Inopinatus corneliae sp. nov. gen. nov. isolated from human skin: A newly discovered keratinophilic hyphomycete, order Onygenales.

BACKGROUND: Fungi clinically relevant to human skin comprise prevalent commensals and well-known pathogens. Only rarely human skin harbours fungi that evade identification. OBJECTIVE: To characterise an enigmatic specimen isolated from a skin lesion. METHODS: A comprehensive clinical and mycological workup including conventional methods for phenotypic characterisation and sequencing based on internal transcribed spacer (ITS) and large subunit (LSU) regions to infer a phylogenetic tree. RESULTS: Cultures on common solid media were macroscopically inconspicuous initially until mycelial tufts developed on the surface, notably on potato dextrose agar. Polymorphous chlamydospores were detected but no aleurospores and ascomata. At 26°C, the isolate grew on standard agars, plant materials and garden soil and utilised peptone, keratins, lipids, inulin, erythrocytes and cellulose. It also grew at 5°C and at 37°C. Nucleotide sequences of its ITS region showed 93% similarity to sequences of different Malbranchea species. The closest matches among LSU rRNA sequences were obtained with the genera Amauroascus, Arthroderma, Auxarthronopsis and Malbranchea (93%-95%). A combined phylogenetic analysis placed the fungus in a sister clade to Neogymnomycetaceae, classified as incertae sedis in Onygenales, on a large distance to either Diploospora rosea or 'Amauroascus' aureus. CONCLUSIONS: The genus Inopinatus gen. nov. (MB854685) with the species Inopinatus corneliae sp. nov. (MB854687) is introduced to accommodate our isolate (holotype: DSM 116806; isotypes: CBS 151104, IHEM 29063). Probably Inopinatus corneliae is a geophilic species that, although potentially harmful, was no relevant pathogen in our case. Its ecology, epidemiology and pathogenicity need to be further clarified.

S1 Guideline onychomycosis.

Onychomycosis is a fungal infection of the fingernails and toenails. In Europe, tinea unguium is mainly caused by dermatophytes. The diagnostic workup comprises microscopic examination, culture and/or molecular testing (nail scrapings). Local treatment with antifungal nail polish is recommended for mild or moderate nail infections. In case of moderate to severe onychomycosis, oral treatment is recommended (in the absence of contraindications). Treatment should consist of topical and systemic agents. The aim of this update of the German S1 guideline is to simplify the selection and implementation of appropriate diagnostics and treatment. The guideline was based on current international guidelines and the results of a literature review conducted by the experts of the guideline committee. This multidisciplinary committee consisted of representatives from the German Society of Dermatology (DDG), the German-Speaking Mycological Society (DMykG), the Association of German Dermatologists (BVDD), the German Society for Hygiene and Microbiology (DGHM), the German Society of Pediatric and Adolescent Medicine (DGKJ), the Working Group for Pediatric Dermatology (APD) and the German Society for Pediatric Infectious Diseases (DGPI). The Division of Evidence-based Medicine (dEBM) provided methodological assistance. The guideline was approved by the participating medical societies following a comprehensive internal and external review.

Expression of epidermal antimicrobial peptides is increased in tinea pedis.

BACKGROUND: Tinea pedis is often chronic or recurrent, but not all individuals are equally susceptible to this infection. Dermatophytes are able to induce the expression of antimicrobial peptides and proteins (AMPs) in human keratinocytes and certain AMPs can inhibit the growth of dermatophytes. OBJECTIVE: The focus of this study was to analyse the secretion of relevant AMPs, especially RNase 7, human beta-defensin-2 (hBD-2) and the S-100 protein psoriasin (S100A7), in patients with confirmed tinea pedis. METHODS: To verify the diagnosis, skin scales were obtained from all patients (n = 13) and the dermatophytes were identified by potassium hydroxide mount, culture and molecular analysis. To determine the AMP concentrations, the lesional skin area of the foot was rinsed with a buffer that was subsequently analysed by ELISA. The corresponding area of the other unaffected foot as well as defined healthy skin areas of the forearm and forehead and samples from age and gender-matched healthy volunteers served as controls. RESULTS: In tinea pedis patients the AMP concentrations were higher in lesional skin than in non-lesional skin and in healthy skin of controls. In particular, concentrations of hBD-2 and psoriasin were significantly elevated. CONCLUSIONS: The induction of AMPs in tinea pedis might be triggered directly by the dermatophytes; furthermore, attendant inflammation and/or differentiation processes may play a role. Our results indicate that there is no defect in the constitutive expression and induction of the analysed AMPs by dermatophytes in the epidermis of affected patients. However, it is not known why the elevated AMP concentrations fail to efficiently combat dermatophyte growth.

[Arthroderma crocatum on human skin]. / Arthroderma crocatum auf menschlicher Haut.

We report on three cases in which Arthroderma (A.) crocatum was isolated from human skin in Germany. The characteristics and epidemiology of this rare geophilic and probably mostly apathogenic dermatophyte are described paying special attention to its gymnothecia. The combination of KOH mount, culture and genetic analysis is the foundation for clinically meaningful conclusions. It is likely that the prevalence of A. crocatum is currently underestimated.

"Indian" strains of Trichophyton mentagrophytes with reduced itraconazole susceptibility in Germany.

We use published reports and three of our own tinea cases as an opportunity to report on "Indian" strains of Trichophyton (T.) mentagrophytes with ITS genotype VIII and reduced susceptibility to itraconazole due to the mutation c.1342G>A in the SQLE gene in Germany. In vitro measurements of resistance revealed normal susceptibility to terbinafine, but markedly reduced susceptibility to itraconazole - although no valid breakpoints are currently defined and minimum inhibitory concentrations (MICs) depend on the methods used. Problems related to the determination and interpretation of MICs are outlined. Our cases show that azole-resistant "Indian" strains of T. mentagrophytes with ITS genotype VIII occurred in Germany as early as 2011, which is earlier than was previously assumed. This variant of the pathogen cannot be phenotypically distinguished from customary strains of T. mentagrophytes; its identification is based on genetics. The taxonomic classification is still under debate. This variant is anthropophilic and causes only mildly inflammatory tinea lesions with many fungal elements. Its further dissemination must therefore be expected. Prerequisites for rapid and valid antimycotic testing against dermatophytes need to be developed.

Clinical isolates of Trichophyton rubrum are completely inhibited by photochemical treatment with a γ-cyclodextrin formulation of curcuminoids.

INTRODUCTION: It was shown previously that dermatophytes can markedly be inhibited by a photochemical treatment with curcumin. This kind of photo-inactivation needs to be improved, however, because curcumin is poorly water-soluble. Therefore, a new water-soluble γ-cyclodextrin formulation of curcuminoids was tested for its photochemical inactivation of Trichophyton (T.) rubrum. MATERIALS AND METHODS: Conidia were harvested from 6 typical strains of T rubrum and used to inoculate wells of microtiter plates. These wells were also filled with a γ-cyclodextrin curcuminoid formulation with 0.1% DMSO and Sabouraud broth. The assays were then irradiated with visible light (wavelength 420 nm, 45 J/cm2 ). After 24 hours, curcuminoid was added once more, and irradiation was repeated. Fungal growth was monitored photometrically for 8 days and compared with controls. RESULTS: Growth of all 6 T rubrum strains was completely inhibited by the photochemical treatment with the γ-cyclodextrin formulation of curcuminoids. The same curcuminoid formulation applied without irradiation had only a minor inhibitory effect. DISCUSSION: Photo-inactivation of dermatophytes with a γ-cyclodextrin formulation of curcuminoids plus visible light is a very promising procedure with potential for a new treatment of patients with superficial tinea.

S1 guidelines: Tinea capitis.

Tinea capitis describes a dermatophyte infection of scalp and hair that predominately occurs in children. The diagnostic workup includes microscopic examination, culture and/or molecular tests. Treatment is guided by the specific organism involved and should consist of systemic agents as well as adjuvant topical treatment. The aim of the present update of the interdisciplinary German S1 guidelines is to provide dermatologists, pediatricians and general practitioners with a decision tool for selecting and implementing appropriate diagnostic and therapeutic measures in patients with tinea capitis. The guidelines were developed based on current international guidelines, in particular the 2010 European Society for Pediatric Dermatology guidelines and the 2014 British Association of Dermatologists guidelines, as well as on a review of the literature conducted by the guideline committee. This multidisciplinary committee consists of representatives from the German Society of Dermatology (DDG), the German-Speaking Mycological Society (DMykG), the German Society for Hygiene and Microbiology (DGHM), the German Society of Pediatric and Adolescent Medicine (DGKJ) and the German Society for Pediatric Infectious Diseases (DGPI). The Division of Evidence-based Medicine (dEBM) provided methodological assistance. The guidelines were approved by the participating medical societies following a comprehensive internal and external review.

Arthroderma chiloniense sp. nov. isolated from human stratum corneum: Description of a new Arthroderma species.

A 68-year-old woman was submitted to our hospital because of erythematous and scaly skin lesions. To exclude tinea samples of stratum corneum were collected and used for mycological investigations. In this material, no fungal elements were detected microscopically, but inoculation on Sabouraud agar with cycloheximide yielded a presumptive dermatophyte fungus. Subsequent detailed investigations with conventional morphological and physiological methods and a phylogenetic analysis of the combined LSU rRNA gene (D1/D2 domains) and ITS region sequences suggested that the fungus represents a hitherto undescribed species of the genus Arthroderma. Here, we describe this species as Arthroderma chiloniense sp. nov., EMBL accession no. LT992885. This new species can be distinguished from phylogenetically related Arthroderma species using ribosomal ITS and LSU genes, and 60S L10 protein sequences; specific macroscopic, microscopic and physiological features are lacking. Our attempts to re-isolate this fungus from the patient's skin failed although her skin lesions persisted. Most likely A. chiloniense is a geophilic species that incidentally contaminated or transiently colonised the patient's skin. To avoid diagnostic misinterpretations, it is necessary to distinguish A. chiloniense from truly pathogenic dermatophytes like Trichophyton (T.) rubrum and T. interdigitale which can easily be confused with A. chiloniense based on similar mycelium morphology.

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.

S3 Guidelines: Epicutaneous patch testing with contact allergens and drugs - Short version, Part 2.

Epicutaneous patch testing is the diagnostic standard for the detection of allergic contact dermatitis. The present guidelines are aimed at residents and board-certified physicians in the fields of dermatology and allergology as well as other medical specialties involved in establishing the indication for patch testing and its execution in patients with contact dermatitis and other forms of delayed-type hypersensitivity. The target audience also includes other health care providers and insurance funds. Based on a systematic literature search and a formal consensus process (S3), the guidelines were developed by dermatologists in collaboration with pediatricians, occupational medicine physicians, nursing staff as well as patient representatives. The systematic methodological approach and appraisal of evidence upon which the recommendations are based are outlined in a separate method report that also contains evidence tables. The guidelines address general aspects of patch testing as well as medicolegal issues. The recommendations given relate to topics such as the indication for patch testing, informed patient consent, as well as the choice of test substances, test chambers and test site, duration of exposure, reading times and interpretation of test reactions. Furthermore, recommendations are provided with respect to endogenous and exogenous factors, specific patient groups (children, pregnant women, immunosuppressed individuals) as well as possible risks and adverse events associated with patch testing using contact allergens.

S3 guidelines: Epicutaneous patch testing with contact allergens and drugs - Short version, Part 1.

Epicutaneous patch testing is the diagnostic standard for the detection of allergic contact dermatitis. The present guidelines are aimed at residents and board-certified physicians in the fields of dermatology and allergology as well as other medical specialties involved in establishing the indication for patch testing and its execution in patients with contact dermatitis and other forms of delayed-type hypersensitivity. The target audience also includes other health care providers and insurance funds. Based on a systematic literature search and a formal consensus process (S3), the guidelines were developed by dermatologists in collaboration with pediatricians, occupational medicine physicians, nursing staff as well as patient representatives. The systematic methodological approach and appraisal of evidence upon which the recommendations are based are outlined in a separate method report that also contains evidence tables. The guidelines address general aspects of patch testing as well as medicolegal issues. The recommendations given relate to topics such as the indication for patch testing, informed patient consent, as well as the choice of test substances, test chambers and test site, duration of exposure, reading times and interpretation of test reactions. Furthermore, recommendations are provided with respect to endogenous and exogenous factors, specific patient groups (children, pregnant women, immunosuppressed individuals) as well as possible risks and adverse events associated with patch testing using contact allergens. Note: This publication is part 1 of the short version of the S3 guidelines for "Epicutaneous patch testing using contact allergens and drugs" (registry no. 013 - 018; date: March 20, 2019; valid until December 31, 2021). Part 2 of the short version will be published in the next issue. The long version of these guidelines can be accessed at www.awmf.org. The method report is available as online publication (https://www.awmf.org/leitlinien/detail/ll/013-018.html) and contains the evidence tables in its appendix.

Photochemical inhibition of Trichophyton rubrum by different compoundings of curcumin.

Recently, we had shown that conidia-derived growth of many dermatophytes can be inhibited by curcumin plus exposure to visible light. This method of photo inactivation should be developed further aiming for an option to stop mycelial growth in superficial tinea. Wells of microtitre plates were inoculated with either mycelial or conidial elements collected from 5 strains of Trichophyton rubrum. Then either micellar curcumin or curcumin dissolved with DMSO was added and after 20 min the wells were filled up with Sabouraud broth. Thereafter the assays were irradiated once with visible light (wave length 420 nm, 20 J/cm2 ) and fungal growth was monitored photometrically. Identical effects were measured with conidia and mycelial elements of all 5 T. rubrum strains. Curcumin dissolved with DMSO plus irradiation had a marked dose-dependent inhibitory effect on fungal growth that was almost complete with 5.0 mg/L (P < .01) over a period of 9 days. In contrast, the same procedure with micellar curcumin had no inhibitory effect on growth obtained from conidia or mycelial elements. Mycelial elements of T. rubrum and its conidia are equally sensitive to photochemical inactivation with curcumin and the galenic compounding of curcumin is essential to achieve this photochemical effect.

Inhibition of dermatophytes by photodynamic treatment with curcumin.

Treatment of dermatophytoses with currently available antimycotic agents is often tedious and sometimes unsatisfactory. A search for better therapeutic methods-ideally with an immediate fungicidal effect-has, among others, lead to photodynamic procedures as a promising alternative, and recently curcumin was found to be a suitable agent for this application. In this study the effect of photodynamic treatment with curcumin on dermatophytes was tested in vitro. Wells of microtiter plates were filled with conidia of Trichophyton rubrum, Trichophyton interdigitale, Trichophyton terrestre, Microsporum canis, Microsporum gypseum and Epidermophyton floccosum in buffer. Then curcumin was added to the conidia and after 20 min the assays were irradiated one time only with visible light (peak wave length 367 nm, 5 J/cm2). Thereafter the wells were filled up with Sabouraud's glucose broth and in the following fungal growth was measured photometrically. The results showed that all dermatophytes were markedly inhibited depending on the concentration of curcumin. With 5.4 mg/l curcumin plus irradiation fungal growth was significantly suppressed over a period of 96 h (P < .001). Even after 96 h inhibition of T. rubrum was still complete and marked for all other species as well. M. gypseum was least susceptible. Our results are very encouraging to pursue the development of a photodynamic therapy of tinea with curcumin. The outstanding tolerance of curcumin and the innocuousness of the required light are favorable preconditions for this task.

Xanthothecium peruvianum isolated from human stratum corneum: A case report, characterisation and short review that suggest emendation of Arachnomyces peruvianus.

From stratum corneum samples of a palmar eczema, a fungus was isolated that developed white colonies with a yellowish dark reverse, suggestive of dermatophytes. The isolate produced numerous chlamydospores and sparse aleuroconidia, was resistant to cycloheximide, grew well on human stratum corneum samples and was positive in tests for urease production and hair perforation, but no dermatophyte could be identified. After several weeks, cleistothecia with delicate asci and disc-shaped ascospores were formed, suggesting Arachnomyces spp. The analyses of the ribosomal ITS and LSU (D1/D2 domains) nucleotide sequences proved a good match with the ex-type strain of Xanthothecium peruvianum (family Onygenaceae, order Onygenales), and LSU sequence showed 99% similarity with Arachnomyces glareosus. This is the first report of X. peruvianum isolated from human skin. The description of our isolate provides new information about this species and proposes its transfer to the genus Arachnomyces with the subsequent emendation of the description of Arachnomyces peruvianus. Morphologically and physiologically it mimics dermatophytes and other species of the genus Arachnomyces. Although the clinical situation did not suggest any relevance for A. peruvianus as a primary pathogen, this fungus may act as a secondary pathogen under suitable conditions due to its keratinolytic capacity.