Forty four years of dermatophytes in a Chicago clinic (1944-1988).

Data are presented on 39,270 cultures taken over a 44 year span (1944-1988) at the University of Chicago's Dermatology Clinic. In the mid 1940's Microsporum audouinii accounted for 60-80% of isolates. It gradually decreased over the next two decades and disappeared altogether in the 1970's. Trichophyton rubrum, rare in the 1940's accounted for over 60% of isolates in the mid-1960's only to be overtaken by T. tonsurans. This species, not isolated till the mid 1950's, became and remains the dominant dermatophyte at the present time. Both T. mentagrophytes and Epidermophyton floccosum increased in the 1970's and decreased later. Unusual circumstances resulted in clusters of T. verrucosum, T. terrestre, and T. schoenleinii isolates. Infections were associated with rural dairy workers, zoo handlers and immigrant families respectively. M. canis and M. gypseum were steady at a low rate throughout the entire period. Rare isolates included M. cookei, M. persicolor, M. racemosum, T. simii, T. soudanense, T. violaceum, and the soil keratinophile, Aphanoascus fulvescens.

Inflammatory tinea capitis caused by Microsporum gypseum in a five-year-old girl.

An otherwise healthy five-year-old girl presented for evaluation of a large patch of erythematous scaling alopecia on the vertex of her scalp. Previous attempts to treat this with various topical agents resulted in no improvement. Our evaluation included examination of fungal cultures, which grew out a colony with characteristic morphology of Microsporum gypseum, supported by lactolphenol blue tease mounts, demonstrating the characteristic conidia for this fungus. Treatment was begun with oral griseofulvin, and evidence of inflammation resolved along with conversion to negative cultures for M. gypseum, although an area of scarring alopecia from the kerion remains. The epidemiologic basis, clinical presentation, differential diagnosis, evaluation, and treatment principles for this important geophilic organism are reviewed. Physicians need to be aware of this agent of tinea capitis, since it is destructive and only responsive to oral therapy.

Hendersonula toruloidea infection in man. Index cases in the non-endemic North American host, and a review of the literature.

Hendersonula toruloidea (HT) is a dematiaceous fungus that is an endemic human pathogen in tropical and subtropical countries. Infection with this fungus is often clinically indistinguishable from Trichophyton rubrum or other dermatophytoses. However, because HT will not grow on standard cycloheximide containing fungal media, and because HT is usually resistant to standard anti-fungal therapies, we believe that HT is a more common cause of 'recalcitrant dermatophytosis' in the United States than is currently recognized. HT may be especially prevalent among immigrant patients from endemic countries. We report the first cases of HT to occur in a non-endemic region of the United States. This suggests that HT may become a significant pathogen in the native American host as well. Moreover, we report the first case of a tinea capitis-like infection due to HT.

Phaeomycotic cyst (chromoblastomycosis) of the neck.

An unusual fungal infection of the neck caused by Phialophora verrucosa (chromoblastomycosis) is presented. The patient acquired this fungus by cutting his chin on a wooden floor. Surgical and medical therapy of this unusual disease is discussed.

Tinea of the face caused by Trichophyton rubrum with histologic changes of granuloma faciale.

We report a case of tinea of the face caused by Trichophyton rubrum in which the histologic changes were consistent with granuloma faciale. We recommend that local infection with dermatophytes be considered in all cases of histologic granuloma faciale, especially when the clinical presentation is atypical for this dermatosis.

Disseminated cutaneous and peritoneal hyalohyphomycosis caused by Fusarium species: three cases and review of the literature.

Three recent cases of hyalohyphomycosis caused by Fusarium sp. illustrate differing aspects of infections produced by these organisms. One patient was undergoing continuous ambulatory peritoneal dialysis when peritonitis developed caused by Fusarium moniliforme. Removal of the catheter and amphotericin B were used in successful management. In a neutropenic patient on therapy for leukemia, multiple persistent infections occurred including JK diptheroids, and Candida albicans sepsis. Finally, numerous florid skin lesions caused by Fusarium oxysporum developed even while the patient was receiving amphotericin B and he died. In a second neutropenic patient on treatment for leukemia, sinus and cutaneous lesions developed due to Fusarium. These resolved on amphotericin B therapy following the return of circulating neutrophils. The literature on Fusarium infections and aspects of the biology of the organism are reviewed.

Trichosporon beigelii endocarditis as a complication of peritoneovenous shunt.

Trichosporon is a common cause of superficial mycotic infection but has rarely been associated with endocarditis. The case of a patient who had a peritoneovenous shunt for chronic intractable ascites due to Laennec liver cirrhosis is described. The shunt was revised on several occasions, and the last procedure was complicated by a draining skin sinus wound. To the authors' knowledge, this is the first reported case of Trichosporon endocarditis complicating a peritoneovenous shunt.

'Golden tongue' syndrome caused by Ramichloridium schulzeri.

A 54-year-old woman entered the hospital for induction chemotherapy for acute lymphocytic leukemia. On hospital day 23, while the patient was neutropenic, an erosive lesion appeared on the left side of the tongue. During the next several days the lesion extended over the dorsum of the tongue and was golden orange. Surface scrapings were obtained; the involved site underwent a biopsy and was cultured. Branching septate mycelia of varying diameters were seen on microscopic examination of direct mounts and a biopsy specimen of the tongue. Eight to ten colonies of a fungus grew out in culture. The fungus was golden orange on Sabouraud's glucose agar and brown-gray on corn-meal agar, and was identified as Ramichloridium schulzeri. The lesion regressed during the next two weeks while the patient received amphotericin B therapy and showed an increased granulocyte count. This case seems to be the first authenticated infection caused by this uncommonly encountered soil saprophyte.

The changing epidemiology and emerging patterns of dermatophyte species.

The anthropophilic agents of tinea capitis are being eradicated from their historic areas in developed and developing nations. The one exception is T. tonsurans in the United States and Canada. In these nations, the infections are increasing among black children, probably because of hair style and hygiene habits. Elsewhere in the world, M. canis has become or is becoming the dominant agent of tinea capitis. Tinea corporis reflects either the dominant agent of tinea capitis or the sphere of T. rubrum. Trichophyton rubrum is the most common agent worldwide of crural and pedal disease and often tinea corporis. The other anthropophilic species, T. mentagrophytes var. interdigitale and E. floccosum, are also firmly established, but as a distant second and third. These five species account for most ringworm worldwide. Other species are of lowlevel infection, are rare, are locally endemic, or--in the case of some anthropophiles--are dying out. The only evidence of active evolution among the dermatophytes is seen in M. canis and T. mentagrophytes. In both, host-specific strains have emerged and will probably separate as species. This probably has happened already in the case of the variety interdigitale of T. mentagrophytes.

Osteomyelitis secondary to cutaneous mucormycosis. Report of a case and a review of the literature.

An unusual case of osteomyelitis secondary to cutaneous mucormycosis developed in a diabetic with chronic renal insufficiency. Recovery followed curettage of the osseous lesion and "suboptimal" treatment with amphotericin B. A review of the literature on mucormycosis of bone and skin follows the report of the case.

Case report: blastomycosis causing sciatic neuritis.

A patient presented with pain in the right lower back, radiating down the right leg. Initial pelvic X-rays did not reveal any lesion. A follow up computerized tomography (CT) scan and technitium scan showed a sharply lytic lesion of the right ilium extending to the right sacroiliac joint. Open biopsy revealed a granulomatous inflammation with many budding yeast from consistent with Blastomyces dermatitidis. Subsequent culture confirmed this identification. There was no other site of fungal infection. Two courses of Amphotericin B (each to 2 g total dose) failed to eradicate this infection. The patient is now responding to Ketoconazole.

Immunohistopathological studies of blastomycosis: the use of labeled specific antigens in a hamster model of disease.

We applied a modified immunofluorescence and immunoperoxidase method, utilizing labeled Blastomyces dermatitidis antigens, to look for specific antibody-bearing B/plasma cells in the tissue infiltrates of blastomycosis lesions induced in hamsters. No specific anti-blastomyces antibodies were detectable by this method, although such antibodies were present in blood samples as demonstrated by routine immunodiffusion techniques. These studies suggest that humoral immune reactions do not play a major role in the pathogenesis of lesions of blastomycosis in hamsters.

Actinomyces meyeri presenting as an asymptomatic lung mass.

A 55-year-old man was admitted to the hospital for an elective herniorrhaphy. A significant past history of smoking and alcohol abuse was noted. The patient had no other complaints but a routine chest X-ray revealed an isolated left upper lobe mass. Laboratory tests were unrevealing and the impression was that the patient had a carcinoma. The surgical specimen consisted of a lobular mass containing multiple microabscesses. Grains consistent with actinomycosis were seen and the culture grew out Actinomyces meyeri. There was no other evidence of disease.

Localized oxalosis associated with simultaneous Aspergillus and Mucor infection in diabetic foot gangrene.

A case of simultaneous aspergillosis and mucormycosis complicating diabetic foot gangrene is reported. The recognition of this combined opportunistic fungal infection was brought about by an initial finding of birefringent calcium oxalate crystals associated with a background of acute inflammatory exudate, which is considered a strong clue to the diagnosis of infection caused by Aspergillus niger.

Disseminated Trichosporon beigelii (cutaneum).

Two cases of invasive Trichosporon beigelii (syn. cutaneum) infection are reported and are compared with the eight other previous reports. All affected patients were either immunosuppressed or had recently undergone a surgical procedure. The diagnosis had been delayed and the prognosis was poor. Only two patients recovered after vigorous antimycotic therapy and concomitant remission of their leukemia. A biopsy of the skin lesion, as illustrated in one of our patients, may prove to be useful in the early diagnosis.