Morphological and ultrastructural changes in fungal agents after LASER application.

BACKGROUND: Onychomycosis is a fungal nail infection of difficult treatment due to the fungal survival capacity and reduced number of effective therapies. The present study aimed to isolate fungal agents that cause onychomycosis in immunocompetent patients and evaluate how LASER treatments affect the growth and ultrastructure of isolates. METHODS: In total, 21 patients with positive direct microscopic examination (DME) for onychomycosis had nail samples collected for cultivation and phenotypic identification of microorganisms. From these patients, 12 underwent LASER treatment, divided in Group 1 (n = 5) treated with Nd: YAG 1,064 nm, and Group 2 (n = 7) treated with Nd: YAG 1,064 nm + Er: YAG 2,940 nm + topical isoconazole. Transmission Electron Microscopy (TEM) was performed to evaluate ultrastructural changes after treatment. RESULTS: DME, cultivation, and phenotypic identification showed that the most identified fungus was Trichophyton rubrum spp. After LASER therapy, sample cultivation showed alterations in the fungal morphology with reduction of hyphae, conidia, and reproductive structures. Alterations in fungal cell wall structure, cytoplasm density, and organelles were observed by TEM. CONCLUSION: LASER irradiation causes changes in the fungal cells, especially in the number of hyphae and the presence of conidia. In addition, it affects fungal growth and reproduction capacity, which interferes with their infection ability and virulence.

Risk factors for nonmelanoma skin cancer in renal transplant recipients: a case-control study from a reference outpatient clinic in Southeast Brazil.

BACKGROUND: Nonmelanoma skin cancer (NMSC) is the most common tumor in humans, and its incidence increases among renal transplant recipients (RTRs). The aims of this study were to characterize the RTRs with NMSC, to identify risk factors, and to calculate the probability of this tumor in this population. METHODS: This was a hospital-based case-control study. Epidemiological and clinical variables were evaluated. Hierarchical logistic regression was used, and a mathematical model was built. RESULTS: In total, 245 subjects were included. Possible associations were identified using a univariate analysis. Multivariate analysis identified risk factors with respective odds ratios and confidence intervals (95% CI): males 2.5 (1.3-4.7), age over 50 years 5.4 (2.3-12.9), Fitzpatrick's skin phototypes I-III 3.7 (1.6-8.7), occupational sun exposure 4.1 (2.1-8.1), timetable of recreational sun exposure all day 3.0 (1.4-6.1), and duration of transplantation (80 months or more) 3.3 (1.6-6.5). The Hosmer-Lemeshow test and the receiver operating characteristics curve showed a strong fit and accuracy, respectively. The probability of an NMSC ranged from less than 1 to 92.5%. CONCLUSIONS: This study characterized the RTRs with NMSC and identified risk factors. The multivariate analysis by hierarchical logistic regression proved to be a useful tool and allowed for the determination of the probability of NMSC in this population.

Spectral Manifestation of Melanized Fungal Infections in Kidney Transplant Recipients: Report of Six Cases.

Chromoblastomycosis and phaeohyphomycosis are melanized fungal infections, which affect skin and subcutaneous tissues in immunocompetent and immunosuppressed patients, as solid-organ transplant recipients, respectively. In this present study, we report six cases of melanized fungal infection in kidney transplant recipients. In five cases, culture of tissue specimens identified two cases of Exophiala spp. and three cases of Fonsecaea spp. Molecular identification was performed in three cases based on sequencing of rDNA (ITS region) that revealed the following agents: Exophiala xenobiotica, Exophiala bergeri and Fonsecaea monophora. Clinically, they presented verrucous lesion, erythematous-squamous plaque, nodules and lymphangitic distribution. Histopathological aspect was tuberculous granuloma, with concomitant presence of muriform bodies and hyphae. Some patients presented fungal transepithelial elimination. One patient received only terbinafine. Three patients underwent surgery, and two of them received itraconazole. In these four cases, the infection did not relapse. The other two patients were treated only with itraconazole, one of them is still under treatment and the other one was lost to follow-up. These patients presented clinical and histopathological characteristics ranging from resistant to nonresistant forms.

Molecular identification of melanised non-sporulating moulds: a useful tool for studying the epidemiology of phaeohyphomycosis.

Subcutaneous infections caused by melanised fungi have been increasingly reported among transplant patients, and these infections have the potential for blood and visceral dissemination. Some moulds, such as Mycelia sterilia, cannot grow and sporulate on different media, making their identification impossible by conventional methods. The fast and accurate identification of melanised fungi at the species level is important because species may have tropism to different organs and different susceptibilities to antifungal agents. Molecular tools have been reported to be helpful for the species identification of non-sporulating moulds. Our goal was to identify the species of M. sterilia isolates obtained from clinical samples of transplant patients using sequences of ITS and the D1/D2 regions of rDNA. Clinical samples were obtained from eight kidney transplant recipients who developed subcutaneous fungal infections. The diagnosis was confirmed by histopathology and conventional culture. Histopathology showed septated, melanised hyphae, and the cultures identified non-sporulating fungi. Therefore, the DNA from the M. sterilia isolates was subjected to PCR amplification and sequencing of the ITS and D1/D2 regions. Genus/species identification was obtained by comparison with gene banks. We obtained the following identifications: Alternaria sp. (2), Cochliobolus lunatus/Curvularia lunata (2), Cochliobolus hawaiiensis/Bipolaris hawaiiensis (1), Ochroconis sp. (1), Medicocopsis romeroi/Pyrenochaeta romeroi (1) and Nigrograna mackinnonii/Pyrenochaeta mackinnonii (1).

Lymphoscintigraphic analysis in chromoblastomycosis.

BACKGROUND: One of the main complications of chromoblastomycosis is lymphedema. The purpose of this study was to evaluate the lymphatic system of the limbs of patients with chromoblastomycosis using lymphoscintigraphy. It is a reliable, objective and noninvasive means of supporting the diagnosis of lymphedema. METHODS: Lymphoscintigraphy was performed in seven patients with chromoblastomycosis, six with lesions in the lower limb and one in the upper limb. Tc-99 m dextran was injected into the interdigital spaces of the upper or lower extremities. The qualitative parameters analyzed were the visibilization of the lymph vessels and the lymph nodes, dermal backflow, and existence of collateral vessels. All patients were treated with the association of itraconazole and cryotherapy with liquid nitrogen. RESULTS: Three out of the 14 extremities examined had lymphedema clinically, and the lymphoscintigraphy showed abnormalities in the qualitative parameters; whereas these parameters were normal in the extremities without lymphedema. During the treatment of chromoblastomycosis, a second lymphoscintigraphy exam was performed on 10 limbs and did not show any improvement of the previous lymphoscintigraphic alterations. CONCLUSIONS: The qualitative lymphoscintigraphy was a reliable method to show the morphology of the lymph vessels and confirm objectively the diagnosis of lymphedema secondary to chromoblastomycosis. The association of oral itraconazole and cryotherapy did not modify the lymphatic alterations in chromoblastomycosis.

Comparative study of autoantigen profile between Colombian and Brazilian types of endemic pemphigus foliaceus by various biochemical and molecular biological techniques.

BACKGROUND: Besides Brazilian endemic pemphigus foliaceus (EPF), we have described another focus of EPF in Colombia. Our previous study suggested that Colombian EPF seemed to react various plakin family proteins, such as envoplakin, periplakin and BP230. OBJECTIVE: To further characterize the Colombian EPF and study the difference from Brazilian EPF, we examined the antigen profile of the two types of EPF. METHODS AND RESULTS: Immunoblotting using normal human epidermal extracts revealed that 38% Colombian EPF sera and 25% Brazilian EPF sera showed IgG antibodies reactive with desmoglein (Dsg) 1, pemphigus foliaceus antigen. The sera of both types of EPF showed protein bands co-migrating with plakin family proteins, particularly periplakin. Immunoblotting analyses using recombinant proteins of various domains of envoplakin, periplakin and BP230 revealed that a considerable number of Colombian EPF sera reacted with recombinant proteins of periplakin, while only few Brazilian sera reacted with some of the recombinant proteins of any plakins. Enzyme-linked immunosorbent assay (ELISA) for Dsg1 and Dsg3 showed that Dsg1 was reacted by almost all sera of both types of EPF. However, unexpectedly, while none of Colombian EPF sera reacted with Dsg3, about half of Brazilian EPF sera reacted with Dsg3. CONCLUSION: These results suggested that the Colombian EPF is basically similar to Brazilian EPF in terms that major antigen is Dsg1, but there were some different antigen profiles between the two types of EPF.

Unusual location of cutaneous leishmaniasis on the hallux in a Brazilian patient.

A 70-year-old white Brazilian woman from a rural area had a 2-year history of a painful lesion on her left toe. The lesion increased progressively in size followed by toenail destruction. She was treated with systemic antibiotics for secondary bacterial infection several times without any clinical response. Physical examination showed an erythematous swelling on the first toe with an irregular 2.5 cm ulcer with a raised edge that was infiltrating and destroying the toenail. The bottom of the ulcer was granular and partially covered with a crust (Fig. 1). Laboratory studies showed a strong positive Montenegro intradermal reaction (2.5 mm). Other intradermal reactions were also performed, such as purified protein derivative (PPD) and sporotrichin, which were negative. On X-ray examination of the left foot, bone destruction of the distal phalanx of the first toe and a soft tissue swelling were observed (Fig. 2). A biopsy was taken and the histologic picture showed a chronic inflammatory change with tuberculoid-type granuloma and necrosis suggesting leishmaniasis, although parasites were not observed. Based on the clinical, histologic, and immunologic aspects, we concluded that this was a case of leishmaniasis. Methylglucamine (Glucantime) was introduced at a total dose of 17 g of the salt (10 mg/kg daily for 40 days). Immediately after the start of treatment, the lesion began to improve, and 4 months later the lesion had healed completely and the dystrophic nail had started to grow (Fig. 3).

Mycetoma caused by Fusarium solani with osteolytic lesions on the hand: case report.

Eumycetoma is a mycotic disease caused by saprophytic soil fungi that are usually inoculated through minor injuries. A case of mycetoma in a Brazilian farmer aged 71 years is reported. This patient presented erythema and edema on the dorsal surface of the left hand with multiple crusted and cicatricial lesions. No macroscopic grains were observed. The histopathological findings showed grains consisted of numerous hyphae which stained well with Gomori-Grocott method. This material obtained by cutaneous biopsy was submitted to culture on Sabouraud's medium and the colonies were identified as Fusarium solani. The radiological studies revealed bone osteolytic lesions and the ultrasound showed pseudocysts and fistulae at the site of this infection. The patient was treated with oral ketoconazole with a good clinical response.