PCR a tiempo real comercial para diagnóstico rápido de las onicomicosis: un nuevo algoritmo de trabajo en el laboratorio clínico / Commercial real time PCR implementation for rapid diagnosis of onychomycosis: A new workflow in a clinical laboratory

Introduction: Onychomycosis is a frequent and underdiagnosed condition. Approximately 90% of toenail onychomycosis infections are caused by dermatophytes, but classical diagnosis based on culture and microscopy observation is slow and has low sensitivity. Both limitations can be solved incorporating molecular techniques to routine diagnosis of onychomycosis. Objective: Prospective evaluation of the utility of incorporating in the clinical laboratory workflow a commercial real time PCR (qPCR) for dermatophytes detection in nails after potassium hydroxide direct observation screening. Materials and methods: 152 nail samples were included (34 KOH negative and 118 KOH positive) and processed by culture and qPCR. Results: In the negative KOH group, only one dermatophyte grew in culture and three were detected by qPCR. In the group of positive KOH, 57 dermatophytes grew in culture and 81 were detected by qPCR. In this group, 25% of diagnosed dermatophytes were detected only by qPCR. The sensitivity of qPCR compared to culture is 92.8% and time of response decreases from days to hours. Conclusion: Based in our results, we propose a workflow algorithm for a clinical laboratory that eliminates culture for qPCR positive samples.(AU)

Introducción: La onicomicosis es una patología frecuentemente infradiagnosticada. Aproximadamente el 90% de las infecciones en las uñas del pie están causadas por dermatofitos, pero el diagnóstico microbiológico clásico basado en cultivo y microscopia es lento y tiene una baja sensibilidad. Ambas limitaciones pueden resolverse incorporando técnicas moleculares al diagnóstico de la onicomicosis. Objetivo: Evaluación prospectiva de la utilidad de incorporar en un laboratorio clínico una PCR a tiempo real (qPCR) comercial para detección de dermatofitos en uñas tras cribado por examen directo con hidróxido de potasio (KOH). Materiales y métodos: Se incluyeron 152 muestras de uñas (34 KOH negativas y 118 KOH positivas) y se procesaron mediante cultivo y qPCR. Resultados: En el grupo KOH negativo, solo un dermatofito creció en cultivo y 3 se detectaron mediante qPCR. En el grupo KOH positivo, 57 dermatofitos crecieron en cultivo y 81 se detectaron por qPCR. En este grupo, el 25% de los dermatofitos diagnosticados se detectaron únicamente mediante qPCR. La sensibilidad de la qPCR comparada con el cultivo es del 92,8% y el tiempo de respuesta disminuye de días a horas. Conclusión: En base a nuestros resultados, proponemos un algoritmo de flujo de trabajo para los laboratorios de microbiología clínica, que elimina el cultivo para aquellas muestras con qPCR positiva.(AU)

Social media and dissemination: impressions of fish pedicures following a case of onychomadesis.

Although the popularity of fish pedicures as cosmetic or routine services and/or tourist attractions has peaked in the past decade, the practice is still trending today and accompanying risks are less well-known by the public. More recently, a case of onychomadesis following fish pedicure has gained interest in both public and dermatologic populations, highlighting the importance of patient education. In this study, we aimed to demonstrate the wide reach of the manuscript through social media and news outlets. The majority of social media correspondences have come from Thai accounts whereas news outlets were mostly from the United States and various European or Asian countries. Analyzed by Altmetric score, the report was within the top 5% of all research outputs ever scored by Altmetric. Finally, Google Trend data indicates that fish pedicure interest decreased thereafter to the lowest levels in the past decade after the case report was published, signifying its likely effect on diminishing public interest. This case report and analysis of its news/social media reach emphasize the importance of literature/media outlets in informing patients and the public of adverse effects. As fish pedicures continue to be popular both in the US and overseas, appropriate education of the public remains important in preventing complications.

[Current Status of Onychomycosis Topical Therapy Conducted at Home].

　Patients usually consult a dermatologist for the treatment of onychomycosis. However, in the case of home care, visiting nurses may assist with bathing, which offers the opportunity to observe patients' feet for possible signs of onychomycosis without causing anxiety. It is estimated that more than 30% of patients receiving home care have onychomycosis. Before the approval of efinaconazole, healthcare personnel hesitated to treat onychomycosis because of: 1) possible side effects, especially liver dysfunction and pain due to repeated blood collection, as a major goal of home care is to minimize pain; and 2) the questionable efficacy of previously available antifungal medications. In addition, many patients report fear of "transmitting athlete's foot to others" and "do not want to show my dirty toenails". On the other hand, caregivers reportedly worry about "athlete's foot being transmitted to them".

The survey of tinea capitis and scalp dermatophyte carriage in nursing home residents.

Tinea capitis is a contagious dermatophyte infection of scalp and associated hairs. On the other hand, asymptomatic carriage is a status of positive dermatophyte scalp culture, but without signs or symptoms of tinea capitis, and no evidence of hair shaft invasion confirmed by direct microscopy. Tinea capitis and asymptomatic carriage mostly occur in children, but adult females are becoming another population in recent decades. In this study, we focused on the prevalence and related fungi of tinea capitis and asymptomatic carriage in elderly by the shampoo brush method, as well as the source of transmission, in 10 nursing home residents. Two hundred and thirteen residents were screened, and 186 isolates were identified, of which only three were dermatophytes (1.4%). The scalp dermatophyte isolates were identified as Trichophyton rubrum by morphological characters and sequences comparisons in all three cases. After revisiting, these cases were proved to be asymptomatic carriers by negative microscopic and culture examination; however, two cases were found to have concurrent tinea pedis and onychomycosis, which were identified as T. rubrum and Trichophyton interdigitale. The source of the T. rubrum scalp carriage may come from tinea elsewhere on the body of the same subject or from other people in the same institute. Finding and treating the source of carriage, as well as treating scalp carriage patients according to the colony counts, may help prevent disease spreading.

High prevalence of superficial white onychomycosis by Trichophyton interdigitale in a Japanese nursing home with a geriatric hospital.

A mycological survey on feet was performed in a nursing home with a geriatric hospital to ascertain the prevalence of tinea lesions. Of 100 subjects, comprising 62 in the nursing home and 38 in the geriatric wing, 70 were diagnosed with tinea pedis, tinea unguium (onychomycosis) or both of which 54 had onychomycosis alone, nine tinea pedis alone and seven had co-existing onychomycosis and tinea pedis. The most common clinical type of onychomycosis was distal lateral subungual onychomycosis (DLSO) at 30 cases, followed by superficial white onychomycosis (SWO) at 23 cases. Fifteen strains of Trichophyton (T.) interdigitale isolated from 23 SWO patients comprised six molecular types (D2II, nine cases; C2II, two cases; four other types, one case of each), based on the non-transcribed spacer region (NTS) of the ribosomal DNA. The pathogen of three other SWO cases was identified as T. rubrum. Direct physical contact between the subjects was unlikely because they were bedridden most of the time. Nine T. interdigitale strains were isolated from a bathtub used by patients on the floor with a high incidence of SWO alone, and all nine strains were D2II type, which suggests nosocomial infection. Consequently, the hospital infection control policy committee was consulted, bathing arrangements were changed, and nursing staff were educated about onychomycosis.

Molecular analysis of dermatophytes suggests spread of infection among household members.

Dermatophyte infection from the same strains may be an important route for transmission of dermatophytoses within a household. In this study, we used molecular methods to identify dermatophytes in members of dermatophyte-infected households and evaluated variables associated with the spread of infection. Fungal species were identified by polymerase chain reaction (PCR) using primers targeting the internal transcribed spacer (ITS) regions (ITS1 and ITS4). For strain differentiation, fungal DNA was probed with a ribosomal DNA-specific probe (containing ITS1, 5.8S ribosomal DNA, and ITS2) to detect restriction fragment length polymorphisms (RFLPs). Associations between the spread of a dermatophyte infection and fungal/host variables were determined using χ² and logistic regression analyses. Among the 50 households enrolled in this study, 18 included multiple infected members (MIMs). Trichophyton rubrum was the most commonly isolated dermatophyte species, followed by Trichophyton mentagrophyts and Epidermophyton floccosum. Sixteen T rubrum strains (TR-A to TR-P) were identified, with spread of infection detected in 8 MIM households. Factors that were significantly (P<.05) associated with the spread of infection included the presence of strains TR-B or TR-D, a history of concomitant tinea pedis and onychomycosis, and plantar scaling and/or nail discoloration. This study is unique in that it used molecular evidence to demonstrate the association of certain strains with the spread of dermatophyte infection among members of the same household.

Onychomycosis in close quarter living review of the literature.

Onychomycosis is defined as a fungal infection of the nail bed and/or nail plate. The prevalence of onychomycosis has increased dramatically as a worldwide condition in the twentieth century due to occlusive footwear, global wars and natural migration. Risk factors generally leading to onychomycosis development include bodily spread of dermatophyte and non-dermatophyte tinea pedis, peripheral vascular disease, damaged nails via sports and trauma, older age, genetics, immunodeficiency and diabetes. Many publications discuss prevalence, symptoms and treatment of the disease in individual cases, hospitals or specific locations, but few strongly link the cause of onychomycosis to living environments. This is a review of the current literature on the prevalence of onychomycosis and its relationship to surrounding living environments of those infected. A Pubmed search was performed with 'onychomycosis'. Articles were selected based on the relevance to close quarter living environments. All ages can be affected with onychomycosis, ranging from children in boarding schools to elderly in nursing homes. Although not directly linking living environments to transmission and infection in all articles reviewed, onychomycosis was very prevalent in many different close quarter living settings, including within families, boarding schools, military quarters and nursing homes. This review demonstrates that various close quarter living environments are highly associated with increased transmission and infection with onychomycosis.

Trichophyton rubrum autoinoculation from infected nails is not such a rare phenomenon.

Kerion-like lesions are usually caused by zoophilic dermatophytes. Here, we present a rare case report - an inflammatory tinea barbae due to an anthropophilic fungus (Trichophyton rubrum), which is the main pathogen of onychomycosis and tinea pedis. Probably the infection, in the presented case, spread from diseased fingernails. We do postulate that physicians should consider autoinoculation as a not so rare way of fungal infection transmission.

[Dermatomycosis with epidemic proportions: Tinea capitis and onychomycosis]. / Dermatomykosen mit epidemiologischem Potenzial: Tinea capitis und Onychomykose.

Superficial fungal infections caused by dermatophytes (dermatophytoses) are the most common skin infections with about 10-15% of the population throughout the world being affected. Up to now the occurrence of fungal infections of the skin has been connected, like ectoparasitic infections with poor hygiene and poor living conditions. During the last decades, however, there has been a dramatic change with a significant increase in mycotic scalp infections as well as fungal nail disease mainly in highly developed countries like the US and those on the European continent.

Scytalidium dimidiatum melanonychia and scaly plantar skin in four patients from the Maghreb: imported disease or outbreak in a Belgian mosque?

Scytalidium dimidiatum is a geophilic dematiaceous, non-dermatophyte mould that can become a pathogen for plants and humans particularly in tropical and subtropical regions. We report 4 cases of S. dimidiatum onychomycosis presenting clinically as thickened and dark toenails. The skin of the soles was scaly. The time and location of the contaminations were uncertain. Indeed, the patients were ancient immigrants from the Maghreb to Belgium. They were also regularly travelling to their countries of origin. They were also often barefoot in the same Belgian mosque. The disease was unresponsive to current oral antifungal treatments.

[Dirty nails and mycotoxins]. / Ongles sales et mycotoxines.

Some mycotoxins are among the most toxic natural products. They are metabolites produced by food-borne and feed-borne moulds. Dirty and soiled nails, and contaminated or infected onyxis by these specific moulds can be the origin of oral contamination and mycotoxicosis. Hence, nail cleaning, correct hygiene and treatment of mould onychomycosis have a potentially great impact on health.

[The connection between sports and spores. The foot, its mycoses and onychomycoses]. / Il y a sports et spores. Le pied, ses mycoses et onychomycoses.

The epidemiological survey Achillus on over 76,000 subjects has highlighted the high prevalence of foot diseases. In particular, the risk of contracting skin and nail infections of the foot by fungi is quite important during some sport practices. The interhuman transmission is due to propagules commonly called spores. It often occurs by indirect contamination from the soil. Clinical presentations are diverse, largely depending upon the identity of the pathogen fungus. Prevention and treatment of these infections require both patience and perseverance. Boosting the transformation of spores into an active growing phase might paradoxically increase the clinical efficacy of antifungals.

Estudio etiológico de la onicomicosis pedis en personal militar en formación / Ethiology agent of the onychomycosis in military personnel

Es un estudio prospectivo y longitudinal en donde el objetivo fue identificar al agente etiológico e incidencia de onicomicosis pedis dentro de una población cautiva, de ambos sexos, de 17 a 23 años en personal militar en formación. Se seleccionó pacientes de acuerdo a criterios clínicos establecidos con sospecha clínica de onicomicosis. Se realizó la toma de muestras por raspado, observación directa con KOH al 10 por ciento, cultivo en Agar. Sabouraudy Mycobiotic. De 412 personas evaluadas 178 (43.2 por ciento) fueron clínicamente diagnósticados como onicomicosis pedis (156 hombres, 22 mujeres). De ellos se tomó muestras para estudio microbiológico a 136 (76.4 por ciento), 68 pacientes (50 por ciento) resultaron positivos al examen directo y el 31.62 por ciento fueron positivos al cultivo. Se aisló levaduras en el 66 por ciento, dermatofitos en el 23 por ciento y mohos no dermatofitos en el 11 por ciento de los cultivos. Los dermatofitos aislados pertenecen al grupo Trichophyton y las levaduras a los géneros candida y rhodotorula. Conclusiones: 1. Sobre el total de la población evaluada, la incidencia de onicomicosis pedis fue 10.4 por ciento. 2. El agente etiológico más frecuente en la población masculina fueron levaduras, mientras que en la femenina fueron dermatofitos. 3. Se confirma que el esfuerzo físico y el tipo de calzado afecta en la incidencia de onicomicosis pedis. 4. Se reporta el hallazgo de un moho no dermatofito en la onicomicosis pedis. Pullularia sp.

Tinea pedis et unguium in the Muslim community of Durban, South Africa.

BACKGROUND: In a pilot study performed in eight mosques in the Durban area, it was found that the prevalence of tinea pedis et unguium in the adult Muslim male population regularly attending mosques was higher than in the nonMuslim male population. The aims of the present study were: (i) to determine the prevalence of tinea pedis et unguium in the adult Muslim male population regularly attending mosques; (ii) to investigate the role of mosque carpets and ablution areas in the spread of infection; and (iii) to develop strategies to combat the infection. METHOD: Seventy-eight regular worshippers comprising adult Muslim males, chosen at random from five mosques in the Durban area, were examined for clinical evidence of tinea pedis et unguium. Skin scrapings and nail clippings were taken from clinically infected individuals and submitted for microscopy and culture for fungal organisms. A control group, comprising 72 nonMuslim adult male office workers from the administration departments of King Edward VIII Hospital, was similarly examined. In addition, scrapings from high traffic areas of the mosque carpets and swabs from the ablution areas were cultured for fungi. RESULTS: In the mosque group, it was found that the prevalence of tinea pedis et unguium was 85%, taking either microscopy or culture positivity as indicative of infection. In the control group, the prevalence was 41%. Thus a statistical difference of 44% (P < 0.0001) between the two groups was demonstrated. Dermatophytes and yeasts were isolated from the carpets and/or floors of the ablution areas in all the mosques under investigation. CONCLUSIONS: The high prevalence of tinea pedis et unguium among regular male worshippers in the Muslim community can be attributed to the spread of fungal organisms in the communal ablution areas and prayer carpets of the mosques. Strategies to combat this spread of infection are being developed. These strategies are expected to find important practical applications in other communal environments, such as gymnasia, health spas, swimming pools, changing rooms of sports clubs, public showers, and even hotels.

Human onychomycosis caused by Trichophyton equinum transmitted from a racehorse.

We report fingernail onychomycosis caused by Trichophyton equinum in a farmer who breeds racehorses. In addition to the thumbnail, T. equinum had infected one of the racehorses. Oral terbinafine cured the infection in the farmer.

[Effect of domestic laundry processes on mycotic contamination of textiles]. / Der Einfluss des haushaltsüblichen Waschprozesses auf mykotisch Kontaminierte Textilien.

Inadequately decontaminated clothing may be a source of reinfection following therapy of dermato- and onychomycoses. The objective of this study was to determine whether domestic laundering is suitable for cleansing mycotically contaminated garments. Textile-samples contaminated with Trichophyton rubrum, Trichophyton mentagrophytes, Candida albicans and Scopulariopsis brevicaulis were washed in an ordinary washing machine at different temperatures. Regardless of the textiles and detergents used, reliable decontamination was achieved by laundering at 60 degrees C. Trichophyton rubrum was eliminated with a washing temperature of 30 degrees C.