Dysbiosis of skin microbiota with increased fungal diversity is associated with severity of disease in atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is a multifactorial inflammatory skin disease and an altered skin microbiota with an increase of Staphylococcus aureus has been reported. However, the role of fungi remains poorly investigated. OBJECTIVES: We aimed to improve the understanding of the fungal skin microbiota, the mycobiota, in AD in relation to the bacterial colonization. METHODS: Skin swabs of 16 AD patients and 16 healthy controls (HC) from four different skin sites, that is antecubital crease, dorsal neck, glabella and vertex from multiple time points were analysed by DNA sequencing of the internal transcribed spacer region 1 (ITS1) and 16S rRNA gene for fungi and bacteria, respectively. RESULTS: Malassezia spp. were the predominant fungi in all subjects but with a decreased dominance in severe AD patients in favour of non-Malassezia fungi, for example Candida spp. For bacteria, a decrease of Cutibacterium spp. in AD patients in favour of Staphylococcus spp., particularly S. aureus, was observed. Further, both bacterial and fungal community compositions of severe AD patients significantly differed from mild-to-moderate AD patients and HC with the latter two having overall similar microbiota showing some distinctions in bacterial communities. CONCLUSIONS: We conclude that severe AD is associated with a pronounced dysbiosis of the microbiota with increased fungal diversity. Potentially infectious agents, for example Staphylococcus and Candida, were increased in severe AD.

In vitro efficacy of antifungal agents alone and in shampoo formulation against dandruff-associated Malassezia spp. and Staphylococcus spp.

OBJECTIVE: Dandruff is a complex skin condition characterized by unpleasant itching and flaking of the scalp. It is primarily attributed to the over colonization of Malassezia yeasts such as Malassezia globosa and Malassezia restricta. Some studies also suggest the involvement of staphylococci bacteria in dandruff disease pathogenesis. We aimed to access the effectiveness of anti-dandruff treatments by determining the efficacy of the active antifungal agents alone or in commercial shampoo formulations against Malassezia and Staphylococcus. METHODS: The minimum inhibitory concentrations of three anti-dandruff shampoo antifungals (zinc pyrithione, ketoconazole and ciclopirox) and the witch hazel extract, hamamelitannin were tested against commensal Malassezia and Staphylococcus species using broth microdilution methods. In experiments simulating shampoo exposure and washing conditions on the scalp, we also tested the ability of the above agents in shampoo formulation (Head and Shoulders® (H&S), Ketomed® , Sebiprox® , Erol Healthcare Hair Shampoo® respectively) along with a generic over-the-shelf shampoo to inhibit microbial growth. RESULTS: Ketomed® and H&S shampoo were the most effective treatments against Malassezia in in vitro assays and washing simulation experiments. Erol Healthcare Hair Shampoo® was less effective against Malassezia as it required a longer contact time to achieve growth inhibition for some species. Sebiprox® showed variable efficacy in washing and contact time experiments whereas the generic over-the-shelf shampoo was the least effective in inhibiting Malassezia and Staphylococcus growth. CONCLUSION: From these findings, it is reasonable that patients with dandruff may benefit from applying specific antifungal shampoo although results may vary with microbial species, time of contact and shampoo formulation components.

OBJECTIFS: Les pellicules sont une affection cutanée complexe caractérisée par des démangeaisons et une desquamation du cuir chevelu. Elles sont principalement attribuées à une colonisation excessive par des levures du genre Malassezia telles que Malassezia globosa et Malassezia restricta. Certaines études suggèrent également que des bactéries comme les staphylocoques sont impliquées dans la pathogenèse des pellicules. Nous désirions évaluer l'efficacité des traitements antipelliculaires en déterminant l'efficacité des antifongiques actifs seuls ou dans des formulations commerciales de shampooing contre Malassezia et les bactéries du genre Staphylococcus. MÉTHODES: Les concentrations minimales inhibitrices de trois antifongiques présents dans des shampooings antipelliculaires (pyrithione de zinc, kétoconazole et ciclopirox) ainsi que l'hamamélan, extrait d'hamamélis, ont été évaluées contre des espèces commensales de Malassezia et Staphylococcus en utilisant des méthodes de microdilution en culture. Dans des expériences simulant l'exposition au shampooing et les conditions de lavage sur le cuir chevelu, nous avons également testé la capacité à inhiber la croissance microbienne des agents décrits ci-dessus dans la formulation de shampooings (Head and Shoulders (H&S), Ketomed, Sebiprox, Erol Healthcare Hair Shampoo, respectivement) avec un produit générique trouvé dans le commerce. RÉSULTATS: Les shampooings Ketomed et H&S ont été les traitements les plus efficaces contre Malassezia dans des essais in vitro et dans des expériences de simulation de lavage. Le shampooing Erol Healthcare était moins efficace contre Malassezia in vitro car nécessitant un temps de contact plus long pour obtenir une inhibition de la croissance de certaines espèces. Sebiprox a montré une efficacité variable dans les expériences de lavage et de temps de contact alors que le shampooing générique était le moins efficace pour inhiber la croissance de Malassezia et Staphylococcus. CONCLUSION: Ces résultats suggèrent que les patients avec des pellicules peuvent raisonnablement retirer un bénéfice de l'utilisation d'un shampooing antifongique spécifique bien que les résultats puissent varier selon les espèces microbiennes, la durée du contact et des composants entrant dans la formulation du shampooing.

[Cutaneous manifestations of Lyme disease : Pitfalls in the serological diagnostic workup]. / Kutane Lyme-Borreliose : Fallstricke der serologischen Diagnostik.

Serology, the detection of B. burgdorferi-specific IgM and IgG serum antibodies, is the most common laboratory test to diagnose cutaneous manifestations of Lyme disease. In a two-tiered approach, an ELISA is used as a screening test. A positive or equivocal ELISA result needs confirmation by a specific immunoblot. The sensitivity of this approach reaches 80-95%. The diagnosis of erythema migrans is based on its typical clinical appearance. Serology is only indicated in atypical cases. In contrast, serology is mandatory in the diagnostic workup of borrelial lymphocytoma and acrodermatitis chronica atrophicans. A positive serology can persist for many years, even after adequate antibiotic treatment. A positive serology is no indication for antibiotic treatment if typical symptoms of Lyme disease are absent.

EAACI Molecular Allergology User's Guide.

The availability of allergen molecules ('components') from several protein families has advanced our understanding of immunoglobulin E (IgE)-mediated responses and enabled 'component-resolved diagnosis' (CRD). The European Academy of Allergy and Clinical Immunology (EAACI) Molecular Allergology User's Guide (MAUG) provides comprehensive information on important allergens and describes the diagnostic options using CRD. Part A of the EAACI MAUG introduces allergen molecules, families, composition of extracts, databases, and diagnostic IgE, skin, and basophil tests. Singleplex and multiplex IgE assays with components improve both sensitivity for low-abundance allergens and analytical specificity; IgE to individual allergens can yield information on clinical risks and distinguish cross-reactivity from true primary sensitization. Part B discusses the clinical and molecular aspects of IgE-mediated allergies to foods (including nuts, seeds, legumes, fruits, vegetables, cereal grains, milk, egg, meat, fish, and shellfish), inhalants (pollen, mold spores, mites, and animal dander), and Hymenoptera venom. Diagnostic algorithms and short case histories provide useful information for the clinical workup of allergic individuals targeted for CRD. Part C covers protein families containing ubiquitous, highly cross-reactive panallergens from plant (lipid transfer proteins, polcalcins, PR-10, profilins) and animal sources (lipocalins, parvalbumins, serum albumins, tropomyosins) and explains their diagnostic and clinical utility. Part D lists 100 important allergen molecules. In conclusion, IgE-mediated reactions and allergic diseases, including allergic rhinoconjunctivitis, asthma, food reactions, and insect sting reactions, are discussed from a novel molecular perspective. The EAACI MAUG documents the rapid progression of molecular allergology from basic research to its integration into clinical practice, a quantum leap in the management of allergic patients.

Tinea capitis and tinea faciei in the Zurich area - an 8-year survey of trends in the epidemiology and treatment patterns.

BACKGROUND: Tinea capitis and tinea faciei are dermatophyte infections of the scalp and glabrous skin of the face affecting mainly prepubertal children. During the past 30 years, a significant increase and a change in the pattern of infectious agents has been noted for tinea capitis. OBJECTIVES: The aim of this study was to determine trends in the current epidemiological situation of tinea capitis and tinea faciei in the Zurich area, Switzerland and adjacent Central and Eastern Switzerland. METHODS: Consecutive cases diagnosed between 2006 and 2013 were studied retrospectively. RESULTS: A total of 90 tinea capitis and 40 tinea faciei cases were observed. Anthropophilic isolates (primarily Trichophyton violaceum and Microsporum audouinii) accounted for 76% of tinea capitis cases. In contrast, zoophilic isolates (primarily T. interdigitale) were responsible for 73% of tinea faciei cases. The peak incidence in both conditions was in 4-8 year-old children. While the annual number of tinea faciei cases remained stable over the past 8 years, a trend for an increase in T. violaceum-positive tinea capitis has been observed. This was mainly due to patients of African ethnicity. CONCLUSIONS: Anthropophilic isolates accounted for three quarters of tinea capitis and one quarter of tinea faciei cases. T. violaceum-positive tinea capitis was primarily linked to patients of African ethnicity. Tinea capitis caused by Microsporum spp. was more refractory to therapy and needed longer treatment than Trichophyton spp.-induced infection.

A multicenter prospective trial to asses a new real-time polymerase chain reaction for detection of Treponema pallidum, herpes simplex-1/2 and Haemophilus ducreyi in genital, anal and oropharyngeal ulcers.

Treponema pallidum, herpes simplex virus types 1 or 2 (HSV-1/2) and Haemophilus ducreyi are sexually transmitted pathogens that can cause genital, anal and oropharyngeal ulcers. Laboratory evaluation of these pathogens in ulcers requires different types of specimens and tests, increasing the risk of improper specimen handling and time lapse until analysis. We sought to develop a new real-time PCR (TP-HD-HSV1/2 PCR) to facilitate the detection of T. pallidum, HSV-1/2 and H. ducreyi in ulcers. The TP-HD-HSV1/2 PCR was tested (i) in a retrospective study on 193 specimens of various clinical origin and (ii) in a prospective study on 36 patients with genital, anal or oropharyngeal ulcers (ClinicalTrials.gov # NCT01688258). The results of the TP-HD-HSV1/2 PCR were compared with standard diagnostic methods (T. pallidum: serology, dark field microscopy; HSV-1/2: PCR; H. ducreyi: cultivation). Sensitivity and specificity of the TP-HD-HSV1/2 PCR for T. pallidum were both 100%, for HSV-1 100% and 98%, and for HSV-2 100% and 98%, respectively. T. pallidum and HSV-1/2 were detected in 53% and 22% of patients in the prospective study; H. ducreyi was not detected. In the prospective study, 5/19 (26%) specimens were true positive for T. pallidum in the TP-HD-HSV1/2 PCR but non-reactive in the VDRL. The TP-HD-HSV1/2 PCR is sensitive and specific for the detection of T. pallidum and HSV-1/2 in routine clinical practice and it appears superior to serology in early T. pallidum infections.

Nodular secondary syphilis in a woman.

We report the case of a 21-year-old woman with symmetrically distributed, ulcerated nodules and plaques on the face, neck and arms. Initial differential diagnoses included pyoderma or sarcoidosis based on the clinical presentation and histopathology with non-caseating granulomas. After inefficient treatment with topical and systemic fusidic acid and steroids, we diagnosed nodular secondary syphilis owing to positive serology and immunohistochemical staining of Treponema pallidum in lesional skin. After treatment with benzathine penicillin, skin lesions improved and antibody titres declined significantly within 3 months. Nodular skin lesions in secondary syphilis are rare with 15 reported cases within the last 20 years. Furthermore, the granulomatous histology is often misleading. Our patient's case suggests that the physicians should be aware of syphilis as a possible differential diagnosis also in patients outside a high-risk population for sexually transmitted diseases and with an unusual clinical presentation.

[Skin infections in pregnancy]. / Hautinfektionen in der Schwangerschaft.

The article outlines examples of a viral (varicella-zoster virus, VZV), a bacterial (Lyme borreliosis) and a parasitic (scabies) infection in pregnancy with their risk for the mother and/or child as well as their management. VZV infections cause various clinical scenarios depending on the maternal immune status and the time of infection. Herpes zoster usually poses no risk to the pregnant woman and there is no need for antiviral therapy. VZV infection of a seronegative mother, however, may lead to severe varicella in the pregnant woman and to congenital malformations (congenital varicella syndrome) in case of early infection or neonatal varicella in case of perinatal infection. Prompt therapy with acyclovir or administration of VZV immunoglobulin for prophylaxis is mandatory in those patients. In case of Lyme borreliosis of the mother, adequate antibiotic therapy with amoxicillin prevents harm to the fetus. Doxycycline is contraindicated during pregnancy. Scabies represents an important differential diagnosis of pruritic dermatoses in pregnancy and should be treated with permethrin 5% cream.

Is serological follow-up useful for patients with cutaneous Lyme borreliosis?

Serologic follow-up examinations are frequently performed in patients with erythema migrans, borrelial lymphocytoma, and acrodermatitis chronica atrophicans (the 3 dermatoborrelioses) to evaluate treatment efficacy. There is, however, substantial proof in the literature that antibody titer development after therapy is unpredictable and variable, and moreover it is largely uncorrelated with the clinical course and mode of antibiotic treatment. For example, persistent positive IgG and/ or IgM antibody titers do not indicate treatment failure. Thus, repeated serologic testing is of very limited value for assessing therapy efficacy, and therefore not recommended in the follow-up of dermatoborrelioses patients. Since cultivation of the etiologic agent, Borrelia burgdorferi sensu lato, and polymerase chain reaction are also inadequate for this purpose, the assessment of patients with cutaneous manifestations of Lyme borreliosis in the follow-up rests primarily on the clinical picture.

The impact of immunosuppression on erythema migrans. A retrospective study of clinical presentation, response to treatment and production of Borrelia antibodies in 33 patients.

BACKGROUND: Little is known about the potential influence of immunosuppression on erythema migrans, the hallmark of early Lyme borreliosis. METHODS: We performed a retrospective study to assess the impact of immunosuppression on erythema migrans in 33 patients with a malignant or autoimmune disease, chronic infection, or immunosuppressive therapy for organ transplantation. Only patients with active disease status and/or current immunosuppressive therapy were included. Pre-treatment clinical parameters, such as presentation of the skin lesion and presence of extracutaneous signs and symptoms, the disease course during a median follow-up of 9 months after therapy and serum anti-Borrelia burgdorferi antibodies before therapy and by the end of follow-up in the 33 immunosuppressed patients were statistically compared with 75 otherwise healthy patients with erythema migrans. The 75 control patients were matched for sex, age and antibiotic therapy. RESULTS: With the exception of the site of erythema migrans lesions, which were found more often on the trunk than on the legs in the immunosuppressed patients (vice versa in immunocompetent patients), we found no significant differences for all investigated parameters between the two groups. CONCLUSIONS: It appears that immunosuppression does not influence clinical presentation, response to therapy, or production of anti-B. burgdorferi antibodies of patients with erythema migrans. It is thus not necessary to treat immunosuppressed patients with erythema migrans differently from immunocompetent patients.

[Cause of death and autopsy findings in patients of the Swiss HIV Cohort Study (SHCS)]. / Todesursachen und Autopsiebefunde bei Patienten der Schweizerischen HIV-Kohortenstudie (SHCS).

The Swiss HIV Cohort Study (SHCS) is a prospective cohort study of HIV-infected adolescents and adults seen at 7 outpatient clinics (Swiss University Hospitals in Basle, Berne, Geneva, Lausanne, Zurich, the St. Gall Cantonal Hospital and the Civico Hospital in Lugano). The SHCS serves as an infrastructure for different research projects and includes about 70% of all patients with advanced disease in Switzerland. From April 1984 to November 1995 3120 HIV-infected patients of the SHCS died. Autopsies were performed in 314 of these patients. The aim of our study is to analyse autopsy findings as well as causes of death in those 314 HIV-infected patients. An HIV-related cause of death was found in 271 (86%) of the patients, 12 patients (4%) died of a drug overdose, and 3 (1%) of the patients committed suicide. 28 (9%) died either from an HIV unrelated or unidentified cause. The five most frequent causes of death were: bacterial pneumonia (52 patients, 17%), Pneumocystis carinii pneumonia (40 patients, 13%), lymphoma (34 patients, 11%), cytomegalovirus infection (33 patients, 11%), and toxoplasmosis (30 patients, 10%). During our study marked progress occurred in treating HIV-infected patients and preventing opportunistic infections. These improvements have further changed the natural course of acquired immunodeficiency syndrome. They are reflected in the falling rate of Pneumocystis carinii pneumonia and toxoplasmosis, as well as an increase in lymphoma as a cause of death over the period of our study.

Four-dimensional multiphoton microscopy with time-correlated single-photon counting.

We report on the implementation of fluorescence-lifetime imaging in multiphoton excitation microscopy that uses PC-compatible modules for time-correlated single-photon counting. Four-dimensional data stacks are produced with each pixel featuring fluorescence-decay curves that consist of as many as 4096 bins. Fluorescence lifetime(s) and their amplitude(s) are extracted by statistical methods at each pixel or in arbitrarily defined regions of interest. When employing an avalanche photodiode the width of the temporal response function is 420 ps. Although this response confines the temporal resolution to values greater than several hundreds of picoseconds, the lifetime precision is determined by the signal-to-noise ratio and can be in the range of tens of picosconds. Lifetime changes are visualized in pulsed-laser-deposited fluorescent layers as well as in cyan fluorescent proteins that transfer energy to yellow fluorescent proteins in live mammalian cells.

Neutral phosphate administration generates and maintains renal metabolic alkalosis and hyperparathyroidism.

We examined the effects of chronic intravenous neutral phosphate administration on systemic acid-base equilibrium and parathyroid function in six normal, NaCl-replete male human subjects under metabolic balance conditions. The subjects received 4.35 mmol of neutral sodium phosphate.kg body wt-1.day-1 intravenously and continuously for 7 days and the same amount of sodium as NaCl during control and recovery. Blood pH increased from 7.388 to 7.411 (P < 0.001) and plasma bicarbonate from 23.5 to 26.0 mmol/l (P < 0.001). Urinary pH increased from 6.58 to 6.79 (P < 0.001). Net acid excretion increased from 59 to 100 mmol/24 h (P < 0.001). Plasma ionized calcium concentration decreased and plasma phosphate concentration increased transiently. Serum intact parathyroid hormone increased from 24 to 62 pg/ml (P < 0.001). Chronic phosphate administration also resulted in a significant increase in renal phosphate clearance (35 to 229 ml/min) and decrease in the fractional excretion of calcium (1.8 to 0.9%). Thus chronic intravenous phosphate administration generates and maintains renal metabolic alkalosis in salt-replete humans and induces hyperparathyroidism. The severity of metabolic alkalosis is mitigated by an apparent increase in effective endogenous acid production as evidenced by the significant increase in steady-state net acid excretion.