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)

Modified PAS stain: A new diagnostic method for onychomycosis.

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.

Candida species isolation in peristomal skin in patients with abdominal stomas and correlation to clinical signs: a descriptive pilot study.

The reported prevalence of candidiasis in peristomal skin varies greatly. Very few studies exist that correlate the clinical findings around the peristomal skin to the mycology. In this study, the authors report on Candida species prevalence, clinical correlation, and mycology.

Feohifomicosis subcutánea producida por Curvularia lunata en un paciente receptor de un trasplante renal / Subcutaneous phaeohyphomycosis due to Curvularia lunata in a renal transplant patient

Fundamento. La feohifomicosis se define como una infección causada por hongos dematiáceos (melanizados). Predomina en climas tropicales y en la actualidad es bien conocido que se manifiesta en forma superficial, cutánea, subcutánea y sistémica del sistema nervioso central o pulmonar diseminada. Curvularia es uno de los numerosos géneros que pueden causar esta infección. En las formas subcutáneas es más frecuente aislar Phialophora, Alternaria o Exophiala. Caso clínico. Un hombre de 25 años de edad, receptor de un trasplante renal, se presentó con una úlcera en la pierna izquierda. Mediante examen micológico y los hallazgos histopatológicos se estableció el diagnóstico de feohifomicosis subcutánea producida por Curvularia lunata. Se trató satisfactoriamente con itraconazol sistémico y la resección quirúrgica de la úlcera. Conclusión. A pesar de que, en las últimas décadas, se ha incrementado la incidencia de feohifomicosis, en particular en pacientes inmunosuprimidos, el número de casos no permite que se emprendan ensayos controlados terapéuticos. Por esta razón, consideramos que es importante comunicar los casos clínicos individuales y revisar los estudios publicados para aumentar los conocimientos sobre esta enfermedad, su presentación clínica y la respuesta al tratamiento(AU)

Background. Phaeohyphomycosis is defined as an infection caused by melanized fungi. It predominates in tropical climate and is currently classified as superficial, allergic, central nervous system or lung infections, and disseminated. Curvularia is one of the many genres which can cause this disease. Phialophora, Alternaria and Exophiala are more commonly isolated from subcutaneous lesions. Case report. A 25-year-old male, renal transplant recipient presents with an ulcer on his left leg. Subcutaneous phaeohyphomycosis due to Curvularia lunata was diagnosed based on mycological examination and histopathological findings. He was successfully treated with systemic itraconazole and surgical resection. Conclusion. The incidence of phaeohyphomycosis has increased in the last decades, especially in immunosuppressed individuals; nevertheless the number of cases does not allow for therapeutic controlled trials to be performed. Hence, we consider that it is important to communicate individual cases and reviews of the literature, to increase awareness of the disease, its clinical presentation and response to treatment(AU)

Subcutaneous phaeohyphomycosis due to Curvularia lunata in a renal transplant patient.

BACKGROUND: Phaeohyphomycosis is defined as an infection caused by melanized fungi. It predominates in tropical climate and is currently classified as superficial, allergic, central nervous system or lung infections, and disseminated. Curvularia is one of the many genres which can cause this disease. Phialophora, Alternaria and Exophiala are more commonly isolated from subcutaneous lesions. CASE REPORT: A 25-year-old male, renal transplant recipient presents with an ulcer on his left leg. Subcutaneous phaeohyphomycosis due to Curvularia lunata was diagnosed based on mycological examination and histopathological findings. He was successfully treated with systemic itraconazole and surgical resection. CONCLUSION: The incidence of phaeohyphomycosis has increased in the last decades, especially in immunosuppressed individuals; nevertheless the number of cases does not allow for therapeutic controlled trials to be performed. Hence, we consider that it is important to communicate individual cases and reviews of the literature, to increase awareness of the disease, its clinical presentation and response to treatment.

Sporotrichosis.

Sporotrichosis is the most common subcutaneous mycosis. It is usually acquired by traumatic inoculation, and it is caused by one of the species of the Sporothrix schenckii complex. More than 6 species, such as S schenckii sensu stricto, Sporothrix brasiliensis, Sporothrix globosa, Sporothrix mexicana, and Sporothrix albicans, have been identified by molecular techniques. The most common presentation is cutaneous disease, which is classified into fixed and lymphocutaneous forms. Osteoarticular, pulmonary, mucosal, disseminated, and systemic infections are less common and usually occur in immunosuppressed individuals. The diagnosis is suggested by biopsy specimen and confirmed by tissue culture. Itraconazole is considered the treatment of choice, although in some undeveloped countries potassium iodide is still used, owing to its safety and low cost. For systemic or disseminated cases, amphotericin B is the treatment of choice.

Efficacy of imipenem therapy for Nocardia actinomycetomas refractory to sulfonamides.

BACKGROUND: Actinomycetomas are chronic, granulomatous, subcutaneous infections caused by actinomycetes bacteria. Despite prolonged high-dose and combination antibiotic therapies, some cases remain resistant with risks of bone and visceral involvement. OBJECTIVES: We sought to evaluate the efficacy and safety of imipenem monotherapy, and in combination with amikacin for the treatment of severe and refractory disease, and to identify the disease characteristics that might predict therapy failure with first-line sulfonamides. METHODS: A retrospective study was performed of all microbiologically confirmed cases of actinomycetomas treated since 1995 at a tertiary center for mycology. Eleven patients (Nocardia, n = 10) were treated with sulfonamide combinations (trimethoprim/sulfamethoxazole and dapsone). Eight patients (Nocardia, n = 7) refractory to previous therapies including sulfonamides received a 3-week course of either parenteral imipenem monotherapy (1.5 g daily, n = 3) or combination therapy with amikacin (1 g daily, n = 5), which was repeated at 6-month intervals. RESULTS: Eleven patients with limited disease and mean disease duration of 1.7 years responded successfully to sulfonamides after a mean treatment period of 15 months (range 6-48 months). Patients receiving imipenem had mean disease duration of 10 years, with visceral and bone involvement in 4 patients. Imipenem treatment was well tolerated, and 4 patients achieved clinical and microbiological cure after one to two courses of treatment, the others demonstrating greater than 75% clinical improvement and negative culture results. LIMITATIONS: Patient cohorts in this study were small because strict criteria for inclusion included species identification and adequate follow-up periods. The efficacy data for imipenem +/- amikacin therapy cannot be extrapolated to all Nocardia mycetomas, as the cohort treated in this study had particularly refractory infection. CONCLUSIONS: Sulfonamides are effective for limited disease of relatively short duration. Imipenem monotherapy or in combination with amikacin is well tolerated and demonstrates efficacy in severe disease refractory to sulfonamides.

[Onychomycosis among children. A retrospective study of 233 Mexican cases]. / Onicomicosis en niños. Estudio retrospectivo de 233 casos mexicanos.

BACKGROUND: Worldwide recent reports point towards a rising prevalence ofonychomycosis in the pediatric population, especially among adolescents. Dermatophytes are the most common etiologic agents. MATERIAL AND METHODS: We carried out a retrospective review of the last 12 years, comprising 332 medical records from children with clinical suspicion of onychomycosis. We analyzed the following variables: gender, age, predisposing factors, affected nails, other concurrent superficial mycoses and potassium hydroxide direct examination and culture. RESULTS: A total of 233 onychomycosis cases were identified, cases constituted 33% of superficial mycoses of children seen at our unit. Two thirds were adolescents with no significant difference among the sexes. Toenails were more affected (94%) than fingernails (4.2%) with distal and lateral subungueal onychomycosis being the most common clinical presentation. In 70% of cases infection was caused by dermatophytes (mainly Trichophyton rubrum). CONCLUSIONS: Onychomycosis constitute 33% of superficial mycoses among children seen at our medical facility. We confirm a rise in prevalence, toenails were the most common (94%) and had a dermatophytic etiology (70%). We suggest to all physicians caring for children and adolescents, to become familiar with diagnostic and therapeutic tools for this type of mycosis.

Onicomicosis en niños: estudio retrospectivo de 233 casos mexicanos / Onychomycosis among children: a retrospective study of 233 Mexican cases

Antedecentes: Estudios recientes alrededor del mundo indican que la prevalencia de la onicomicosis está aumentando en la población pediátrica, sobre todo en adolescentes. Los dermatófitos son los agentes etiológicos más frecuentes. Material y métodos: Revisión retrospectiva de 12 años de los expedientes de 332 niños con sospecha clínica de onicomicosis. Se analizaron variables como sexo, edad, factores predisponentes, uñas afectadas, otras micosis superficiales y los resultados del estudio micológico. Resultados: Se identificaron 233 casos de onicomicosis, que representan 33% de las micosis superficiales en nuestro departamento. Dos terceras partes correspondieron a adolescentes, sin encontrar diferencia significativa en sexo. Las uñas de los pies se afectaron con mayor frecuencia (94%) que las de las manos (4.2%) y la variedad clínica predominante fue la onicomicosis subungueal distal y lateral. Los dermatófitos (sobre todo Trichophyton rubrum) fueron los responsables de la infección en 70%. Conclusiones: Las onicomicosis constituyen 33% de las micosis superficiales en niños. Corroboramos el aumento en su frecuencia, el predominio en uñas de pies (94%) y la etiología dermatofítica (70%). Recomendamos a médicos que atienden niños y adolescentes, la implementación de medidas de diagnóstico y tratamiento.

BACKGROUND: Worldwide recent reports point towards a rising prevalence ofonychomycosis in the pediatric population, especially among adolescents. Dermatophytes are the most common etiologic agents. MATERIAL AND METHODS: We carried out a retrospective review of the last 12 years, comprising 332 medical records from children with clinical suspicion of onychomycosis. We analyzed the following variables: gender, age, predisposing factors, affected nails, other concurrent superficial mycoses and potassium hydroxide direct examination and culture. RESULTS: A total of 233 onychomycosis cases were identified, cases constituted 33% of superficial mycoses of children seen at our unit. Two thirds were adolescents with no significant difference among the sexes. Toenails were more affected (94%) than fingernails (4.2%) with distal and lateral subungueal onychomycosis being the most common clinical presentation. In 70% of cases infection was caused by dermatophytes (mainly Trichophyton rubrum). CONCLUSIONS: Onychomycosis constitute 33% of superficial mycoses among children seen at our medical facility. We confirm a rise in prevalence, toenails were the most common (94%) and had a dermatophytic etiology (70%). We suggest to all physicians caring for children and adolescents, to become familiar with diagnostic and therapeutic tools for this type of mycosis.

Antimicóticos en niños / Antifungals in Children

Las micosis superficiales son padecimientos frecuentes en la infancia y para su manejo se pueden utilizar antimicóticos tanto tópicos como sistémicos. Sin embargo, en las últimas décadas, ha aumentado la población infantil susceptible a infecciones diseminadas o sistémicas por agentes oportunistas que ponen en riesgo la vida. Las principales son la candidosis y la aspergilosis. Se han desarrollado nuevos antimicóticos con espectros más amplios de acción y menor toxicidad, pero la mayoría de los reportes en la literatura se refieren a estudios hechos en adultos, cuyos resultados son extrapolados a la población pediátrica. La presente revisión tiene como objetivo condensar la información referente al uso de antimicóticos en niños, con énfasis en las diferencias farmacocinéticas con respecto a los adultos y las indicaciones principales para su uso (AU)

Superficial mycoses are common in childhood, either topical or systemic antifungals can be used for treatment. However, in the past decade, the pediatric population at risk of a disseminated or systemic infection by opportunistic fungi has increased. The most important are candidiasis and aspergillosis. New antifungals, with a wider spectrum of action and less toxicity have been developed, nevertheless, most of the studies and reports of the literature focus on adults and the findings are extrapolated to children. The objective of this paper is to review what has been published on the use of antifungals in the pediatric age, focusing in pharmacokinetic differences regarding adults and current indications for this group of drugs (AU)