Neoscytalidium dimidiatum as onychomycosis causative agent in an Iranian patient: a case report and literature review.

A 38-year-old healthy male presented to our medical mycology center with whitish opaque discoloration of the right toenail. He reported a history of some sand scratches subsequent to walking barefoot on the beach two years ago and wearing hard safety shoes for a period of two years. On clinical examination, onycholysis, onychodystrophy, and apparent thickening of the ungual bed in the left big toe were found. The microscopic examination of nail clippings using 15% potassium hydroxide (KOH/) revealed the presence of septate pigmented hyphae. The fungus was identified as Neoscytalidium dimidiatum based on the cultural characteristics, the arrangement of arthroconidia on lactophenol cotton blue (LPCB) staining, blocky-brown pigmented hyphae on serum physiology mounts, and sequencing. Susceptibility of the isolated fungi to amphotericin B, itraconazole, voriconazole, and terbinafine was tested using the standard broth microdilution M38-A2 method developed by the Clinical and Laboratory Standards Institute (CLSI). The minimum inhibitory concentrations (MICs) of the four antifungal drugs used in this study were: amphotericin B: 1 mg/L, itraconazole: 2 mg/L, voriconazole: 0.25 mg/L, and terbinafine: 1 mg/L. The patient underwent terbinafine and clobetasol topical treatments for 6 months.

Chronic mucocutaneous candidiasis, a case study and literature review.

Chronic mucocutaneous candidiasis (CMC) is a clinically heterogeneous disease. Some immunologic and hormonal abnormalities have been associated with CMC. The factors that predispose host to CMC infection could be autosomal or acquisitive. The disease usually occurs in childhood. Here, we reviewed the published literature on chronic mucocutaneous candidiasis and a four years old girl is presented with CMC. She had a history of recurrent thrush and otomycosis since the age of one. Candida albicans was detected in skin scraping and biopsy samples. Serum iron was low. TSH hormone level was high and T4 level was low. Giardia cysts were found in stool sample. Mucocutaneous and nail manifestations of the disease were disappeared after a period of Itraconazole therapy.

Evaluation of outcomes of suction drainage in patients with haemophilic arthropathy undergoing total knee arthroplasty.

INTRODUCTION: Closed suction drainage has been extensively applied for orthopaedic procedures for the sake of avoiding fluid collections around the wound at the operated limb. AIM: We believed that without application of suction drainage after total knee arthroplasty (TKA), the risk of infection and haematoma formation will not increase while the need for blood transfusion because of decreased blood loss will be lesser. METHODS: In a prospective randomized clinical trial from April 2010 to April 2014, 176 patients with haemophilia who underwent TKA were included. The study group consisted of 88 patients (108 knees), in which we did not insert suction drain and the control group included 88 patients (106 knees), in which drain was inserted at the end of the surgery. All patients underwent TKA via anterior knee incision and medial parapatellar approach. RESULTS: The mean follow-up period of study group and control group was 21 ± 11 months vs. 20 ± 9 months consecutively (P = 0.54). The mean hospital stay was 13 ± 8 days vs. 14 ± 8 days in study and control group consecutively (P = 0.40). In both groups, the major part of improvement in clinical knee society score was due to increase in pain subset (mean increase of 42 vs. 39 points consecutively) and to a lesser extent to alleviation of flexion contracture (mean increase of 13 vs. 15 points consecutively). We observed no differences in the mean visual analogue scale (VAS) value between both groups. Average functional outcome in both groups improved during follow-up visits. CONCLUSION: We can conclude that there is no rationale for the use of drain after primary TKA.

The impact of topical Saint John's Wort (Hypericum perforatum) treatment on tissue tumor necrosis factor-alpha levels in plaque-type psoriasis: A pilot study.

CONTEXT: Psoriasis is an inflammatory disorder, formed by inappropriate interaction of T lymphocytes with keratinocytes, and consequent eruption of immune responses. High concentrations of tumor necrosis factor-alpha (TNFα) are found in the skin lesions and plasma of patients with psoriasis. Hypericum perforatum, a phytomedicine that has both anti-inflammatory and antiproliferative properties, has been recently reported to be clinically helpful for improvement of psoriatic lesions. AIMS: The aim of the present study was to investigate the effects of topical H. perforatum on TNFα levels in psoriatic lesions for possible identification of the mechanism by which Hypericum reduces inflammation and modulates the disease in patients with plaque-type psoriasis. SETTINGS AND DESIGN: A double-blind, placebo-controlled, pilot study with intraindividual comparison was conducted on twenty patients with mild to moderate plaque-type psoriasis. SUBJECTS AND METHODS: TNFα levels in tissue samples were measured with immunohistochemistry method. Moreover, Psoriasis Area Severity Index (PASI) scores and histological and clinical changes were investigated after topical application of Hypericum extract. STATISTICAL ANALYSIS USED: The Wilcoxon signed-rank test was used to evaluate the possible differences between the drug and placebo group. RESULTS: TNFα concentrations in dermis (p= 0.025), endothelial cells (p=0.033), and dendrite cells (p=0.014) were significantly reduced in lesions treated with drug and the reduction observed in epidermis was superior to placebo (p=0.046). Results of PASI scores showed that erythema, scaling, and thickness were significantly lower where the ointment had been applied compared to application of placebo (p=0.014, p=0.004, p=0.003, respectively). Moreover, significant improvement in clinical and histological features of treated lesions in comparison with untreated lesions was observed (P < 0.05). CONCLUSIONS: H. perforatum ointment can help decrease PASI scores and TNFα levels in psoriatic tissue. Its efficacy is probably related to its effect on lowering cytokines including TNFα.

Efficacy and safety of permethrin 5% topical gel vs. placebo for rosacea: a double-blind randomized controlled clinical trial.

BACKGROUND: Rosacea is a chronic, multifactorial, dermatological condition. Increased density of Demodex folliculorum mites in the skin of rosacea patients suggests a possible role for these mites in the pathophysiology of rosacea. OBJECTIVE: To evaluate the effects of permethrin 5% topical gel vs. placebo on Demodex density (Dd) and clinical presentations of rosacea patients, and also to further refine the quantitative assessment of Dd in the non-invasive standard skin surface biopsy (SSSB). METHODS: Twenty patients with bilateral papulopustular rosacea and ≥5 mites/cm2 were enrolled in the study. Participants and physicians were blinded to the group assignments. Each patient applied permethrin on one side and placebo on the other side of the face twice daily for 12 weeks. SSSB and photography and Rosacea Clinical Scorecard of the National Rosacea Society were used to assess the patients at the baseline, 2nd, 5th, 8th, and 12th weeks for both sides of the face. Causality and severity of adverse drug reactions (ADRs) were assessed by WHO Scale and Hartwig Scale, respectively. RESULTS: Dd was not significantly different between the two groups at the baseline. In both groups, Dd significantly decreased after 12 weeks compared to the baseline. At the end of the 12th week, the Dd in the permethrin group was significantly lower than the placebo group. Severity of the clinical presentations decreased in both groups at the end of week 12 in comparison to the baseline, particularly in the permethrin group. ADRs were all mild and in most cases unlikely related to permethrin. CONCLUSION: Permethrin 5% gel can significantly reduce the Dd and severity of presentations in rosacea patients and can be a safe and effective option in the management of this chronic disorder. This new SSSB technique offers an easy, quick, inexpensive, and non-invasive sampling method proper for quantitative assessment of Dd.

Differential expression of mRNA for T-bet and GATA-3 transcription factors in peripheral blood mononuclear cells of patients with vitiligo.

BACKGROUND: There is accumulating evidence that aberrant T helper (Th)1 and Th2 cell responses play critical roles in the pathogenesis of autoimmune diseases. However, their importance in the pathobiology of vitiligo have yet to be elucidated. AIM: To evaluate the expression profile of two transcription factors, namely, T-bet, a Th1-specific T box transcription factor and GATA binding protein 3 (GATA-3), a Th2-specific transcription factor, and to measure expression levels of interferon (IFN)-γ and interleukin (IL)-4 mRNAs as the signature cytokines of Th1 and Th2 cells, respectively. METHODS: Gene expression analysis of peripheral blood mononuclear cells (PBMCs) was performed using real-time reverse transcriptase PCR. RESULTS: In patients with vitiligo compared with controls, mRNA expression was significantly higher for T-bet and IFN-γ, and significantly lower for GATA-3 and IL-4 mRNAs (P ≤ 0.05). CONCLUSION: These data suggest additional implications for the role of Th1/Th2 balance in the immunopathogenesis of vitiligo.

Involvement of nitric oxide in serotonin-induced scratching in mice.

BACKGROUND: Serotonin is a pruritogenic substance in humans and animals, but the mechanisms of action through which serotonin induces itch response are not yet understood. AIM: To examine the possible role of nitric oxide (NO) in the profile of scratching behaviour due to intradermal injection of serotonin in mice. METHODS: Intradermal injection of serotonin (14.1-235 nmol per site) into the nape of the neck was used to elicit itch in mice. Scratching behaviour was evaluated by counting the number of bouts during 60 min after injection. To determine the possible involvement of the nitrergic system in serotonin-induced scratching, L-NG-nitroarginine methyl ester [L-NAME; a nonselective nitric oxide synthase (NOS) inhibitor], aminoguanidine [a selective inducible (i)NOS inhibitor] and L-arginine (an NO precursor) were administered intraperitoneally to control and serotonin-injected animals. RESULTS: Intradermal serotonin caused scratching in mice with a bell-shaped dose-response correlation, and the peak effective dose was 141 nmol per site. The majority of scratching bouts in animals occurred 5-10 min after injection. Ineffective doses of L-NAME (3 mg/kg IP) and aminoguanidine (100 mg/kg IP) decreased the scratching induced by intradermal serotonin injection in animals (P < 0.001 and P < 0.001), while an subeffective dose of L-arginine (100 mg/kg IP) augmented the scratching effect of serotonin (P < 0.001). CONCLUSIONS: We show for the first time that the scratching induced by intradermal serotonin is mediated by NOS, especially iNOS, activation. We conclude that NO may play a role in mediating itch responses. NO and NOS could be new targets for antipruritic agents.

Evaluation of the efficacy of cysteamine 5% cream in the treatment of epidermal melasma: a randomized double-blind placebo-controlled trial.

BACKGROUND: Melasma is a difficult-to-treat hyperpigmentary disorder. While cysteamine is a known potent depigmenting agent, its efficacy in treating melasma has not been tested. OBJECTIVES: To study the efficacy of cysteamine 5% cream in the treatment of patients with epidermal melasma. METHODS: In this double-blind randomized study, participating patients (n = 50) received either placebo (n = 25) or cysteamine cream (n = 25). Cysteamine cream or placebo were applied on the lesions once a day at bedtime over 4 months. The efficacy of treatments was determined through Mexameter skin colorimetry, Melasma Area Severity Index (MASI) score, Investigator's Global Assessment (IGA) and patients' questionnaires, all performed at baseline and after 2 and 4 months of treatment. RESULTS: At baseline, the mean differences between pigmented and normal skin (calculated by Mexameter) were 75.2 ± 37 and 68.9 ± 31 in the cysteamine and placebo groups, respectively. After 2 and 4 months of application of cysteamine and placebo cream, the mean differences were 39.7 ± 16.6 and 26.2 ± 16 in the cysteamine group, and 63.8 ± 28.6 and 60.7 ± 27.3 in the placebo group, respectively. Statistically significant differences were found between the group outcomes at both points (P = 0.001 and P < 0.001). At the end of the treatment, the MASI scores were significantly lower in the cysteamine group vs. placebo (7.2 ± 5.5 vs. 11.6 ± 7.9, P = 0.02). The IGA and patients' viewpoints indicated significant efficacy of cysteamine cream vs. placebo. CONCLUSIONS: Cysteamine cream showed significant efficacy in the treatment of melasma.

Severe tinea corporis due to Trichophyton verrucosum mimicking discoid lupus erythematosus.

OBJECTIVE: This study was carried out to show possible similarities between discoid lupus erythematosus clinical signs and histopathological findings and dermatophytosis. PATIENT AND METHODS: A 43-year-old woman with diffused erythematous scaling lesions on her neck was studied. Skin biopsy was performed using H&E and PAS staining. Direct microscopic examination and mycological culture of specimens were done as well. RESULTS: Histopathological examination suggested she was suffering from discoid lupus erythematosus; however mycological findings confirmed Trichophyton verrucosum as the etiologic agent of lesions. She was successfully treated with oral terbinafine and clotrimazole cream. CONCLUSION: Regarding to the results of this study, there are some similarities between dermatophytosis and skin infections such as discoid lupus erythematosus.

Trichophyton Schoenleinii-induced widespread tinea corporis mimicking parapsoriasis.

We report a case of extensive tinea corporis in an 80-year-old woman on her forearms, thighs, legs, buttocks and trunk, mimicking parapsoriasis due to Trichophyton schoenleinii, without scalp involvement. Diagnosis of Trichophyton schoenleinii was confirmed by microscopy and mycological culture specimens.

Lesion area assessment in psoriasis patients.

Psoriasis is an autoimmune skin disease, afflicting skin with red plaques that are usually accompanied by silvery-white scales. Various medical treatments are used, with different impacts on the patients, but there is no definite cure for the disease. The PASI standard is employed to measure the performance of the treatments. It includes four parameters, namely area, erythema, scaliness and skin thickness. The PASI parameters are usually measured manually by physicians through subjective clinical observations which are imprecise, time consuming and in some cases lead to diverse results. This paper presents a computer-based automatic method to measure the area parameter in the PASI standard. In the proposed method, the YCbCr colour space is used to differentiate the plaques from the skin by applying an optimal threshold method. Performance evaluation results indicate that the proposed method is able to determine lesion areas with accuracy higher than 96% for 18 out of 20 cases and higher than 92% for another case. As well as high accuracy the proposed method has another advantage over previous methods: it can automatically detect plaques with silvery-white scales, plaques on hairy skins and tiny plaques, as well as simple (scale-less) plaques.

Possible association of the CD4 gene polymorphism with vitiligo in an Iranian population.

BACKGROUND: Vitiligo is an acquired idiopathic and polygenic disorder with progressive depigmentation of circumscribed patches. Its exact pathogenesis is unknown. The CD4 gene plays an important role in the cell-mediated immune response and its association with type 1 diabetes mellitus, which is an autoimmune disease, has been previously reported. METHODS: Based on the assumption that autoimmunity is also involved in vitiligo, the CD4 gene was selected for study using a candidate gene approach. The pyrimidine-rich pentanucleotide repeat length polymorphism located in the promoter of the gene was studied. We screened 144 unrelated Iranian patients with vitiligo and 144 healthy matched controls by PCR. RESULTS: The CD4*A4 allele has a susceptibility association with the development of vitiligo in the Iranian population (OR = 1.68, 95% CI 1.18-2.42; P < 0.01, P(c) = 0.02). When we compared CD4*A4-containing genotypes in the case and control groups, even more significant positive association was identified (OR = 2.02, 95% CI 1.26-3.22; P < 0.01 and P(c) < 0.01). The CD4 gene polymorphism has a modest association with the development of vitiligo in Iranian patients.

Evaluation of Candida albicans allergens reactive with specific IgE in asthma and atopic eczema patients.

Candida albicans (C. albicans) produces important allergenic components which can induce allergic reactions in sensitised patients. The purpose of this study was to extract the C. albicans antigens for evaluating the specific anti-Candida IgE in sera of atopic eczema (AE) and asthmatic patients (AS). 95 AE, 85 AS, and 70 non-atopic cases were selected with sequential trials. Candida albicans antigens were prepared and then skin prick test (SPT), ELISA and IgE-immunoblotting tests were performed for all patients. Positive SPT reactions were obtained on 52.6% of AE and 54.1% of AS patients and 4.3% of healthy controls (P < 0.05). Using ELISA, specific anti-C. albicans IgE antibody was detected in 32.6% and 41.2% of patients with AE and AS, respectively. No specific IgE antibody was detected in healthy controls (P < 0.05). In SDS-PAGE, protein bands with molecular weights between 13 and 135 kDa were detected, and some of them reacted with specific IgE in immunoblotting. In AE patients, the most important allergenic components were 25, 34, and 57 kDa protein bands, whereas in AS, 22, 25, and 34 kDa protein bands were observed as major allergens. Candida albicans produces different allergenic components that can induce allergic reactions and may be pathogenetically important in patients with AE and AS.

Immediate hypersensitivity to Malassezia furfur in patients with atopic dermatitis.

Atopic dermatitis (AD) is a chronic pruritic dermatitis that has unknown aetiology. It seems that Malassezia furfur has a role in pathogenesis of AD. The purpose of this study was to evaluate skin responses to M. furfur antigens in AD patients. Malassezia furfur was grown and the yeasts were broken. Cells were centrifuged and supernatants were used as crude extracts (CE). Protein components of CE were separated by sodium dodecylsulphate-polyacrylamide gel electrophoresis (SDS-PAGE). In addition, to fractionate CE antigens, gel filtration chromatography was performed. One hundred and fifteen AD patients were selected for skin-prick test (SPT). In SDS-PAGE, CE showed a total of 19 different protein bands (10-100 kDa). Chromatographic gel filtration with M. furfur proteins showed four major fractions (F). The protein pattern of F(1) (tube no. 40) was between 22 and 100 kDa and it was selected for SPT. In SPT, 49.6% and 42.6% patients showed positive reactions with CE and F(1) antigens respectively. The most positive results were obtained in 20-29 aged group (P < 0.001). The allergens of M. furfur may have a role in AD signs; it is suggested to use F(1) antigens in allergy tests.

Identification of peptides specific for antibodies in vitiligo using a phage library.

Patients with vitiligo produce specific autoantibodies that can be detected in their sera. These antibodies are believed to play a role in the pathogenesis of this disease. A random peptide library displayed on phage is a technique that can be used to identify the epitopes that react with monoclonal and polyclonal antibodies. We used this technique to identify the epitopes that react specifically with the vitiligo autoantibodies. By screening the random peptide phage library and using ELISA, two clones that showed a higher frequency of reactivity with the antibodies in the sera of patients with vitiligo were identified. The peptides do not show any similarity with the autoantigens so far implicated in vitiligo, indicating that these epitopes may mimic conformational epitopes in proteins.

Onychomycosis in Tehran, Iran: prevailing fungi and treatment with itraconazole.

A total of 187 Patients with suspected onychomycosis were examined for causative fungal agents between 1996 and 1997. Laboratory examination confirmed onychomycosis in 115 patients, of which 97 cases were presented with positive microscopic and cultural examinations, and they were selected for itraconazole pulse therapy. From an etiological point of view, 48.4% of the nail infections, mainly toenail infections, were caused by dermatophytes, 43.3% were infected with Candida spp, specially infected fingernails, and 8.2% by non-dermatophytic molds. Trichophyton mentagrophytes var. interdigital and T. violaceum were the most prevalent species. Candida albicans and C. parapsilosis were the predominant species of the Genus Candida. Scopolariopsis brevicaulis was the most common non-dermatophyte molds observed. Female affected more frequently than male and in both sexes, those who were 30-49 years old, more infected. Toenails were affected more frequently than fingernails. In this study, itraconazole pulse therapy (400 mg daily) gave during the first week of per month for 3 months. The study included 51 patients with toenail onychomychosis (group 1) and 46 patients with fingernail infections (group 2). Patients were followed up for 9 months after the last treatment. Clinical response rates were 83% in the group 1, 95% in the group 2 at month 12; the corresponding mycological cure rates were 71 and 87%, respectively.

Case report: chronic dermatophyte infection in a patient with vitiligo and discoid lupus erythematosus.

We report the case of a patient suffering from vitiligo and discoid lupus erythematosus. The nails of the left hand were involved with subungual hyperkeratosis. He was treated by local and systemic corticosteroid and chloroquine but hyperkeratotic lesions progressed on the affected sites and were found to be caused by Trichophyton violaceum.