Human pathogenic fungi in China--emerging trends from ongoing national survey for 1986, 1996, and 2006.

This epidemiological survey was a retrospective study on three nodes during the past three decades on fungal infections representing the China, including Taiwan. Owing to rare publications reporting on dynamic epidemiological trends in the pathogen epidemiology in China, we surveyed the isolation rates and pathogenic fungi from 8 representative districts in China using uniform identification with uniform methodology. The pathogenic fungi isolation rates and species obtained from 1986 (n=9,096), 1996 (n=19,009), and 2006 (n=33,022) suggested that Trichophyton rubrum was the commonest organism cultured in 1980s (45.4%) and 1990s (34.5%), but Candida albicans increased significantly and reaching to its peak (26.9%) in 2006s' survey, and has become the most common isolate of fungal infections in China currently. In addition, Candida glabrata became the most common non-albicans species of Candida in 2006s' survey. At the same time, the incidence of molds also gradually increased. According to comparative analysis of the results of these three surveys, we found apparent differences in the isolation rates of different pathogenic fungi and the forefront 10 species in China varied significantly, and the dermatophytes decreased markedly, while yeasts, especially the Candida species and the molds, increased gradually during the past three decades. Less dermatophytic infections may suggest better access to healthcare or increase in Candida species indicated higher incidence of hospital acquired infections.

Changes in frequency of agents of tinea capitis in school children from Western China suggest slow migration rates in dermatophytes.

Tinea capitis is a common dermatophyte infection of the scalp of children in Western China, with the gray-patch from being the most prevalent. Twenty years ago, the most widespread etiologic agent was reported to be Trichophyton violaceum, which was later succeeded by Microsporum ferrugineum and Trichophyton schoenleinii. In the framework of our recent study, 97 isolates were collected from patients with clinically suspected tinea capitis. Identification was performed by conventional methods and by sequencing the ribosomal DNA internal transcribed spacer region. In the case of T. violaceum an additional microsatellite primer set (T1) was used. Five species (in order of frequency, Trichophyton violaceum, T. schoenleinii, Microsporum ferrugineum, zoophilic strains of Arthroderma vanbreuseghemii, and Trichophyton tonsurans) were identified. Results of molecular and phenotypic ID of the same strains showed good correspondence. Comparison with earlier data showed that dermatophytes species in former rural societies must have migrated extremely slowly. Preponderance of local transmission from domesticated animals was proven by the occurrence of zoophilic strains of Arthroderma vanbreuseghemii. Etiologic agents in the rural communities of Western China tend to be different from those of the other regions in the country, despite modern communication and traffic.

Seborrheic dermatitis flare in a Dutch male due to commensal Malassezia furfur overgrowth.

This is a case of seborrheic dermatitis (SD) barbae from which Malassezia furfur (M. furfur) was isolated. The patient was a 57-year-old Dutch male, who was hospitalized for fever and weakness of extremities. He presented with symmetrical erythema with an abundance of greasy chaffy scales on his beard area. No reasons were detected for his fever following a routine search. M. furfur was identified through mycological examination, including direct microscopic examination, culture, Tween test, esculine splitting test and DNA sequencing, of samples from the skin lesions. The patient was treated with oral itraconazole capsules (200 mg, b.i.d. for 8 days, then 200 mg o.d. for 13 days), washing his scalp and face with 2% ketoconazole shampoo (once a day) and topical application of a cream containing 1% naftifine hydrochloride and 0.25% ketoconazole (b.i.d.). After treatment the fever subsided and the SD lesion gradually healed. M. furfur was not isolated again from skin scrapings and 7 days later therapy was terminated and no recurrence was noted after one week follow-up since the cessation of treatment.

Incidence of histoplasmin hypersensitivity in the Philippines.

Long-term residents of the Philippines were skin tested with histoplasmin skin test material. This study was conducted with 143 electric company (MERALCO) employees from Manila, Philippines. We found that 37 (26%) of the subjects were skin test positive. Characteristics of the positive group were: average age of 37 years; all except one were lifelong inhabitants of Metro Manila; 25 were male and 12 were female; one-half of the subjects reported extended contact with chickens. Despite these findings, histoplasmosis is considered to be a very rare disease in the Philippines. This survey indicates that Histoplasma capsulatum is sufficiently present in the Philippines to come in contact with one-fourth of the test population. This reinforces the hypothesis that histoplasmosis is present in the Philippines and is probably being misdiagnosed as granulomatous-inducing diseases such as tuberculosis, e.g., so-called "drug resistant" tuberculosis. We recommend larger surveys of this type and attempts to culture the etiologic agent from natural sources such as chicken and bat droppings.

Training medical myocologists in developing countries.

Although there has over recent years been a marked rise in the incidence of serious fungal infections, many of which are prevalent in developing countries, few facilities exist for diagnosis and research in medical mycology. In most countries, medical mycology is not taught adequately to medical students and consequently there is little awareness of the importance of fungal infections. Model teaching programmes need to be developed. Practical knowledge of mycoses, their diagnosis and treatment and also basic mycology can be disseminated through well-constructed courses and workshops. Formalized training in mycology research also needs to be introduced. To achieve all of this, expertise and additional resources need to be made available. In this regard, ISHAM can and should help.

The antifungal action of dandruff shampoos.

The disease commonly known as "dandruff" is caused by numerous host factors in conjunction with the normal flora yeast Malassezia furfur (Pityrosporum ovale). Indeed, clinical studies have shown that administration of antifungal agents correlates with an improved clinical condition. Almost all commercially available hair shampoos publicize that they contain some form of antifungal agent(s). However, few studies have been published in which antifungal activity of commercially available hair shampoos have been contrasted experimentally. In this study six commercially available shampoos (in the Philippines) were assessed for antifungal activity against a human (dandruff) isolate of M. furfur: (a) Head & Shoulders (Proctor & Gamble); (b) Gard Violet (Colgate-Palmolive); (c) Nizoral 1% (Janssen); (d) Nizoral 2% (Janssen); (e) Pantene Blue (Proctor & Gamble); and (f) Selsun Blue (Abbott). The results demonstrated that all six of the assayed hair shampoos have some antifungal effect on the test yeast. However, there was consider variation in potency of antifungal activity. Nizoral 1% and Nizoral 2% shampoo preparations were the most effective. The 1% Nizoral shampoo was consistently 10X better at killing yeast cells than the next closest rival shampoo. The 2% Nizoral shampoo was 10X better than the Nizoral 1% product and 100 times better than any of the other products assayed. The study demonstrated that shampoos containing a proven antifungal compound were the most effective in controlling the causative yeast.

Yeasts and fluconazole susceptibility in the Philippines.

Identification and fluconazole susceptibility of 579 yeasts isolated from patients in 16 medical centers throughout the Philippines in 1997-98 is reported. Speciation revealed the following distribution of yeasts (with percent occurrence): Candida albicans (49.6%); C. parapsilosis (17.2%); C. tropicalis (14.9%); C. glabrata (6.2%); C. pelliculosa (4.3%); C. krusei (2.4%); C. guilliermondii (1.9%); Trichosporon cutaneum (1.7%); Cryptococcus neoformans (0.9%); Candida famata (0.5%); C. lusitaniae (0.2%) and Saccharomyces cerevisiae (0.2%). Using an agar disk diffusion assay for fluconazole susceptibility it was determined that 94% of the isolates were susceptible, 5% dose-dependent susceptible and only 1% resistant. All isolates of C. albicans were susceptible (one being dose dependent sensitive) to fluconazole. The only yeasts resistant to fluconazole were: C. guillermondii (1 isolate), C. glabrata (3 isolates) and C. parapsilosis (1 isolate).

The role of ISHAM: how developing and developed countries can benefit from it. International Society for Human and Animal Mycology.

The international community of mycologists, ISHAM, is faced increasingly with the needs and demands of supporting the development of organizational structures worldwide in the field of medical mycology. This goes beyond the classical objectives of a scientific association, namely organizing international congresses and publishing a journal. In the early part of the next century, this will become a major challenge to ISHAM. Symposia discussing this subject were presented at the 12th Congress of ISHAM held in Adelaide, Australia, in 1994. This paper outlines the reflections and discussions held by members of our Society in 1997.

Tinea capitis caused by Microsporum praecox in a patient with sickle cell anaemia.

Microsporum praecox Rivalier ex Padhye, Ajello et McGinnis is the validated name for the taxon originally published as Sabouraudites praecox Rivalier. We describe here the first case of small-conidial, ectothrix type hair invasion caused by M. praecox in an adult woman from Oklahoma, U.S.A., suffering from sickle cell anaemia. This fungus is now being encountered with greater frequency as an etiologic agent of ringworm infection.

Cryptococcus neoformans: comparisons of in vitro antifungal susceptibilities of serotypes AD and BC.

Thirty-nine isolates of Cryptococcus neoformans, nineteen serotype AD and twenty serotype BC, were assayed for susceptibility to eight antifungal agents using an in vitro agar dilution assay. Media employed were Kimmig agar and yeast nitrogen base supplemented with 10% glucose. The antifungal agents used were ketoconazole, amphotericin B, 5-fluorocytosine, nystatin, miconazole, BAY N 7133, ICI 153,066, and itraconazole. No clinically significant differences in vitro minimum inhibitory concentrations were detected between serotypes AD and BC against any of the compounds tested. An adverse medium effect was observed in two of the assays, but the outcome of the AD/BC comparison was not affected. This is the first report in which the in vitro antifungal susceptibilities of Cryptococcus neoformans serotypes are analyzed.

Comparison of Media for the Isolation of Cryptococcus neoformans.

Four media, Staib's Guizotia abyssinica, trypan blue, and Staib's with 2 and 10 mg of methyl violet per liter, were compared for the selective and differential isolation of Cryptococcus neoformans from environmental samples. Trypan blue medium allowed for the differentiation of C. neoformans colonies from Candida albicans colonies several days earlier than did Staib's medium. The addition of methyl violet to Staib's medium was found to be inhibitory to some strains of all species tested. Diphenyl in Staib's medium inhibited the growth of 30 strains of C. neoformans and C. albicans.

Localized Darier's disease of the scalp complicated by Trichophyton tonsurans infection.

A unique form of localized keratosis follicularis (Darier's disease) of the scalp occurred in a mother and daughter. The presence of secondary bacterial and fungal infection was responsible for a delay in establishing an accurate diagnosis of the true nature of their disorder.

Modification of macrophage phagocytosis in murine cryptococcosis.

Normal C57BL/6J peritoneal cells exhibited a decreased phagocytosis when cultured with a cell wall antigen of Cryptococcus sp. and lymphocytes from mice infected with C. neoformans. Direct cell-to-cell interaction was not required in that supernatant fluids from cultures of lymphocytes from infected animals could be incubated with normal macrophage monolayers to give comparable suppression. The induction of the suppressor factor required specific cryptococcal antigen; however, suppression at the macrophage level was nonspecific in that the phagocytosis of C. neoformans and Saccharomyces cerevisiae were both decreased. Suppression appeared with lymphocyte supernatants taken from mice infected for 14 days and thereafter. The factor was heat stable, trypsin sensitive, and allospecific.

Suppression of responses to cryptococcal antigen in murine cryptococcosis.

Subpopulations of spleen cells responsible for responsiveness and unresponsiveness to cryptococcal antigen in vitro were identified. Lymphocytes which responded in lymphocyte transformation (LT) assays were nylon wool nonadherent and theta antigen positive. These lymphocytes required the presence of an accessory cell which could be supplied by normal peritoneal exudate cells. Spleen cells taken from mice which had been infected for 3 to 15 days were tested to determine their ability to respond to cryptococcal antigen in LT assays. A minimal response was detected at the ninth day of infection. The response of infected spleen cells was attributed to a nonadherent lymphocyte. Nonadherent spleen cells of infected animals had enhanced responses after removal of adherent cells and addition of normal peritoneal exudate cells. Suppressor cells were detected in the spleens of infected mice by the 12th day of infection and thereafter. A nonadherent suppressor cell was identified, but indirect evidence suggested that an adherent cell could also be present in infected spleens.

Serologic grouping and sexual compatibility of airborne Cryptococcus neoformans.

Through the use of Anderson air samples, 214 isolates of Cryptococcus neoformans were cultured from the air in a vacant tower in a large complex of buildings in Oklahoma City. The tower contained hundreds of pigeons, a massive amount of droppings, nests with eggs and young, dying and dead pigeons. All isolates were serotype A-D and self-sterile for the production of basidiospores. Among these 193 were of the "alpha" mating type, producing basidiospores when paired with "alpha" mating type. No isolates of "alpha" mating type were found. The findings imply that the infectious particles of C. neoformans in nature are relatively small, nonencapsulated yeast cells and not basidiospores.

Control of Cryptococcus neoformans in nature by biotic factors.

Two bacterial species (Pseudomonas aeruginosa and Bacillus subtilis) isolated from pigeon droppings, displayed anti Cryptococcus neoformans activity on 4 of 6 media and sterilized pigeon droppings. Acanthamoeba palestinensis trophozoites isolated from pigeon droppings ingested and killed 99.9% of C neoformans cells after 7 days of incubation. Mites and sow bugs (Metoponorthus pruinosus) isolated from pigeon droppings appear to be fungivorous. These findings suggest that many organisms that occur in pigeon droppings influence C. neoformans persistence, reproduction, morphology and distribution in nature.

A one year study on the viability of Cryptococcus neoformans in nature.

Using four different assat procedures we found a 50 to 86% decrease in viability of Cryptococcus neoformans over a one year period after two towers in the Oklahoma City area were modified to exclude pigeons and weather elements, especially rain. In homogeneous pigeon dropping samples a sharp decrease in viability occurred after 7 to 9 months of storage. The decrease occurred in pigeon dropping samples maintained at the natural sites and at ambient temperature in the laboratory in the laboratory but not in droppings stored at -4 degrees C. Air sampling studies done at the natural sites before and after tower modifications also showed a decrease in C. neoformans viability. The decrease in viability cannot be explained by seasonal temperature variations that occurred at natural sites. Our findings suggest that death of C. neoformans occurred because of lack of available intracellular water exacerbated by low humidity, exclusion of precipitation and moisture from fresh pigeon droppings. In light of our experiences, at one site in south central United States, the feasibility of controlling C. neoformans at heavily contaminated sites, other than by the use of noxious or potentially dangerous chemicals, is discussed.