomfort during breathing in both patients. We propose our idea as one of the reconstruction options for nasal alar defects. It is a simple and easy-to-perform procedure, in addition to enhancing the nasal contour. This method would be useful for patients with a large nostril and an overly curved alar rim.     

皮肤分枝杆菌感染微孔板反向杂交检测法的研究

目的 探讨微孔板反向分子杂交技术与PCR-ELISA相结合的“拟芯片”法检测和鉴定几种常见的皮肤分枝杆菌感染的方法。方法 首先对5种分枝杆菌标准菌株(结核分枝杆菌、鸟分枝杆菌、胞内分枝杆菌、堪萨斯分枝杆菌和偶遇分枝杆菌)16s rRNA DNA进行PCR扩增获得其PCR产物:其次对"拟芯片"法反应条件进行优化;并对其敏感性、特异性进行检测;再用建立的方法对9例临床分离株进行检测和鉴定。结果 "拟芯片"法反应条件优化结果为:探针包被浓度为100 nmol/mL,探针包被时间为15 min,杂交的温度为55℃,杂交时间为45 min,辣根过氧化物酶标记的亲和素的稀释度为1:800;"拟芯片"法敏感性为1×10¹～1×10²个菌细胞/mL;特异性较好,各菌探针与其他分枝杆菌间无交叉。结论 "拟芯片"法是快速、敏感及特异的皮肤分枝杆菌感染诊断方法之一。     

Molecular diagnosis of cutaneous leishmaniasis and species identification: analysis of 122 biopsies with varied parasite index

Background: Cutaneous leishmaniasis is endemic in the Middle East and North Africa. Confirming the diagnosis histologically depends on amastigote identification, which varies significantly depending on the inoculum, strain type, host response and disease stage. Accurate histological diagnosis is mandatory for appropriate therapy. Methods: Skin biopsies from 122 patients from Lebanon, Syria and Saudi Arabia with clinical diagnosis of untreated leishmaniasis were reviewed and clinical data extracted. Cases were classified according to the modified Ridley's parasitic index. DNA was extracted from formalin‐fixed paraffin‐embedded blocks. Polymerase chain reaction (PCR) was performed using Leishmania‐specific ribosomal internal transcribed spacer 1 (ITS1‐PCR). Nested ITS1‐PCR was performed on cases negative for conventional ITS1‐PCR. ITS1‐PCR amplicons were digested with HaeIII for subsequent restriction fragment length polymorphism (RFLP) subspeciation. Results: Of 122 cases, 54 (44.3%) showed a parasitic index of 0–1+ (no unequivocal amastigotes). ITS1‐PCR (conventional and nested) was positive for all cases as compared with negative control tissue. RFLP identified Leishmania tropica in all cases. Patients with clinically suspected leishmaniasis, whose skin biopsies failed to detect amastigotes represented 44.3% of our cases. Conclusions: In this study, we describe a rapid and optimized protocol from DNA extraction to leishmaniasis subspeciation. ITS1‐PCR showed high sensitivity and specificity in confirming clinically suspected cases. Yehia L, Adib‐Houreih M, Raslan WF, Kibbi A‐G, Loya A, Firooz A, Satti M, El‐Sabban M, Khalifeh I. Molecular diagnosis of cutaneous leishmaniasis and species identification: analysis of 122 biopsies with varied parasite index.