Trichosporonosis Presenting as an Exophytic Cutaneous Mass Lesion.

Opportunistic fungal pathogens have increased in frequency with the growing immunosuppressed population. New and emerging pathogens, including the rare yeasts, continue to cause significant morbidity and mortality and frequently develop despite prophylaxis with antifungal agents. We report a previously unreported manifestation of disseminated trichosporonosis. Our patient with underlying acute myeloid leukemia presented with as an exophytic toe lesion found secondary to Trichosporon asahii. We highlight the need for a high index of suspicion to diagnose breakthrough infections and the need for aggressive treatment.

Melioidosis in Colombia, description of a clinical case and epidemiological considerations / Melioidosis en Colombia, descripción de un caso clínico y consideraciones epidemiológicas

Melioidosis is an infectious disease caused by Burkholderia pseudomallei whose clinical diagnosis can be difficult due not only to its varied clinical presentation but also to the difficulties in the microbiological diagnosis.Thus, it may be necessary to use molecular techniques for its proper identification once it is suspected. There are few antibiotics available for the treatment of this disease, which must be used over a long period of time. Although it is known to be endemic in Thailand, Malaysia, Singapore, Vietnam, and Australia, in Colombia there are few reported cases. We describe a case of melioidosis in the northern region of Colombia. Additionally, we review its clinical characteristics and treatment and we describe the local epidemiology of this disease.

La melioidosis es una enfermedad infecciosa causada por Burkholderia pseudomallei cuyo diagnóstico clínico puede ser difícil debido a su variada presentación clínica y a las dificultades del diagnóstico microbiológico, por lo cual pueden requerirse técnicas moleculares para su adecuada identificación una vez se sospecha su presencia. Son pocos los antibióticos disponibles para el tratamiento de esta enfermedad y, además, deben usarse durante un tiempo prolongado. Aunque se conoce por ser endémica en Tailandia, Malasia, Singapur, Vietnam y Australia, en Colombia se han reportado algunos pocos casos. Se presenta un caso de melioidosis en la región norte de Colombia, se hace una revisión de las características clínicas y el tratamiento, y se describe la epidemiología local de esta enfermedad.

Characteristics, Associated Diseases, and Management of Gram-negative Toe-web Infection: A French Experience.

Gram-negative toe-web infection can cause pain and disability, be complicated by a long healing time, management failure, and cellulitis, and recur due to persistent predisposing factors. To describe the clinical features and management of Gram-negative toe-web infection and evaluate predisposing factors and associated diseases, their management, and the effect of controlling them on the rate of recurrence, we conducted a retrospective real-life study of patients with Gram-negative toe-web infection. Among the 62 patients (sex ratio 9:1), 31 experienced more than one episode of Gram-negative toe-web infection. Pseudomonas aeruginosa was the most prominent bacteria. Predisposing factors/associated diseases were eczema (66%), suspected Tinea pedis (58%), humidity (42%), hyperhidrosis (16%), psoriasis (11%), and vascular disorders (40%). Patients in whom associated diseases, such as eczema or psoriasis, were controlled did not relapse, suggesting the benefit of management of such conditions. We suggest that management of Gram-negative toe-web infection be standardised, with a focus on diagnosis and treatment of associated diseases.

Melioidosis en Colombia, descripción de un caso clínico y consideraciones epidemiológicas / Melioidosis in Colombia, description of a clinical case and epidemiological considerations

Resumen La melioidosis es una enfermedad infecciosa causada por Burkholderia pseudomallei cuyo diagnóstico clínico puede ser difícil debido a su variada presentación clínica y a las dificultades del diagnóstico microbiológico, por lo cual pueden requerirse técnicas moleculares para su adecuada identificación una vez se sospecha su presencia. Son pocos los antibióticos disponibles para el tratamiento de esta enfermedad y, además, deben usarse durante un tiempo prolongado. Aunque se conoce por ser endémica en Tailandia, Malasia, Singapur, Vietnam y Australia, en Colombia se han reportado algunos pocos casos. Se presenta un caso de melioidosis en la región norte de Colombia, se hace una revisión de las características clínicas y el tratamiento, y se describe la epidemiología local de esta enfermedad.

Abstract Melioidosis is an infectious disease caused by Burkholderia pseudomallei whose clinical diagnosis can be difficult due not only to its varied clinical presentation but also to the difficulties in the microbiological diagnosis.Thus, it may be necessary to use molecular techniques for its proper identification once it is suspected. There are few antibiotics available for the treatment of this disease, which must be used over a long period of time. Although it is known to be endemic in Thailand, Malaysia, Singapore, Vietnam, and Australia, in Colombia there are few reported cases. We describe a case of melioidosis in the northern region of Colombia. Additionally, we review its clinical characteristics and treatment and we describe the local epidemiology of this disease.

Onset of disseminated cutaneous nodules following toe amputation in heart transplant patient.

Alternaria spp. infections are rare, but organ transplant recipients and immunosuppressed patients are particularly at risk of developing cutaneous alternariosis. Although cutaneous alternariosis is well-defined, instances of disseminated infection are exceedingly rare. We report a case of disseminated Alternaria infection in an immunocompromised patient from a primary focus of ungual phaeohyphomycosis.

Toe web intertrigo in Kaposi's sarcoma patients: a microbiological study in a large cohort of patients.

Kaposi 's sarcoma (KS) is a rare multifocal angioproliferative disease associated with human herpes virus 8 (HHV-8) infection, characterized by cutaneous nodules or plaques especially on the lower limbs. Some skin modifications, such as chronic lymphedema, plantar hyperkeratosis and interdigital desquamation, may be associated with consequent impairment of the local immunosurveillance and increased risk of some bacterial or mycotic infections. With the objective of evaluating if bacterial or mycotic infections in KS patients are supported by different microorganisms compared to control patients, we performed an observational retrospective study, comparing positive cultural swabs of interdigital intertrigo of KS patients with positive cultural swabs of interdigital intertrigo of patients admitted to our dermatologic unit during the last 10 years. One hundred KS patients and 84 control patients were admitted to this study. Some of the skin swabs from interdigital spaces were positive for more than one microorganism, and therefore we found 187 microorganisms among the KS group and 182 microorganisms in the control group. The most common microrganisms among KS patients were T. mentagrophytes (16%), S. aureus (14.9%), P. aeruginosa (13.9%), S. marcescens (5,9%), while among non-KS patients were S. aureus (26,9%), C. albicans (22%), S. agalactiae (7.7%) and E. coli (9.9%). These differences are statistically significant (p < 0.01). KS patients may be more affected by toe web intertrigo due to other bacteria and dermatophytes than the general population. During clinical examination, a careful inspection is necessary for an early diagnosis of toe web intertrigo, in order to prevent serious complications, such as cellulitis and sepsis. Consequently, a cultural examination with antibiogram is required to identify the causative agent of intertrigo and guide antimicrobial therapy.

Colgajo de avance y rotación celuloadiposo de pulpejo para reconstrucción de lecho ungueal / Cell adipose finger pad advancement and rotation flap for nail bed reconstruction

Introducción y Objetivo. Las lesiones de punta de dedo, y en especial de lecho ungueal, son de las más frecuentes en el trauma de mano, generalmente asociadas a traumatismo por agresión y accidentes laborales, con una incidencia y prevalencia elevada en nuestro medio. Presentamos la experiencia con nuestra técnica quirúrgica para reconstrucción de lecho ungueal consiste en el avance y rotación de un colgajo celuloadiposo de pulpejo de dedo basando su vascularización en las arterias palmares ascendentes. Material y Método. La técnica consiste en elevar un colgajo de tejido celuloadiposo del pulpejo desde la falange distal de acuerdo con el tamaño del defecto tisular a nivel del lecho ungueal, realizando una rotación, si se requiere, y un avance, brindando una completa y adecuada cobertura. Hay que destacar que con esta técnica se preservan los tabiques fibrosos favoreciendo la vascularización del colgajo y como ventaja adicional no deja cicatriz en el pulpejo. Resultados. Hemos llevado a cabo la técnica descrita en un total de 120 pacientes (70% hombres, 26% mujeres y 4% niños) con una edad media de 36.5 años, siendo la principal causa traumatismo en accidente laboral: 110 fueron exitosos, 3 se perdieron sufriendo necrosis total, y 7 presentaron sufrimiento inicial sin pérdida. Conclusiones. Esta técnica constituye una herramienta práctica, segura y eficiente como alternativa para la reconstrucción del lecho ungueal, brindado resultados óptimos para este tipo de lesiones (AU)

Background and Objective. Fingertip injuries and nail bed lesions are associated with trauma aggression and work accidents with a high incidence and prevalence in our environment. We present the experience with our surgical technique for reconstruction of nail bed with the advancement and rotation of a cell adipose flap of finger pad, basing its vascularization in the palmar arteries. Methods. The technique consists on lifting the flap (cell adipose finger pad tissue) from the distal phalange according to the size of the tissue defect at the level of the nail bed, performing a rotation, if required, and an advance flap, providing a complete and adequate coverage. It is necessary to emphasize that with this technique the fibrous bands are preserved favoring flap vascularization and, as an additional advantage, does not leave scar in the finger pad. Results. The technique was performed in a total of 120 patients (70% men, 26% women and 4% children) with a mean age of 36.5 years, being the main cause a work-related injury: 110 were successful, 3 were lost suffering total necrosis, and 7 presented suffer without loss. Conclusions. This technique is a practical, safe and efficient tool and an alternative for nail bed reconstruction, providing optimal results for this type of injury (AU)

[Fungal aetiologies and contributing factors of interdigital tinea pedis among policemen in Abidjan (Ivory Coast)]. / Étiologies fongiques et facteurs favorisant les intertrigos inter-orteils chez les gendarmes à Abidjan (Côte d'Ivoire).

AIM OF THE STUDY: Fungal interdigital tinea pedis are poorly documented in Ivory Coast. This study aimed to determine the distribution of fungal species and contributing factors of the disease among policemen in Abidjan. PATIENTS AND METHODS: Our cross-sectional study was carried out at the police school in Abidjan. Our patients consisted of symptomatic or non-symptomatic police students. Samples of scales or serosities taken from inter-toes spaces were examinated with KOH mount and cultured on Sabouraud-chloramphenicol and Sabouraud-chloramphenicol-actidione media. The method of identification depended on the observed fungus. RESULTS: Among the 303 police students with clinical lesions of the inter-toe folds, 233 (76.9%; IC 95%=71.9-81.4) had a positive diagnosis after mycological examination. Lesions were predominantly located in the 3rd and 4th interdigital plantar spaces, with desquamation (100%) followed by maceration (82.5%) as the predominant functional sign. Dermatophytes accounted for 86.3% of the strains isolated with as majority species : Trichophyton interdigitale (40.3%), Microsporum langeronii (30.0%) and Trichophyton rubrum (15.5%). Yeasts accounted for 13.7% of the strains with Candida albicans (7.7%) as the most found species. The duration at the police school (P=0.004) and the practice of sports activities (P=0.0001) were statistically associated with the occurrence of the disease. CONCLUSION: A good hygiene of feet would reduce the incidence of the disease among the defense and security forces. Also, investigations for the influence of the seasons in the occurrence of interdigital tinea pedis will allow a better understand of epidemiology of this dermatomycosis.

Aggregatibacter actinomycetemcomitans osteomyelitis in a 12 year old boy: case report emphasizing the importance of tissue culture, and review of literature.

BACKGROUND: Aggregatibacter actinomycetemcomitans most commonly causes periodontitis but has been reported to infect heart valves, soft tissue, brain and lungs, and distal bones. Osteomyelitis distal to the jaw is rarely described. CASE PRESENTATION: We report an unusual and rare case of chronic osteomyelitis caused by A. actinomycetemcomitans in the toe of a paediatric patient, and review the available literature. The infection was managed with intravenous antibiotics followed by oral antibiotics. CONCLUSION: This is an unusual presentation of A. actinomycetemcomitans causing chronic osteomyelitis presumed due to nidation in a minimally damaged bone, associated with bacteraemia of an oral commensal. It occurred in the toe, without obvious dental predisposition; associated with minimal clinical disturbance and with muted immune response.

Sphingobacterium cellulitidis sp. nov., isolated from clinical and environmental sources.

The taxonomic position of two isolates belonging to the genus Sphingobacterium was determined. The first isolate, R-53603T, was obtained from purulent discharge from the toe of a cellulitis patient in Kuwait. Comparative 16S rRNA gene sequence analysis revealed 99.87 % similarity of R-53603T with environmental isolate P031 (=R-53745) originating from activated sludge in Singapore. The two isolates were phylogenetically positioned on the same sub-branch. Highest 16S rRNA gene sequence similarity was found with the type strains of Sphingobacterium mizutaii (98.23 %), Sphingobacterium lactis (97.78 %) and Sphingobacterium daejeonense (97.14 %). DNA-DNA hybridizations revealed <70 % relatedness between the two isolates and the type strains of the close phylogenetic neighbours S. mizutaii(18.0-24.5 %), S. lactis(20.3-25.9 %) and S. daejeonense(13.2-20.0 %). The high relative contribution of iso-C15 : 0, iso-C17 : 0 3-OH and summed feature 3 (iso-C15 : 0 2-OH and/or C16 : 1ω7c) in the cellular fatty acid profiles of R-53603T and R-53745, the presence of sphingophospholipids, MK-7 as the dominant menaquinone and phosphatidylethanolamine as the major polar lipid in strain R-53603T are typical chemotaxonomic characteristics for members of the genus Sphingobacterium. Phenotypic features most useful for differentiation of the two novel strains from the most closely related species S. mizutaii include growth on MacConkey agar, and utilization of stachyose, guanidine HCl and lithium chloride in Biolog GEN III tests. Strains R-53603T and R-53745 thus represent a novel species, for which the name Sphingobacterium cellulitidis sp. nov. is proposed. The type strain is R-53603T (=LMG 28764T=DSM 102028T).

Fungal interdigital tinea pedis in Dakar (Senegal).

Fungal interdigital tinea pedis (FITP) is the most frequent dermatomycosis in industrial countries. In African tropics, it's a rare motive of consultation and is discovered while complicated. The aims of this article were: to determine the frequency of interdigital tinea pedis among overall mycological analysis in our laboratory; to study epidemiological, clinical and mycological aspects of FITP in outpatients attending the Le Dantec mycology laboratory in Dakar. A total of 62 males (60%) and 42 females (40%), mean age: 43.15 years (range: 11-81 years), were received from January 2011 to December 2015 for suspicion of FITP. Skin specimens were taken from all patients for microscopy and fungal culture. The frequency of ITP represents 5.6% (104/1851) among our overall mycological analysis. FITP was confirmed in 68 patients (SPI=65.38%), mainly located between the 4th and 5th toes and 71 fungal species were isolated (CPI=68.27%). Among patients with confirmed FITP, there were 38 males (56%) and 30 females (44%). The prevalence was highest in patients between 44 and 54 years (26%). Candida albicans, Fusarium solani and Trichophyton interdigitale were shown to be the most common pathogens respectively for yeasts (39%), non-dermatophytic filamentous fungi (NDFF; 21%) and dermatophytes (11%). So FITP isn't a common reason for consultation in Dakar but its simple parasitic index (SPI) is still very high and dermatophytes formerly the main causative agents are being relegated to third place behind yeasts and NDFF.

High-Pressure Injection to the Great Toe with River Water.

CASE: A 53-year-old male sustained a high-pressure water injection injury to his foot while working in a river. He was taken to the operating room for emergent irrigation and debridement of copious riverbed sediment. Cultures taken from the operating room were positive for multiple anaerobes, fungus and mold and he was treated with appropriate antibiotics. To date, his only residual deficit is a 1 cm area of numbness at the entrance wound. CONCLUSION: High-pressure water injections to the foot are uncommon injuries. These are serious injuries that require emergent antibiotics, tetanus and surgical debridement.

Toenail Onychomycosis-A Canadian Approach With a New Transungual Treatment: Development of a Clinical Pathway.

BACKGROUND: Onychomycosis is a difficult-to-treat infection whose current treatment paradigm relies primarily on oral antifungals. The emergence of new topical drugs broadens the therapeutic options and prompts a re-evaluation of the current Canadian treatment strategy. OBJECTIVE: To define a patient-centred Canadian treatment strategy for onychomycosis. METHODS: An expert panel of doctors who treat onychomycosis was convened. A systematic review of the literature on treatments for onychomycosis was conducted. Based on the results, a survey was designed to determine a consensus treatment system. RESULTS: First-line therapy should be selected based on nail plate involvement, with terbinafine for severe onychomycosis (>60% involvement), terbinafine or efinaconazole for moderate onychomycosis (20%-60% involvement), and efinaconazole for mild onychomycosis (<20% involvement). Comorbidities, patient preference and adherence, or nail thickness may result in the use of alternative oral or topical antifungals. CONCLUSION: These guidelines allow healthcare providers and patients to make informed choices about preventing and treating onychomycosis.

[New clinical classification for onychomycoses]. / Nouvelle classification clinique des onychomycoses.

We have updated our clinical classification on onychomycosis (2011) to render it of more practical value for the clinician. It should provide a better understanding of onychomycosis and facilitate an improved approach to treatment, taking into account, for example, the link between the proximal subungual variety and some superficial forms emerging from beneath the cuticle.

In-office distal Symes lesser toe amputation: a safe, reliable, and cost-effective treatment of diabetes-related tip of toe ulcers complicated by osteomyelitis.

Diabetes-related tip of lesser toe ulcers have typically been associated with both underlying hammertoe contracture and peripheral neuropathy. The combination of digital deformity and neuropathy commonly results in non-healing, deep sores that frequently become complicated by osteomyelitis. We report on a well-known, but poorly reported, technique for surgical management of non-healing tip of lesser toe ulcers. After approval by the institutional review board, a review was performed of consecutive patients who had undergone office-based distal Symes toe amputation for a non-healing tip of lesser toe ulcer from January 2007 to December 2012. A variety of clinical, laboratory, and radiographic data were collected. A total of 48 consecutive patients (48 toe ulcers) were identified for inclusion in the present study. All patients had ulcers at the time of surgery, and no patient developed repeat ulceration of the involved digit postoperatively. Of the 48 patients, 44 (92%) had hammertoe deformity preoperatively. Also, 30 patients (63%) had positive probe-to-bone results, and 29 (97%) of these patients had culture or histologic findings positive for osteomyelitis. Of the 48 patients (48 ulcers), 73% had positive bone cultures, 69% had positive pathologic findings demonstrating osteomyelitis, and 100% had clean margins. Methicillin-resistant Staphylococcus epidermidis was the most common pathogen isolated (13 of 48, 27%). No patient required additional amputation related to the operative digit. The mean follow-up period was 28.79 months. Our results have shown that in-office distal Symes lesser toe amputation is a safe, reliable, and likely cost-effective treatment of non-healing tip of lesser toe ulcers complicated by osteomyelitis. This office-based procedure allows bone biopsy diagnosis, removes the non-healing ulcer, confirms clear margins regarding the osteomyelitis, and addresses the underlying toe deformity to minimize the chances of repeat ulceration.

Microorganisms of the toe web and their importance for erysipelas of the leg.

BACKGROUND: There has been a steady increase of the incidence of erysipelas in Germany in the recent past. Affected patients also often show defects in the cutaneous barrier caused by microorganisms. The aim of this non-interventional case-control study was to investigate a possible interrelationship between interdigital tinea pedis and bacterial toe web (interdigital space) infections and erysipelas of the leg, as well as a potential interaction among the microorganisms themselves. MATERIAL AND METHODS: The patient population contained 150 people equally distributed among three groups, one retrospective and one prospective erysipelas group (EG = rEG + pEG) plus one control group (KG). RESULTS: 51 % of the patients with erysipelas and 32 % of the control group suffered from interdigital tinea pedis. There was a significant association between interdigital tinea pedis and the recurrence rate of erysipelas, but not with erysipelas itself. Staphylococcus aureus (EG: 30.34 %; KG: 3.23 %) and non-pathogenic aerobic bacteria were significantly associated with erysipelas in each statistical analysis. Staphylococcus aureus showed a positive, the non-pathogenic aerobic germs (EG: 28,09 %; KG: 80,65 %) a negative association. CONCLUSIONS: This study demonstrates an association between the microorganisms of the toe web and erysipelas of the leg. Erysipelas itself is influenced to a great extent by the bacterial flora, while its recurrence relates more to interdigital tinea pedis.