Disseminated histoplasmosis by Histoplasma capsulatum var. duboisii in a paediatric patient from the Chad Republic, Africa.

Histoplasmosis caused by Histoplasma capsulatum var. duboisii is an endemic mycosis of sub-Saharan Africa that usually affects the skin, subcutaneous tissue, lymph nodes and bones. We present a case of a 10-year-old immunocompetent girl with severe cutaneous and subcutaneous abscesses affecting the head and upper body. Microscopic examination showed polar budding yeasts and short mycelium compatible with H. capsulatum var. duboisii. Cultures were not possible but serology showed antibodies against both H. capsulatum var. duboisii and H. capsulatum var. capsulatum antigens. Presumptive diagnosis of histoplasmosis was done but treatment with itraconazole was inefficacious. After 15 days of treatment with Amphotericin B i/v, improvement was evident and, three months later, the patient was discharged with only residual lesions. Seven months later, no relapses were observed.

Seasonal distribution of Alternaria, Aspergillus, Cladosporium and Penicillium species isolated in homes of fungal allergic patients.

BACKGROUND: Allergy to airborne fungi can cause rhinitis and severe asthma, hence the exposure to spores inside home is an important factor of sensitization. The aim of this study was to determine the distribution and prevalence of species of Alternaria, Aspergillus, Cladosporium and Penicillium inside and outside of homes of patients allergic to fungi and to evaluate seasonal variations. METHODS: Air samples were collected in 22 selected homes of patients with allergy to fungi using a volumetric method of impacting plates with culture media. The isolated species were identified and statistical analysis of the presence of the four fungi was carried out. RESULTS: A total of 431 indoor and 150 outdoor exposed plates were cultured, leading to isolation of 11,843 colonies of fungi (range 0- 1 666 colony-forming units per cubic meter (CFUs/m(3)). 85.5% of total colonies belonged to the four genera considered. The highest presence of Aspergillus, Cladosporium and Penicillium in indoor environment was registered in autumn. Alternaria was more frequent in summer. In the outdoor environment, Penicillium was more abundant in winter and Aspergillus in summer (P= .002). The largest numbers of isolations were of Cladosporium and Penicillium during all four seasons, indoors as well as outdoors. Alternaria was present in all the homes studied both in summer and in autumn. The most prevalent species were: Alternaria alternata, Cladosporium herbarum, Cladosporium cladosporioides, Aspergillus niger and Penicillium chrysogenum. CONCLUSIONS: The quantitative analysis of the four taxa related with respiratory allergies demonstrated considerable seasonal variability. Statistical differences between the indoor and outdoor prevalence were detected only in Alternaria. In summer and autumn, the greater level of exposure to the four studied taxas occurred inside homes.

Double blind study of ketoconazole and griseofulvin in dermatophytoses.

Ketoconazole and griseofulvin were compared in a double blind fashion in 47 children with dermatophytosis and positive fungal culture. After 6 weeks of therapy there was clinical and mycologic cure or improvement of the lesions in 92% of patients treated with ketoconazole (Group A) and in 76% of those given griseofulvin (Group B). A patient in Group A showed clinical deterioration of the lesions after 4 weeks of treatment, although modification of antifungal therapy was not necessary to achieve final healing. One ketoconazole-treated patient relapsed within 7 days after cessation of therapy. In Group B the antifungal agent was changed in five cases due to worsening or slow resolution of the lesions and persistence of positive cultures after 6 weeks of treatment. Both ketoconazole and griseofulvin were useful drugs for treatment of dermatophytoses in children.

Candidemia in non-neutropenic critically ill patients: analysis of prognostic factors and assessment of systemic antifungal therapy. Study Group of Fungal Infection in the ICU.

OBJECTIVE: To determine the incidence and prognosis of candidemia in non-neutropenic critically ill patients, to define mortality-related factors, and to evaluate the results of systemic antifungal therapy. DESIGN: A prospective multicenter survey in which medical and/or surgical intensive care units (ICUs) in 28 hospitals in Spain participated. PATIENTS: All critically ill patients with positive blood cultures for Candida species admitted to the participating ICUs over a 15-month period were included. INTERVENTIONS: Candidemia was defined as the presence of at least one positive blood culture containing Candida species. The follow-up period was defined as the time elapsed from the first positive blood culture for Candida species to discharge or death during hospitalization. Antifungal therapy was considered to be "early" when it was administered within 48 h of the date when the first positive blood culture was obtained and "late" when it was administered more than 48 h after the first positive blood culture. MEASUREMENTS AND MAIN RESULTS: Candidemia was diagnosed in 46 patients (mean age 59 years), with an incidence of 1 critically ill patient per 500 ICU admissions. The species most frequently isolated were Candida albicans (60%) and C. parapsilosis (17%). Fluconazole alone was given to 27 patients, amphotericin B alone to 10, and sequential therapy to 6. Three patients did not receive antifungal therapy. The overall mortality was 56% and the attributable mortality 21.7%. In the univariate analysis, mortality was significantly associated with a higher Acute Physiology and Chronic Health Evaluation (APACHE) II score at the onset of candidemia (p = 0.04) and with the time elapsed between the episode of candidemia and the start of antifungal therapy 48 h or more later (p < 0.02). Patients with an APACHE II score lower than 21 at the onset of candidemia had a higher probability of survival than patients who were more seriously ill (p = 0.04). Patients with "early" antifungal therapy (< or = 48 h between the onset of candidemia and the start of antifungal therapy) had a higher probability of survival compared with patients with late therapy (p = 0.06). No significant differences were noted between the two groups on different antifungal therapy. CONCLUSIONS: The incidence of candidemia in ICU patients was very low. An APACHE II score > 20 at the time of candidemia was associated with a higher mortality. Further studies with a large number of patients are needed to assess the effect of early antifungal therapy on the decrease in mortality associated with candidemia and to determine the appropriate dosage of fluconazole and duration of treatment.

New topical antifungal drugs.

The new antifungal drugs used for topical treatment of superficial, skin and mucosal mycoses are reviewed. Amorolfine and allylamines (naftifine and terbinafine) are promising original molecules with new and different modes of action against fungi. Rilopirox is a new pyridone derivative under study. A great number of azole derivatives, such as oxiconazole, isoconazole, sulconazole, and terconazole, are used as topical antifungals. Three of them are synthesized in Barcelona by pharmaceutical laboratories: sertaconazole, flutrimazole and eberconazole. All of them are now in the register process for commercialization. The combination of antifungals with active products, such as keratoplastics, is used mainly for the treatment of onychomycoses; 40% urea associated with 1% bifonazole has shown high efficacy for this indication.

Polyphasic taxonomy of a novel yeast isolated from antarctic environment; description of Cryptococcus victoriae sp. nov.

In 1992 some samples of mosses, lichens and soils were collected from Botany Bay, Southern Victoria Land (77 degrees 01' S 162 degrees 32' E) and, as a result of a routine screening programme some yeasts were isolated. One of them, designated as strain G5, showed marked differences when compared to other antarctic yeasts. According to morphological and physiological characteristics, we were able to identify the strain G5 as a yeast belonging to the genus Cryptococcus. Some characteristics of this genus are the growth response to myo-inositol, celobiose, raffinose and D-glucuronate, no-fermentation, the absence of mycelium and pseudomycelium, asexual reproduction, Diazolium blue B test (DBB) and urea hydrolisis positive and the growth without vitamines. This strain (G5) formed cream colonies of slimy appearance with cells of 3 x 2 microns in size, that grew between 4 degrees C and 20 degrees C. The G + C content of strain G5 was 50.3 mol%. The molecular characterization by whole-cell proteins and RFLP analysis of the 5.8S rRNA gene and the two ribosomal internal transcribed spacers (5.85-ITS region), revealed that this strain was different from other antarctic species of this genus. The phylogenetic tree deduced from the 5.8S rRNA gene sequence showed the strain G5 as a member of the genus Cryptococcus, clearly separated from other basidiomycetous yeasts. On the basis of the physiological, genotypical and phylogenetical data, the new isolate G5 was described as Cryptococcus victoriae, sp. nov., with the type strain G5 (= CECT 11114).

Early diagnosis of candidiasis in non-neutropenic critically ill patients.

OBJECTIVE: To determine a method for the early diagnosis of candidiasis in non-neutropenic critically ill patients in order to reduce mortality. METHODS: A prospective study in non-neutropenic critically patients in whom Candida spp. were detected, was made in an intensive care unit (ICU) during an 8-year period from 3389 patients admitted. A diagnostic and therapeutic protocol was designed. Invasive candidiasis was defined according to dissemination and multifocality. RESULTS: Candida spp. were found in 145 cases (4.3%): 120 (83%) were considered as invasive candidiasis and 25 as colonisation (17%). The hospital mortality was 46% (67/145). A post-mortem study was carried out in 54% (36/67) of hospital deaths. Candida albicans was the most frequently isolated species (87%), followed by Candida glabrata (18%). There were 24 candidemias and three cases of endophtalmitis. Digestive and respiratory samples and non-C. albicans yeasts were risk factors for invasive candidiasis. The mortality rate was related statistically to invasive candidiasis and inversely to the appropriate antifungal treatment. CONCLUSIONS: Invasive candidiasis is related to digestive and respiratory samples and to the presence of non-C. albicans species. A simpler definition of invasive candidiasis in non-neutropenic critically ill patients will permit more rapid and accurate specific antifungal therapy.

[Spectophotometric method for preparing the inocula of dematiaceous fungi.]. / Método espectrofotométrico en la preparación del inóculo de hongos dematiáceos.

The aim of this study was to adapt a spectrophotometric method for preparing the inocula of dematiaceous fungi used for in vitro susceptibility tests. Fifty-two isolates of 17 different species of dematiaceous fungi were used for this purpose. Homogeneous suspensions of conidia and hyphae of these isolates were obtained and adjusted for reading at 530 and 550 nm at 40% and 50% of transmittance. The suspensions were standardised to 1-5 x 10 e6 CFU/ml. Quality controls of the inocula were done by quantitative cultures on agar-Sabouraud plates. The inocula obtained by spectrophotometry showed little variability within all the isolates. This method can be useful for in vitro antifungal evaluation of dematiaceous fungi.

[Unusual fungal species causing onychomycosis.]. / Especies fúngicas poco comunes responsables de onicomicosis.

Dermatomycoses caused by non-dermatophytic mycelial fungi are very rare with the exception of onychomycoses. Controversies regarding the pathogenic role often arise when these species and yeasts are isolated from nail scrapings. Candida albicans and Candida parapsilosis are the species identified more frequently from nails, particularly from finger nails. Because they could be resident flora of the skin, cultures should be interpreted according to clinical data, direct microscopic observation of clinical samples, and quantification of colonies. The recognition of other yeasts, such as Candida guillermondii, Candida famata or Candida krusei is more problematic. Isolation of moulds form toe nails accounts for 2 to 12% in different studies, with a prevalence of 7.6% in Barcelona being Scopulariopsis brevicaulis the most frequent species, but Aspergillus versicolor is also a particular etiologic agent of onychomycosis (2.5%). To confirm the etiology of any onychomycosis, standard criteria for mycological diagnosis and identification of moulds should be strictly applied. Experience in the diagnosis of superficial mycosis due to new species of fungi is required for improving current knowledge on the prevalence and clinical importance of this type of infections.

[Minimal inhibitory concentrations of Candida species to five antifungals by using the reference dilution micromethod and the E-test.]. / Concentraciones mínimas inhibitorias de levaduras a cinco antifúngicos utilizando un micrométodo de dilución estandarizado y el E-test.

It is accepted that the frequency of candidosis has increased during the last decade, specially in hospitalized patients. The more frequent use of azole antifungals and the recognition of isolates of Candida sp resistant to these and other drugs such as 5-fluorocytosine constitute a great need for a reproducible and useful C. albicans in vitro susceptibility testing method for monitoring antifungal therapy in clinical mycological laboratories. The E-test is a novel agar diffussion technique for testing the susceptibility of yeasts against a defined continous gradient of drug and could be used by most clinical laboratories. In this study the E-test and the NCCLS reference microbroth method (M27-P guidelines) were used to determine the MICs of amphotericin B, 5-flucytosine, itraconazole, fluconazole and ketoconazole for 50 clinical isolates of Candida albicans, Torulopsis glabrata, C. tropicalis and Hansenula anomala and five reference ATCC strains. The main purpose of the study was to compare the results obtained by the two methods. In general good agreement (+/- 1 dilution) was otained between both methods, despite differences observed for some species-antifungal combinations in which the MICs were lower by the E-test than by the microbroth method. MICs for C. albicans and T. glabrata to amphotericin B were < 0.50 microg/mL. Two isolates of C. albicans and two others of H. anomala, showed MIC < 8 microg/mL for 5- flucytosine. All isolates of T. glabrata and 40% of C. albicans showed MICs > 16 microg/mL for fluconazole. The results of this study indicate that E-test is an alternative for susceptibility testing to the NCCLS reference method. Because its simplicity it seems to be an easier test for routine clinical laboratories.

[Topical treatment with eberconazole of the experimental guinea pig cutaneous candidosis.]. / Tratamiento tópico de la candidosis cutánea experimental del cobayo con eberconazol.

Eberconazole is a new azole antifungal drug for topical treatment of superficial mycoses. The usefulness of this drug was evaluated in an experimental model of cutaneous candidosis in guinea pigs comparing with the classical clotrimazole in a single blind trial. Twenty-five animals were inoculated in two symmetrical areas of the back with Candida albicans developing skin infection. One group of 10 animals were treated once per day with clotrimazole 1% cream in one side and with excipient in the other. Other group of 10 guinea pigs received eberconazole 1% cream and excipient. Five animals did not receive any treatment and were used as controls. After five days of treatment most lesions cured or improved and cultures were negative when clotrimazole or eberconazole were applied. Seventy per cent of lesions treated with excipient were clinically improved and 10% cured, but 85% of cultures remained positive for C. albicans. The therapeutic efficacy of eberconazole 1% cream was similar to clotrimazole 1% cream in the guinea ping model of cutaneous candidosis. Tolerance of both drugs was excellent. These results suggest the usefulness of eberconazole in human cutaneous infections due to C. albicans.

[Diagnostic usefulness of the intradermal test with histoplamin in non-endemic areas of histoplasmosis]. / Utilidad diagnóstica de la pruebal intradérmica con histoplasmina, en áreas no endémicas de histoplasmosis.

The histoplasmosis in Spain is an imported disease presenting in most of case diagnostic difficulties. In this paper, the intradermal skin test with Histoplasma capsulatum antigen as diagnostic method in immunocompetent patients with clinical and radiological signs compatible with histoplasmosis after being visited Central and South American endemic counties, in which this mycosis is endemic. Nine Spanish patients coming from different countries of Latin America with fever and acute respiratory symptoms compatible with histoplasmosis were studied. Other nine accompanying subjects and five controls were also evaluated. Patients underwent mycological cultures and and serological tests for H. capsulatum. Intradermal test with 1% histoplasmine were done in all patients. Serology and skin tests tests were also performed in accompanying people. Intradermal were done in healthy controls. Skin test with histoplasmine were positive in seven of the nine patients. Six of these showed precipitating antibodies against the same antigen. H. capsulatum was only isolated from bone marrow biopsy samples in one patient. The seven patients were given itraconazole by oral route and all symptoms improved after 2 and 4 weeks. In five accompanying subjects the skin test were also positive so that a subclinical histoplasmosis was diagnosed. In the remaining patients and healthy accompanying subjects histoplasmosis infection was excluded. In non endemic geographical areas of histoplasmosis intradermal skin test with histoplasmin when used in immunocompetent individuals is an easy and reliable method for the diagnosis of this mycosis as well as for epidemiological studies.

[Oral terbinafine for the tinea unguium of the toenails. Efficacy between 12 and 24 weeks of treament.]. / Terbinafina por vía oral en el tratamiento de la tinea unguium de los pies. Eficacia entre 12 y 24 semanas de tratamiento.

Terbinafine 250 mg po daily was administered to 21 patients affected by tinea unguium of the toenails. In 14 cases Trichophyton rubrum was the aetiological agent while Trichophyton mentagrophytes var. interdigitale affected the rest. The treatment was administered randomized during 12 or 24 weeks in two groups of 11 (group A) and 10 (group B) patients. The clinical and mycological response was evaluated at week 12, 24 and 48. Adverse events were registered during the therapeutic period. At week 24, 55.5% of patients from group A were cured, only one patient did not improve and cultures were positive. In group B 66.6% were cured and three were clinically improved but cultures were positive. In the last control after 48 weeks the results were similar except one patient of the group B who worsened of his nails lesions. Only one case of acute urticaria was noted, the symptoms disappeared after the withdrawal of terbinafine. Terbinafine per os is a safe and effective antifungal for the treatment of the tinea unguium of the toenails. A period of 12 weeks of administration is enough in most of cases but when T. rubrum is the aetiology relapse could be possible.

[Isolation of Cryptococcus neoformans from environmental samples in Alicante]. / Aislamiento de Cryptococcus neoformans en muestras de medio ambiente de Alicante.

A study of the incidence of Cryptococcus neoformans in Alicante was carried out in environmental samples from the cities of Alicante and Santa Pola. The samples were pigeons faeces and Eucalyptus camaldulensis tissues. This study shows that the prevalence of the yeast in faeces from captive pigeons is higher (81.5%) than in the same samples from urban pigeons (16.3%). Regarding the biotype and varieties, a 79.3% of the isolates belonged to C. neoformans, and all of them were C. neoformans var. neoformans. None of the E. camaldulensis samples showed C. neoformans growth, although some Cryptococcus laurentii strains were isolated from flowers.

[Candidemia in AIDS. A retrospective study of nine cases]. / La candidemia en el síndrome de inmunodeficiencia adquirida. Estudio retrospectivo de nueve casos.

Prevalence of candidemia has increased during the last decade, numerous predisposing factors are invoked, like parenteral drug abuse in the case of brown heroin syndrome, neutropenia, prolonged antibiotic therapeutics and immunosupression. Only a few articles are published about candidemia. Candidemia in AIDS patients seems very low; its incidence is estimated approximately one candidemia per 120 patients.

[In vitro resistance to fluconazole and itraconazole in clinical isolates of Candida spp and Cryptococcus neoformans]. / Resistencia in vitro al fluconazol e itraconazol en aislamientos clínicos de Candida spp y Cryptococcus neoformans.

An in vitro susceptibility testing of 181 strains of six species of Candida and 21 strains of Cryptococcus neoformans was carried out in order to investigate the resistance to new antifungal drugs. We have studied clinical isolates from 200 different patients of Hospital del Mar (Barcelona) and Hospital La Inmaculada (Almería). An agar diffusion method (NeoSensitabs, Rosco, Taastrup, Denmark), was employed with fluconazole, itraconazole, and reference drugs amphotericin B, flucytosine, tioconazole and ketoconazole. A high level of susceptibility was found for amphotericin B in C. neoformans strains while 19% of them were resistant to flucytosine. All the strains of C. neoformans and Candida guilliermondii were susceptible to the new azoles derivatives and also Candida parapsilosis and Candida albicans had a great susceptibility to this antifungals. A greater level of resistance was found for Candida krusei, Candida tropicalis and Candida glabrata to fluconazole, itraconazole and ketoconazole, but resistance to fluconazole and itraconazole is not always linked because ten resistant strains for fluconazole were susceptible to itraconazole, and two other resistant to itraconazole were susceptible to fluconazole.

[Epidemiological study of cryptococcosis in Spain: first results]. / Estudio epidemiologico de la criptococosis en España: primeros resultados.

The study constitutes an approach to the knowledge of the epidemiology of cryptococosis in Spain. For detection of cases 167 Spanish hospitals were contacted. All cases included were accompanied by the correspondent isolate of Cryptococcus neoformans, together with clinical, demographic and mycological data. Results obtained from January 1998 to end of December 1999 are analysed and presented here. Fifty-six Spanish hospitals reported 58 cases of cryptococcosis; only 43 of them were adequately documented and accompanied by the clinical isolate. The results showed a higher incidence in males (88.4%) than in females (11.6%); being most frequently affected those between 30 and 40 years old (48.8%). The 84.6% (33) corresponded to new cases and 15.4% (6) to relapses of the disease. The HIV infection was the most frequent risk factor reported (86%) and, for 29.7% (11) of them, cryptococcosis was the AIDS defining disease. For the diagnosis, CSF analysis showed the best results (India ink; culture and antigen detection). All strains collected (100%) corresponded to C. neoformans variety neoformans. Serotypes distribution was 45.5% for serotype A and 22.7% for each of serotypes D and AD.

Multicenter survey of in vitro antifungal resistance in yeasts of medical importance isolated from Spanish patients.

Twelve Spanish laboratories collected 325 yeast clinical isolates during a 30 day's period, among them 224 Candida albicans, 30 Candida glabrata, and 27 Candida parapsilosis. In vitro antifungal susceptibility to amphotericin B, ketoconazole, fluconazole and itraconazole was determined by an agar diffusion test (Neo-Sensitabs, Rosco, Denmark). All the isolates tested were susceptible in vitroto amphotericin B and nearly all (97.2%) to itraconazole. In vitrosusceptibility to fluconazole and ketoconazole was high (90.2% and 91.4% of isolates, respectively) but showed variations depending on the species tested. Resistance to fluconazole and ketoconazole was low in C. albicans (4% and 3%, respectively), but 30% of Candida guilliermondii and 36% of C. glabrata isolates were resistant to fluconazole. Ketoconazole resistance was observed in 40% of C. glabrata, and 17% of Candida tropicalis. Resistance to antifungal drugs is very low in Spain and it is related to non-C. albicans isolates.

[In vitro antifungal susceptibility of dematiaceous filamentous fungi using the E-test]. / Sensibilidad in vitro de hongos dematiáceos a los antifúngicos utilizando E-test.

The usefulness of the E-test((R) )has been studied to determine the in vitro susceptibility of 52 isolates of 17 species to five antifungal drugs: amphotericin B, 5-flucytosine, ketoconazole, itraconazole and fluconazole. Minimal inhibitory concentrations were determined following the manufacturers' instructions, except in the preparation of the inoculum. In this case a spectrophotometric method was used to obtain 1-5 ' 10(6) CFU/ml. Two different culture media were included: casitone-agar and RPMI 1640 agar. Most isolates showed clear growth in both media after 96 h of incubation at 37 degrees C. The species showed low MIC concentrations to ketoconazole and itraconazole. Only 55.8% of isolates showed MICs

[Usefulness of total dry blood samples on filter paper in the detection of antitoxoplasma antibodies]. / Utilidad de las muestras de sangre total desecada en papel de filtro en la detección de anticuerpos antitoxoplasma.

Direct Agglutination (DA) techniques, both, using dry blood samples in filter paper and serum samples, were compared with the ELISA test in order to detect antibodies against Toxoplasma gondii. The results show the validity of the dry blood samples in filter paper for detecting antitoxoplasma antibodies with a DA test. Our results would confirm their usefulness in field epidemiological surveys.