Rhino-Orbital mucormycosis in an immunocompetent pediatric patient with hyperglycemia of the hospitalized patient.

INTRODUCTION: Acute invasive rhino-orbital mucormycosis usually affects diabetic or neutropenic patients, and only exceptionally develops in immunocompetent adults and children. METHODOLOGY: A 12-years-old immunocompetent female, presented with complicated rhinosinusitis with a subperiosteal orbital abscess, without improvement after initial medical and surgical management, the patient also developed hyperglycemia of the hospitalized patient that represented a challenging and potentially lethal clinical scenario. RESULTS: Diagnosed with an unsuspected rhino-orbital mucormycosis by direct microscopy and PCR, she survived after amphotericin B and surgical treatment. CONCLUSIONS: In cases with torpid clinical evolution, even in apparently immunocompetent patients, appropriate multidisciplinary workup must be performed to rule out opportunistic etiologies including mucormycosis to improve survival.

Subclinical Onychomycosis in Apparently Healthy Adults.

INTRODUCTION: Onychomycosis is a frequent chronic nail infection, with a worldwide prevalence of 5.5% making it the most common nail disease, and its incidence increases with age. Clinically, it causes discoloration and thickening of the nail plate and may be accompanied by onycholysis. However, little is known of the subclinical infection. METHODS: We studied adult male and female outpatients auto-referred as healthy and that had healthy appearing toenails. Nail distal clippings were obtained from the right first toenail. This sample was stained with PAS and observed by an expert dermatopathologist searching for fungal structures. RESULTS: A total of 32 samples were included: 8 from men (25%) and 24 from women (75%), with ages ranging from 27 to 66 years (mean age of 43 years). Twenty-four patients did not present any histopathological finding suggestive of infection (75%), while 7 patients had a single finding (spores or hyphae) (21.8%), and 1 patient had both findings (3.12%). DISCUSSION/CONCLUSION: We found 4 patients with yeasts, 3 with hyphae, and 1 patient with a combined infection with both yeasts and hyphae (3.1%). These add up to 25% of the clinically apparent healthy nails. Our results show that we still have much to learn from the initial stages of onychomycosis and that our population probably has higher incidence of this nail disease, so we must be alert to subtle nail changes. As our participants signed an informed consent, we will contact those that resulted positive for follow up consultations.

Molecular identification of yeasts from the order Trichosporonales causing superficial infections.

BACKGROUND: The molecular reclassification of the order Trichosporonales placed the medically relevant Trichosporon species into three genera of the family Trichosporonaceae: Cutaneotrichosporon, Trichosporon, and Apiotrichum. From the clinical and epidemiological standpoint, it is important to identify any species of the family Trichosporonaceae because they present different antifungal susceptibility profiles. In Mexico, little is known about trichosporonosis etiology because the fungi are identified through phenotypic methods. AIMS: To identify at a molecular level 12 yeast isolates morfologically compatible with Trichosporon, obtained from patients with superficial infections. METHODS: The yeast isolates were obtained from patients with white piedra, onychomycosis, and hand and foot dermatomycosis, and were identified morphologically and genotypically (sequencing of the IGS1 region and phylogenetic analysis using the Maximum Likelihood Method). The phylogenetic analysis included 40 yeast sequences from the order Trichosporonales and one from Cryptococcus neoformans as outgroup. RESULTS: Based on the molecular analysis, we identified three (25%) Trichosporon inkin isolates, two (16.7%) Trichosporon asteroides, two (16.7%) Cutaneotrichosporon mucoides, and one each (8.3%) of Trichosporon aquatile, Trichosporon asahii, Apiotrichum montevideense, Cutaneotrichosporon cutaneum, and Cutaneotrichosporon jirovecii. CONCLUSIONS: The molecular characterization of the isolates showed a broad diversity of species within the order Trichosporonales, particularly among onychomycosis. It is essential to identify these yeasts at the species level to delve into their epidemiology.

[Prevalence of anogenital condylomas in patients with HIV infection in a center for sexually transmitted infections in Leon, Guanajuato, Mexico]. / Prevalencia de condilomas ano-genitales en pacientes con infección por VIH en un centro para infecciones de transmisión sexual en León, Guanajuato, México.

BACKGROUND: Condylomas are the most frequent sexually transmitted infection worldwide, and thus, have a close relation to HIV infection. The site and serology vary, and some pose higher risk of malignancy. AIM: To describe the prevalence, characteristics and associated factors to the presence of anogenital condylomas in patients with HIV/AIDS. METHODS: Descriptive cross-sectional study conducted in the period from June to December 2014. Adult HIV/AIDS positive patients from "CAPASITS" in Leon, Mexico, from both sexes were included. A questionnaire was performed that included: identification data, and risk factors related to anogenital condylomas. Anogenital area was examined for condylomas. Descriptive statistics were carried out according to the type and distribution of the variables, and the CD4 lymphocyte medians of patients with and without condylomas were compared using U- Mann-Whitney test. RESULTS: A total of 213 HIV/AIDS patients were included; 181 (85%) were male. The prevalence of anogenital condylomas was 30% (IC95%: 23-36%), predominating in the anal region, observed in 21% of the cases. A significant difference was found between median CD4 cell count of patients with and without condylomas (425 vs 510 CD4/mL, p= 0.034). CONCLUSION: A high prevalence of patients with anogenital condylomas was obtained. The presence of condylomas was higher in patients with lower CD4 count. Considering the high prevalence, the application of the vaccine is recommended in this patient group.

Rhinocerebral mucormycosis to the rise? The impact of the worldwide diabetes epidemic

Abstract The authors present seven cases of rhinocerebral mucormycosis associated to diabetes mellitus, which is a disease with epidemic proportions affecting individuals worldwide, particularly in developing countries, and which poses significant morbidity and mortality. Mucormycosis is an opportunistic fungal infection with high mortality and requires an invasive therapeutic approach to save the patient's life with significant morbidity and sequelae, thus prevention is crucial.

Rhinocerebral mucormycosis to the rise? The impact of the worldwide diabetes epidemic.

The authors present seven cases of rhinocerebral mucormycosis associated to diabetes mellitus, which is a disease with epidemic proportions affecting individuals worldwide, particularly in developing countries, and which poses significant morbidity and mortality. Mucormycosis is an opportunistic fungal infection with high mortality and requires an invasive therapeutic approach to save the patient's life with significant morbidity and sequelae, thus prevention is crucial.

Prevalencia de condilomas ano-genitales en pacientes con infección por VIH en un centro para infecciones de transmisión sexual en León, Guanajuato, México / Prevalence of anogenital condylomas in patients with HIV infection in a center for sexually transmitted infections in Leon, Guanajuato, Mexico

INTRODUCCIÓN: Los condilomas son la infección de transmisión sexual más frecuente en el mundo y tiene estrecha relación con la infección por VIH. La topografía y la serología son variables, y algunos presentan mayor riesgo de malignización. OBJETIVO: Describir la prevalencia, características clínicas, topográficas y factores asociados a la presencia de condilomas ano-genitales en pacientes con infección por VIH/SIDA en Guanajuato. MATERIAL Y MÉTODOS: Estudio descriptivo y transversal realizado entre junio y diciembre de 2014. Se incluyeron pacientes adultos con infección por VIH/SIDA, de ambos sexos, del CAPASITS León, México. Se aplicó un cuestionario que incluyó: datos de identificación, y factores de riesgo relacionados a los condilomas ano-genitales, y se les revisó dicha región corporal en busca de condilomas. Se realizó estadística descriptiva de acuerdo al tipo y distribución de las variables y se compararon las medianas de linfocitos T CD4 (LTCD4+) de los pacientes, con y sin condilomas, con la prueba U- Mann-Whitney. RESULTADOS: Se incluyeron 213 pacientes con infección por VIH/SIDA, 181 (85%) hombres. La prevalencia de condilomas ano-genitales fue de 30% (IC95%:23-36%), con mayor frecuencia en la región anal, con 21% de los casos. Encontramos una diferencia significativa entre las medianas en el recuento de linfocitos LTCD4+ en los pacientes, con y sin condilomas, (425 vs 510 LTCD4+/mL, p = 0,034). CONCLUSIONES: Se obtuvo una prevalencia alta de pacientes con condilomas ano-genitales. La presencia de condilomas fue mayor en pacientes con menor recuento de linfocitos LTCD4+. Considerando la elevada prevalencia, se recomienda la aplicación de la vacuna en este grupo de pacientes.

BACKGROUND: Condylomas are the most frequent sexually transmitted infection worldwide, and thus, have a close relation to HIV infection. The site and serology vary, and some pose higher risk of malignancy. AIM: To describe the prevalence, characteristics and associated factors to the presence of anogenital condylomas in patients with HIV/AIDS. METHODS: Descriptive cross-sectional study conducted in the period from June to December 2014. Adult HIV/AIDS positive patients from "CAPASITS" in Leon, Mexico, from both sexes were included. A questionnaire was performed that included: identification data, and risk factors related to anogenital condylomas. Anogenital area was examined for condylomas. Descriptive statistics were carried out according to the type and distribution of the variables, and the CD4 lymphocyte medians of patients with and without condylomas were compared using U- Mann-Whitney test. RESULTS: A total of 213 HIV/AIDS patients were included; 181 (85%) were male. The prevalence of anogenital condylomas was 30% (IC95%: 23-36%), predominating in the anal region, observed in 21% of the cases. A significant difference was found between median CD4 cell count of patients with and without condylomas (425 vs 510 CD4/mL, p= 0.034). CONCLUSION: A high prevalence of patients with anogenital condylomas was obtained. The presence of condylomas was higher in patients with lower CD4 count. Considering the high prevalence, the application of the vaccine is recommended in this patient group.

Disseminated Sporotrichosis: An Important Differential Diagnosis for Venous Ulcers.

The authors present the case of a 45-year-old immunosuppressed man with lower extremity ulcers. Initially treated as venous ulcers, the wounds were later correctly diagnosed as cutaneous disseminated sporotrichosis. After appropriate treatment with systemic antifungals was initiated, the patient healed within 4 months.

Isolation of Malassezia spp. in HIV-positive patients with and without seborrheic dermatitis.

BACKGROUND: Malassezia, a skin saprophyte, is frequently isolated from patients with seborrheic dermatitis, which is one of the most common dermatoses in HIV-infected patients. Its role in pathophysiology has not been defined. OBJECTIVE: To determine whether patients living with HIV and seborrheic dermatitis have more Malassezia than those without seborrheic dermatitis. METHOD: This is an descriptive, observational, prospective cross-sectional study to which all adult patients living with HIV that attend the infectious disease outpatient clinic at the Dr. Manuel Gea González General Hospital were invited. Patients presenting with scale and erythema were included in Group 1, while patients without erythema were included in Group 2. Samples were taken from all patients for smear and culture. RESULTS: Thirty patients were included in each group. All patients with seborrheic dermatitis had a positive smear, with varying amounts of yeasts. In the control group, 36.7% of patients had a negative smear. The results are statistically significant, as well as the number of colonies in the cultures. Study limitations The study used a small sample size and the subspecies were not identified. CONCLUSIONS: Patients with clinical manifestations of seborrheic dermatitis have larger amounts of Malassezia. Further studies need to be performed to analyze if the greater amount is related to imbalances in the microbiota of the skin.

Isolation of Malassezia spp. in HIV-positive patients with and without seborrheic dermatitis

Abstract Background Malassezia, a skin saprophyte, is frequently isolated from patients with seborrheic dermatitis, which is one of the most common dermatoses in HIV-infected patients. Its role in pathophysiology has not been defined. Objective To determine whether patients living with HIV and seborrheic dermatitis have more Malassezia than those without seborrheic dermatitis. Method This is an descriptive, observational, prospective cross-sectional study to which all adult patients living with HIV that attend the infectious disease outpatient clinic at the Dr. Manuel Gea González General Hospital were invited. Patients presenting with scale and erythema were included in Group 1, while patients without erythema were included in Group 2. Samples were taken from all patients for smear and culture. Results Thirty patients were included in each group. All patients with seborrheic dermatitis had a positive smear, with varying amounts of yeasts. In the control group, 36.7% of patients had a negative smear. The results are statistically significant, as well as the number of colonies in the cultures.Study limitations The study used a small sample size and the subspecies were not identified. Conclusions Patients with clinical manifestations of seborrheic dermatitis have larger amounts of Malassezia. Further studies need to be performed to analyze if the greater amount is related to imbalances in the microbiota of the skin.

Subclinical Onychomycosis: Not Present in HIV-Positive Population?

BACKGROUND: Onychomycosis is one of the most common nail diseases and constitutes up to 50% of all nail conditions. It is a chronic fungal nail infection common in the HIV-infected population. Few studies have found fungal organisms in the nail without clinical evidence, and thus, termed subclinical onychomycosis. OBJECTIVES: We analyzed the nails of the HIV population in our hospital, searching for subclinical onychomycosis. METHOD: A distal nail clipping was stained with PAS and observed by a trained dermatopathologist. RESULTS: All of our samples (n = 48) turned out to be negative for fungal structures. CONCLUSIONS: The epidemiology of onychomycosis is changing, treatment options are much better now, and diagnosis and infection detection are being done earlier. Therefore, we will continue to further study this disease in other patient populations so that we can compare our results and see whether the incidence of onychomycosis in the HIV population is now similar to that in those without HIV infection of the same age.

First Report of Bacillary Angiomatosis by Bartonella elizabethae in an HIV-Positive Patient.

We present the case of an HIV-positive patient who developed polymorphous lesions in which the evidence in the skin biopsy corresponds to the diagnosis of bacillary angiomatosis, and further tests proved the pathological agent involved in this case is not the usual Bartonella species, B. henselae and B. quintana, but B. elizabethae. As far as we know, this is the first case of bacillary angiomatosis secondary to this etiological agent.

[Mexican case of tinea incognito and granuloma de Majocchi acquired from a hedgehog]. / Tiña incógnita y granuloma de Majocchi adquirido de un erizo. Un caso mexicano.

Exotic pets, such as the ground hedgehog, are capable of transmitting to the human being different zoonoses, such as salmonellosis, mycobacteria, protozoa such as Cryptosporidium parvum, and dermatophytosis. We present the case report of a male adult patient, who had recently acquired a ground hedgehog, who presented in his hand a ringworm lesion incognito and a Majocchi granuloma. The etiological agent was identified as Trichophyton erinacei by mycological culture and molecular biology. The patient was treated with terbinafine oral, with excellent response.

Tiña incógnita y granuloma de Majocchi adquirido de un erizo. Un caso mexicano / Mexican case of tinea incognito and granuloma de Majocchi acquired from a hedgehog

Resumen Las mascotas exóticas, como el erizo de tierra, son capaces de transmitir al ser humano diferentes infecciones, como salmonelosis, micobacterias, protozoos como Cryptosporidium parvum, y dermatofitosis. Presentamos el caso de un paciente adulto masculino, que recientemente había adquirido un erizo de tierra, que presentó en la mano una lesión de tiña incógnita y un granuloma de Majocchi. Se identificó el agente etiológico como Trichophyton erinacei, por cultivo micológico y biología molecular. El paciente se trató con terbinafina por vía oral, por seis meses, con excelente respuesta.

Exotic pets, such as the ground hedgehog, are capable of transmitting to the human being different zoonoses, such as salmonellosis, mycobacteria, protozoa such as Cryptosporidium parvum, and dermatophytosis. We present the case report of a male adult patient, who had recently acquired a ground hedgehog, who presented in his hand a ringworm lesion incognito and a Majocchi granuloma. The etiological agent was identified as Trichophyton erinacei by mycological culture and molecular biology. The patient was treated with terbinafine oral, with excellent response.

Acneiform Rash Caused by an Unlikely Drug: Topiramate.

Topiramate is an antiepileptic drug that can also be used for migraine prophylaxis, weight control, and even for methamphetamine dependence; the dosage margin is wide, and the list of side effects is shorter than with other anticonvulsants. We present the case of a 35-year-old man with a disseminated rash of the trunk and extremities after treatment with 25 mg of topiramate daily as a prophylactic migraine treatment. This case report is useful, as this patient was not polymedicated and had a score of 7 on the Naranjo Adverse Drug Reaction Probability Scale. The patient was diagnosed as atypical DRESS syndrome and resolved satisfactorily with symptomatic treatment and topiramate withdrawal; slowly, the lesions regressed. He required no further drugs for the dermatologic condition.

Accelerated nail growth rate in HIV patients.

BACKGROUND: Many factors have been noted to alter the growth rate of both finger and toe nails, some with harder evidence than others. Infectious diseases are among the ones reported as slowing the growth rate. However, on previous studies we noticed that patients living with HIV and onychomycosis could be cured without the use of antifungal therapy, only with the immunological improvement provided by the combined antiretroviral therapy, and we wanted to prove that the growth rate is also increased in this group and thus probably contributes to the cure of onychomycosis. METHODS: This was an observational, descriptive, and prospective study. We marked with a scalpel the nail plate of the first finger of the non-dominant hand and the same foot, and measured the nail growth in the subsequent medical appointments with a magnifying glass and a millimetric scale. RESULTS: Thirteen patients completed the study, and were paired with healthy controls by age and gender. After performing Mann-Whitney U test, our results showed statistical significance among both groups, showing that patients with HIV have faster nail growth rates than those in the HIV negative group. CONCLUSIONS: There is little data on HIV nail growth rate to compare our results, but what we see in the clinical practice is that this group of patients shows a faster nail growth rate, as has also been reported for longer eyelashes, and this could be an important factor in the cure rates of onychomycosis.

[Treatment of interdigital foot Erythrasma with ozonated olive oil]. / Tratamiento de eritrasma interdigital de pies con aceite de oliva ozonificado.

BACKGROUND: Erythrasma is caused by Corinebacterium minutissimum producing a porphyrin that with Wood's light emits a coral-red fluorescence. It is the most common bacterial infection of the feet. Ozonated olive oil decreases the cytoplasm and damages bacterial proteins and lipids. Treatment is with oral erythromycin and there is no consensus regarding the topical therapy of choice. The aim of this paper is to evaluate the therapeutic efficacy of ozonated olive oil in a pilot trial for Erythrasma. METHODS: Experimental, open, observational, descriptive, longitudinal clinical trial at the section of Mycology, of the General Hospital "Dr. Manuel Gea González". PATIENTS: 10 individuals with interdigital feet Erythrasma. INTERVENTION: ozonated olive oil every 12 hours for 10 days was given. RESULTS: All patients had disappearance of coral-red fluorescence, erythema, fissures, pruritus, and maceration; two patients persisted with scaling. A cure was obtained in 100 % of patients, similar to oral erythromycin response. CONCLUSIONS: Ozonated olive oil is a good topical treatment option for interdigital Erythrasma avoiding oral medications. Larger studies are required.

Introducción: el eritrasma es causado por Corinebacterium minutissimum que produce una porfirina que con la luz de Wood emite una fluorescencia rojo coral es la infección bacteriana más frecuente en los pies. El aceite de oliva ozononificado disminuye el citoplasma y daña las proteínas y los lípidos bacterianos. El tratamiento es mediante eritromicina oral y no hay consenso respecto a la terapia tópica de elección. El objetivo de este trabajo es evaluar la eficacia terapéutica del aceite de oliva ozonificado en el eritrasma en una prueba piloto. Métodos: estudio clínico experimental, abierto, observacional, descriptivo y longitudinal, llevado a cabo en la sección de Micología del Hospital General "Dr. Manuel Gea González". Se incluyeron 10 pacientes con eritrasma interdigital de pies, a quines se les administró aceite de oliva ozonificado cada 12 horas por 10 días. Resultados: en todos los pacientes hubo desaparición de la fluorescencia rojo coral, eritema, fisuras, prurito y maceración; en dos de ellos persistió la descamación. Se obtuvo una cura clínica en el 100 % de los pacientes, respuesta similar a la eritromicina oral. Conclusiones: el aceite de oliva ozonificado es una buena opción terapéutica tópica para el eritrasma interdigital, que permite evitar la prescripción de medicamentos por vía oral. Se requieren estudios más extensos.

Modified PAS stain: a new diagnostic method for onychomycosis / Examen directo teñido con PAS: un nuevo método diagnóstico de la onicomicosis

Background. Onychomycosis is the most common nail disease and represents around 50% of nail disorders. Accurate diagnosis with adequate evidence is ideal before starting any treatment. Current diagnostic methods offer low specificity and sensitivity. Aims. To create a new method for the diagnosis of onychomycosis, and to compare its sensitivity and specificity with the existing methods. Methods. One hundred and ninety-two samples with clinical suspicion of onychomycosis were included and underwent modified PAS stain (M-PAS), KOH/chlorazol black (KOH/CB) and culture testing. Sensitivity, specificity, positive and negative predictive values were calculated. Results. In 152 out of 192 samples (79.2%) fungi structures were found in at least one of the three tests performed, and the patients were diagnosed with onychomycosis; 40 samples out of 192 (20.8%) were negative. Using M-PAS, filaments and/or spores were seen in 143 samples from the 152 positive (94%); 39 of them were negative to KOH/CB and positive to M-PAS (25.6%). With KOH/CB, filaments and/or spores were seen in 113 cases from the 152 positive samples (73.8% of the onychomycosis cases). Thirty-five cultures were positive, of which 77% were identified as Trichophyton rubrum; 117 onychomycosis cases were diagnosed despite the negative culture (76.9%). M-PAS showed 92.5% sensitivity and 55.55% specificity, a 67.5% positive predictive value and a 81.6% negative productive value. Conclusions. This procedure, a combination of the existing methods to diagnose onychomycosis, KOH/CB together with a nail clipping biopsy, proved to have high sensitivity, as well as being rapid, easy, inexpensive and readily available in most hospital settings. M-PAS allowed us to diagnose 39 cases (25.6% of the cases of onychomycosis) that were false negative using only KOH/CB and culture (AU)

Antecedentes. La onicomicosis es la enfermedad más común de las uñas y representa un 50% del total de las enfermedades que afectan a esta parte del cuerpo. Antes de iniciar un tratamiento, es muy recomendable contar con un diagnóstico preciso y pruebas suficientes. En la actualidad, los métodos diagnósticos ofrecen una sensibilidad y especificidad bajas. Objetivos. Crear un nuevo método de diagnóstico de la onicomicosis y comparar su sensibilidad y especificidad con los métodos diagnósticos existentes. Métodos. Se recogieron ciento noventa y dos muestras con sospecha clínica de onicomicosis en las que se aplicaron las pruebas de examen directo con KOH/Negro de clorazol (KOH/CB), cultivo y examen directo teñido con PAS (M-PAS). Se calcularon la sensibilidad, la especificidad, y los valores predictivos positivo y negativo. Resultados. En 152 de las 192 muestras (79,2%) se hallaron estructuras micóticas en una de las tres pruebas realizadas como mínimo, y se diagnosticó onicomicosis en dichos pacientes; 40 de las 192 muestras (20,8%) dieron resultados negativos. Mediante M-PAS, se observaron filamentos o esporas en 143 de las 152 muestras (94%); 39 de ellas resultaron negativas con KOH/CB y positivas con M-PAS (25,6%). En el caso de KOH/CB, se observaron filamentos o esporas en 113 de las 152 muestras, (73,8% de los casos de onicomicosis). Treinta y cinco cultivos dieron resultados positivos, conel 77% de los aislamientos obtenidos identificados como Trichophyton rubrum; se diagnosticaron 117 casos de onicomicosis a pesar de los resultados negativos en el cultivo (76,9%). La sensibilidad de M-PAS fue del 92,5%, la especificidad del 55,55%, y los valores predictivos positivo y negativo de 67,5% y 81,6%, respectivamente. Conclusiones. Este procedimiento, una fusión de métodos ya existentes para el diagnóstico de la onicomicosis, que aplica KOH/CB junto con una biopsia de fragmentos de uña, mostró una gran sensibilidad. Es además un método rápido, fácil, económico y disponible en la mayoría de los ámbitos hospitalarios. M-PAS permitió diagnosticar 39 casos (25,6% de los pacientes con onicomicosis) con resultados falsos negativos al utilizar únicamente KOH/CB y cultivo (AU)