A human case of protothecosis successfully treated with itraconazole.

Cutaneous protothecosis developed in a 63-year-old Japanese female. The patient had a long history of steroid use for bronchial asthma. A tender, swollen, erythematous plaque with white papules covered the dorsal aspect of the patients right hand. Histopathological examination showed typical protothecosis with numerous mulberry-like sporangia positive for periodic acid-Schiff stain. The pathogen was identified as Prototheca wickerhamii. After a 6-week course of 150-200 mg/day itraconazole (ITCZ) therapy, the patients culture was negative for P. wickerhamii. No recurrence was seen after 12 weeks of ITCZ therapy. This case of protothecosis and those of 16 patients are summarized. All the patients had lived in mid- to southern Japan. Only 12 cases of protothecosis treated with ITCZ have been reported in the literature; 8 of these cases were cured with ITCZ therapy alone. In cases treated with ITCZ at no more than 100 mg/day, medication was typically needed for 2 months; most of the cases treated with ITCZ at 200 mg/day were successfully cured within 2 months. A 2-month course of ITCZ at 200 mg/day appears to be adequate treatment for human protothecosis.

[A case of lymphocutaneous sporotrichosis].

We report a case of lymphocutaneous sporotrichosis in a 69-year old man who had nodular-ulcerated lesions on the right hand and forearm. Small nodules remained on the right hand after 8 weeks of 0.5 g daily treatment with potassium iodide. Alternatively, terbinafine therapy (125 mg/day) resulted in healing with atrophic scars after 9 weeks without side effects. We reviewed 67 patients of cutaneous sporotrichosis in Japan from 1993 to 1999. Those cure rates (and mean durations of treatments in parentheses) are 90.9% (8.1 weeks) with potassium iodide, 86.6% (12.6 weeks) with itraconazole (100 mg/day) and 71.4% (12.8 weeks) with terbinafine (125 mg/day) treatments, respectively. These results lead us to consider a daily dose of 250 mg as more appropriate for terbinafine.

Characterization of an extracellular keratinase from Microsporum canis.

Extracellular keratinase (Ekase) 48-, 34- and 31.5-kDa polypeptides, which were isolated from Microsporum canis and examined by immunoblotting reacted with a monoclonal antibody against Ekase of M. canis. We analyzed the amino acid and determined the first 17 amino acid NH2-terminal sequences of the 48-, 34- and 31.5-kDa polypeptides. These polypeptides had a high aspartic acid, glycine and alanine content, respectively. The first 17 amino acid residues of the 34-kDa polypeptide were homologous to those of thermomycolin. This indicated that the 34-kDa polypeptide of Ekase is homologous to the thermomycolin produced by Malbranchea pulchella. Furthermore, Ekase was very heat-stable in the presence of 50 mM CaCl2 at 55 degrees C, since 50% of the initial activity remained. In contrast, no activity was detected after heating in the absence of CaCl2. These results indicate a close relationship between dermatophytes and M. pulchella.

[Dermatophytosis of the external auditory meatus].

Dermatophytosis of the external auditory meatus is believed to be a fairly rare disease. In the past three and a half years we have had seven cases of dermatophytosis in the external auditory meatus. All cases except one were associated with tinea of other lesions. Case 1: A 44-year-old man had tinea of the auricle, tinea pedis and tinea unguium. Case 2: A 14-year-old boy, the son of case 1 had no tinea elsewhere on his body, including the auricle. He scratched the auditory meatus with an earpick which his father had used. Case 3: A 62-year-old man had tinea of the auricle, tinea pedis and tinea unguium. Case 4: A 50-year-old man had tinea of the auricle, tinea pedis and tinea unguium. Case 5: A 36-year-old man had tinea of the auricle, tinea pedis, tinea unguium and tinea cruris. Case 6: A 30-year-old woman had tinea of the auricle. Case 7: A 68-year-old man had tinea of the auricle, tinea pedis, tinea unguium and tinea manuum. Endoscopic examination (except for cases 4 and 7) revealed dry cerumen from cartilaginous to bony region of the external auditory meatus. Direct examination using KOH method of the cerumen in all cases demonstrated numerous fungal elements. Fungal cultures identified Trichophyton rubrum except for cases 3 and 6. All cases were successfully treated with oral itraconazole or terbinafine. We suggest that tinea of the external auditory meatus is frequently associated with that of the auricle.

Purification of protease from a mixture of exfoliative toxin and newborn-mouse epidermis.

Although the role of exfoliative toxin in staphylococcal scalded-skin syndrome has been suggested to be that of a serine protease, it has not been demonstrated to show proteolytic activity. Our purpose was to purify a proteolytic enzyme from a mixture of exfoliative toxin and newborn-mouse epidermis. We used gel filtration and ion-exchange and hydroxyapatite chromatography with a high-pressure liquid chromatography system. A casein-hydrolyzing enzyme was isolated from the mixture. The molecular mass of the enzyme was confirmed to be 20 kDa by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Subcutaneous injection of the purified enzyme into newborn mice reproduced the epidermal splitting that is seen in staphylococcal scalded-skin syndrome. These results suggest that exfoliative toxin does not work as a protease itself but that some reaction between exfoliative toxin and an epidermal component(s) first produces a protease, after which epidermal splitting occurs.

A case of seborrhoeic blepharitis.

A fifty five-year old woman suffered from itching and scaling of the edge of her eyelid. She had long used topical corticosteroid for this condition. Direct examination of the scale by Parker KOH showed numerous fungal elements of spores and hyphae of Malassezia furfur. She was treated with oral itraconazole (100 mg daily or twice a week) for 8 weeks and was cured clinically and mycologically. The result suggests the possibility of treatment with an anti-fungal drug for seborrhoeic blepharitis or seborrhoeic dermatitis.

[Statistical surveillance of mucocutaneous candidiasis in Showa University Fujigaoka Hospital in the past 5 years].

We investigated the epidemiology of 618 patients of mucocutaneous candidiasis who visited our outpatient clinic between 1993 and 1997. Compared with previous reports in Japan, the incidence of candida intertrigo increased and that of erythema mycoticum infantile decreased. The incidence of "others", such as nail candidiasis and candidiasis developed under plaster increased. We identified the species of Candida from patients in 496 recent cases, and these species were cultured successfully in 79.2%. As reported by previous authors, a majority or our results were Candida albicans serotype A. We also investigated the risk factors such as diseases or conditions which might be related to immunodeficiency (neoplasm, AIDS) and that might force a patient to restrict himself to bed for a long period (neurological disease). The former was found in 22.7%, and the latter in 23.3% of patients.

[Experimental studies on the penetration into the human stratum corneum of the dermatophyte].

We present results on the experimental penetration of Trichophyton mentagrophytes and T. rubrum under designated condition of humidity into human stratum corneum obtained from a healthy human heelregion. When mycelia were applied to the surface side of stratum corneum and then incubated at 100 % humidity, T. mentagrophytes and T. rubrum were observed in the stratum corneum on day 1 and day 1.5, respectively. At 95% humidity, T. mentagrophytes and T. rubrum penetrated on day 1.5 and day 4, and at 90% humidity, they penetrated on day 3 and day 7, respectively. At less than 85% humidity, no fungal elements of either strain were observed in stratum corneum for up to 7 days. These datasuggest that at least 90% humidity is necessary for these two fungi to penetrate into stratum corneum within a few days. However, when T. mentagrophytes was applied to the cutting side of the stratum corneum and thenincubated at more than 70% humidity, the mycelia were able to penetrate within a day. The same results were obtained when T. rubrum was applied on the cutting side and incubated at 95 and 100% humidity. T. rubrum was also able to penetrate into the stratum corneum within several days at 70 and 80% humidity. These results may indicate that not only persistent moisture but also minor injuries of stratum corneum are the most important factors in the development of tinea pedis.

[Evaluation of the efficacy of small-dose itraconazole pulse therapy (200 mg/day) for tinea unguium].

Thirty-six patients with tinea unguium were treated with 200 mg of itraconazole daily for 7 days each month. We suggested that a patient who had a lesion in the thumbnail needed 5 months of treatment for mycologial cure, while in a patient without thumbnail lesion, 3 months of treatment was enough.

Experimental penetration of Trichophyton mentagrophytes into human stratum corneum.

We present confirmation of the experimental penetration of Trichophyton mentagrophytes into human stratum corneum under designated conditions of temperature and humidity. When stratum corneum, obtained from healthy human heel region, was incubated at 100% humidity, mycelium was observed in the corneum layer on day 2 at 35 degrees C and 27 degrees C, and on day 4 at 15 degrees C. At 90% humidity, the hyphae penetrated into the stratum corneum on day 4 at 35 degrees C, and on day 6 at 27 degrees C. Whereas, at 80% humidity, no fungal elements were observed in the stratum corneum at both 27 degrees C and 35 degrees C for up to 7 days. These data suggested that humidity was a more important environmental factor for penetration than temperature, and that at least 90% humidity is necessary for dermatophytes to penetrate into the stratum corneum within a few days. Mean humidity in the interdigital space between the fourth and fifth toes was found to be approximately 98%.

[Two cases of dermatophytosis of the external auditory meatus].

We report two cases of dermatophytosis of the external auditory meatus. Case 1: A 44-year-old man suffered from severe itching in the right external auditory meatus for a year, and had also had tinea unguium for several years. He visited our outpatient clinic because of scaly erythema which had developed on the auricle. Otoscopic examination revealed yellow-brown dry cerumen and redness from the cartilaginous to the bony portion of the external auditory meatus. Case 2: A 14-year-old boy, the son of Case 1, suffered from severe itching in the left external auditory meatus. He scratched the auditory meatus with an earpick which his father had used. Otoscopic examination revealed a similar lesion as in the father's case, although he had no history of dermatophytosis elsewhere on his body, including the auricle. Direct examination using a KOH method of the cerumen from both cases demonstrated numerous fungal elements. Fungal culture identified Trichophyton rubrum. Both cases were successfully treated with oral itraconazole. We suggest that infection from father to son was transferred by the earpick.

[Topical treatment of onychomycosis by occlusive dressing using bifonazole cream containing 40% urea].

Topical treatment with an antifungal agent was performed in 70 cases of onychomycosis (69 cases of tinea unguium and 1 case of Candida onychomycosis). The patients were treated every night by occlusive dressing using bifonazole cream containing 40% urea, and then by simple application of 1% bifonazole solution in the morning. During the treatment period, the softened affected nails were removed as completely as possible with nail clippers and files. The nails were observed every two weeks, and the efficacy was evaluated after 12 weeks. Two cases were excluded and 28 cases dropped out leaving 40 cases for efficacy evaluation. Among the 40 patients, 20 appeared to be mycologically negative (mycological cure rate: 50.0%). Clinical response was judged by the changes in opacity and thickness of the nails. Nine patients were evaluated as showing "marked improvement" and 16 as showing "improvement" (improvement rate: 62.5%). Erosion was noted as an adverse reaction in 2 patients. In one patient, treatment was stopped and the lesion was improved by antibiotic ointment, and in another, treatment was resumed when erosion was cured by discontinuation of the treatment. These results suggest that the topical treatment of onychomycosis by occlusive dressing is a useful method for those patients who have difficulties in or do not wish to be treated with oral antifungal agents.

Seborrhoeic dermatitis: treatment with anti-mycotic agents.

In order to elucidate the effectiveness of anti-mycotics in treating seborrhoeic dermatitis, an attempt was made to isolate Malassezia from seborrhoeic lesions of patients of seborrhoeic dermatitis. The results revealed that, in male patients, 46/49 cases were positive for Malassezia furfur on the face and 30/48 cases were positive for M. furfur on the scalp. In female patients, 7/13 cases were positive for M. furfur on the face, and 6/17 cases were positive for M. furfur on the scalp. Anti-mycotic agents were excellent in 50% and good in 31% of the spore-positive cases, yielding an overall efficacy rate of 81%. In contrast, the treatment of the face with vehicle alone showed only one excellent result out of 8 cases. Although clinical improvement was rapid on the side treated with a topical corticosteroid in the half-side-test, numerous fungal elements remained. While the improvement with anti-mycotic agents was slower than that with the corticosteroid, clinical improvement became evident by the third week of administration and fungal elements disappeared.

Bullous pemphigoid complicated with pemphigus vulgaris?

A 67-year-old housewife had polymorphous eruptions with tense bullae on the extremities and upper trunk. Erosions were noted on the oral and esophageal mucosa. A skin biopsy showed subepidermal blistering with linear deposition of IgG and C3 at the basement membrane zone. In addition, intercellular deposition was observed at the lower part of the epidermis. On the basis of clinical and histological features, a diagnosis of bullous pemphigoid (BP) was made. After she was treated with prednisolone, the whole-skin lesions soon disappeared. An esophageal biopsy showed intercellular deposition of IgG and C3. Indirect immunofluorescence testing using esophageal mucosa of guinea pigs showed the same deposition at the titer of 1:20. Immunoblottings with this patient's serum revealed no reactions with either BP or pemphigus antigens. Her serum reacted strongly with a 190-kD protein, the nature of which was unknown. A treatment with ciclosporin was added to this steroid therapy, and the mucosal lesions improved gradually.

Experimental production of DLE lesion with a single exposure to UVB (2.7 MEDs) radiation.

Keratotic erythematous lesions developed on the face, ears, neck, and upper back of a 38-year-old man. The patient had a history of photosensitivity to sunlight manifested by the development of new lesions. One week after an MED (2.7 mJ/cm2) was determined using UV-B light, persistent erythema with fine scales were observed at test sites irradiated over 72 mJ/cm2. These lasted for at least 2 months. A biopsy specimen obtained from the test site irradiated at 72 mJ/cm2 showed liquefaction degeneration of the basal cell layer. Within the upper part of the dermis, perivascular and disseminated lymphocytic infiltrates were seen. However, when irradiated again under the same conditions 7 and 12 months after the initial phototest, no persistent erythema was observed.

Partial purification and some characteristics of proteinase(s) induced by staphylococcal exfoliative toxin.

After 8 hrs incubation with epidermis of newborn mice and exfoliative toxin, a marked increase in caseinolytic activity was detected, which reached a maximum at 12 hrs. Casein-hydrolyzing enzyme(s) induced by ET were partially purified by chromatography. A substantial increase in caseinolytic activity was detected in the fractions obtained from Sephadex G-50, while practically no caseinolytic activity was observed when the extract obtained from the epidermis incubated without ET was applied. The caseinolytic activity appeared as a single peak eluted from DEAE-Sepharose CL-6B and Sephadex G-75. However, on SDS-PAGE, the partially purified fractions exhibited several protein bands. The molecular weights of these band were estimated as 78 KD, 68 KD, 45 KD, 14.5 KD and 8.8 KD. When the partially purified enzyme(s) was preincubated with EGTA or EDTA, substantial inhibition of the activity was observed; however, no recovery of the activity was detected after the addition of CaCl2. Treatment of the enzyme(s) with PMSF and NEM caused little inactivation of the activity. Enzyme activity retained about 57% of the initial activity following 3 min incubation at 60 degrees C, but was completely inactivated after 4 min.