Angioinvasive fungal infections impacting the skin: Background, epidemiology, and clinical presentation.

Angioinvasive fungal infections cause significant morbidity and mortality because of their propensity to invade blood vessel walls, resulting in catastrophic tissue ischemia, infarct, and necrosis. While occasionally seen in immunocompetent hosts, opportunistic fungi are emerging in immunosuppressed hosts, including patients with hematologic malignancy, AIDS, organ transplant, and poorly controlled diabetes mellitus. The widespread use of antifungal prophylaxis has led to an "arms race" of emerging fungal resistance patterns. As the at-risk population expands and new antifungal resistance patterns develop, it is critical for dermatologists to understand and recognize angioinvasive fungal pathogens, because they are often the first to encounter the cutaneous manifestations of these diseases. Rapid clinical recognition, histopathologic, and culture confirmation can help render a timely, accurate diagnosis to ensure immediate medical and surgical intervention. Superficial dermatophyte infections and deep fungal infections, such as blastomycosis and histoplasmosis, have been well characterized within the dermatologic literature, and therefore this article will focus on the severe infections acquired by angioinvasive fungal species, including an update on new and emerging pathogens. In the first article in this continuing medical education series, we review the epidemiology and cutaneous manifestations. The second article in the series focuses on diagnosis, treatment, and complications of these infections.

Erosio interdigitalis blastomycetica: A review of interdigital candidiasis.

Erosio interdigitalis blastomycetica (EIB) is a Candida infection affecting the third web space, between the third and fourth fingers. In 1915, Gougerot and Goncea first described saccharomycetic organisms isolated from the hands and feet. Johannes Fabry later named it in 1917, well before the genus Candida was introduced in 1923. EIB is most common among those who work with their hands frequently in water, such as dishwashers, launderers, bartenders, and homemakers. Clinical presentation most commonly consists of a central erythematous erosion surrounded by a rim of white macerated skin involving at least one interdigital web space. The differential diagnosis is narrow, consisting of irritant contact dermatitis (ICD), erythrasma, inverse psoriasis, and bacterial infection (i.e. impetigo). The diagnosis is made by clinical examination in addition to fungal culture and KOH testing. The prognosis is good and treatment options include avoidance of frequent water immersion and topical or oral antifungal agents. Suspicion for secondary infections such as erysipelas and cellulitis should remain high until lesions have resolved. This review aims to address the history, epidemiology, pathophysiology, histopathology, clinical presentation, differential diagnoses, diagnosis, prognosis, and management of EIB. It also suggests an alternative name in place of the current misnomer.

Primary immunodeficiency update: Part II. Syndromes associated with mucocutaneous candidiasis and noninfectious cutaneous manifestations.

Several primary immunodeficiencies (PIDs) have recently been described that confer an elevated risk of fungal infections and noninfectious cutaneous manifestations. In addition, immunologic advances have provided new insights into our understanding of the pathophysiology of fungal infections in established PIDs. We reviewed PIDs that present with an eczematous dermatitis in part I. In part II of this continuing medical education article we discuss updates on PIDs associated with fungal infections, their biologic basis in PIDs, and noninfectious cutaneous manifestations.

[Superficial mycoses in patients from Anzoátegui state, Venezuela, period 2002-2012]. / Micosis superficiales en pacientes del estado Anzoategui, Venezuela, periodo 2002-2012.

Superficial fungal diseases that affect the skin and its appendages are frequently seen in basic triage and in dermatology services. These diseases are distributed in Venezuela with an incidence of 92.9%. The aim of this study was to determine the genera and species that cause dermatomycoses in residents of Anzoátegui state, Venezuela, during the period 2002-2012. A total of 4257 patients with a presumptive diagnosis of superficial mycoses were studied, with ages from 7 months to 79 years. The overall prevalence was 30.9%. The most frequent were dermatophytosis (44.7%). M. canis produced 148 cases of tinea capitis. Three dermatophytic agents represented 95% of all cases, with a significant predominance of T. mentagrophytes with 50%. Candidosis occurred in 28.4%. C. albicans, and the C. parapsilosis complex, were responsible for 80% of the cases. The other species identified were C. tropicalis (n = 41, 11.0%), C. glabrata (n = 10, 2.7%), C. guilliermondii (n = 6, 1.6%), C. krusei (n = 4, 1.1%). Pityriasis versicolor occurred in 22.4% of the cases studied, and less frequently were present onychomycosis produced by a non dermatophytic mold: Fusarium oxysporum (n = 34, 65.4%), Aspergillus terreus (n=16, 30.8%) and Scytalidium dimidiatum (n=2; 3.8%). Rare cases of Trichosporon onychomycosis (0.5%) and one case of black tinea were also found. Health education in the population is recommended to promote measures to prevent transmission of these fungi and prevent the spread of this silent public health problem.

[Onychomycoses: epidemiology, causative agents and assessment of diagnostic laboratory methods]. / Onicomicosis: epidemiología, agentes causales y evaluación de los métodos diagnósticos de laboratorio.

Since March 2007 to March 2011, 414 patients with onychopathies were prospectively analyzed. Prevalence of the toenail and fingernail mycoses was 78 % and 58 %, respectively. The major etiological agents were Trichophyton rubrum, Candida spp. and Trichophyton mentagrophytes. Dermatophytes were more frequently cultured from toenails, whereas Candida spp. from fingernails (both, p < 0.05). In candidal onychomycosis, species different from C. albicans were prevalent. A higher prevalence of toenail and fingernail mycoses, a predominance of T. rubrum in toenails (p < 0.05), and greater positivity in the direct examination (DE) and in culture (both, p < 0.05) were more frequently observed in men than in women. The correlation between DE and culture was 68 %. DE and culture yields were associated with a greater size lesion. DE was more effective in onycodystrophies with duration of more than 5 years. Culture positivity was independent of nail affection chronicity.

Epidemiological and etiological study of foot mycosis in Tunisia.

BACKGROUND: Tinea pedis and onychomycosis are among the commonest fungal diseases in the world. Recently, there has been an increase in the numbers of fungal agents implicated in these conditions. OBJECTIVE: To analyze the epidemiology of fungal foot diseases and to identify associated etiological factors in outpatients attending the Department of Dermatology of Charles Nicolle Hospital in Tunis, Tunisia. PATIENTS AND METHODS: One hundred and forty eight patients were assessed for the presence of fungal foot diseases during the period between January and April 2009. The mean age was 41.5 years (range: 2-87 years) and sex ratio was 0.8. A complete dermatological examination was performed on all subjects, and specimens of the feet were taken from patients presenting signs of tinea pedis or onychomycosis for microscopy and fungal culture. RESULTS: Fungal foot infection was suspected in 71 subjects, and the diagnosis was confirmed in 67 cases (45.3%) by positive microscopy or culture. Older age and family history of mycosis were predisposing factors for foot fungal infection. The condition was caused by dermatophytes in 57.1% of cases and Candida species in 35.7%. Trichophyton rubrum and Candida parapsilosis were the predominant dermatophyte and yeast species, respectively.

Genital candidosis in heterosexual couples.

BACKGROUND: Evidence suggests that Candida can be sexually transmitted; however, the contribution of sexual transmission to the pathogenesis of genital candidosis needs further elucidation. OBJECTIVE: The aim was to evaluate genital candidosis and its transmissibility in heterosexual couples. METHODS: Heterosexual couples were recruited among attendees of an Sexually Transmitted Diseases clinic. Specimens for yeast culture were collected from the glans penis and inner preputial layer using direct impression on CHROMagar Candida medium; vaginal exudates were collected using a cotton swab with subsequent inoculation on CHROMagar Candida medium. Mitochondrial DNA restriction analysis was performed to compare Candida isolates from both partners. RESULTS: A total of 64 couples were enrolled in the study. Frequency of sexual intercourse was significantly higher in couples where both partners yielded positive cultures and with at least one having genital candidosis (Odds ratios: 6.844; 95% CI 1.408-33.266). The same Candida species was found in both partners in 25% (16/64) of all couples but only 17.2% (11/64) were genetically similar. In total 12 of the 34 women suffering from vulvovaginal candidosis (VVC) had recurrent VVC (RVVC); two sexual partners of RVVC women (16.7%) had candida positive cultures, compared with 15 (68.2%) sexual partners of non RVVC women (Odds ratios: 0.093; 95% CI 0.016-0.544). CONCLUSIONS: Only in a few heterosexual couples a genetic similarity of Candida species recovered from both partners was found. RVVC women were more likely to have an asymptomatic candida negative sexual partner. This study suggests that male genitalia do not represent a relevant reservoir for RVVC; thus, the relevance of sexual transmission should not be emphasized.

Infections in the monogenic autoimmune syndrome APECED.

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is caused by mutations in the Autoimmune Regulator (AIRE) gene, which impair the thymic negative selection of self-reactive T-cells and underlie the development of autoimmunity that targets multiple endocrine and non-endocrine tissues. Beyond autoimmunity, APECED features heightened susceptibility to certain specific infections, which is mediated by anti-cytokine autoantibodies and/or T-cell driven autoimmune tissue injury. These include the 'signature' APECED infection chronic mucocutaneous candidiasis (CMC), but also life-threatening coronavirus disease 2019 (COVID-19) pneumonia, bronchiectasis-associated bacterial pneumonia, and sepsis by encapsulated bacteria. Here we discuss the expanding understanding of the immunological mechanisms that contribute to infection susceptibility in this prototypic syndrome of impaired central tolerance, which provide the foundation for devising improved diagnostic and therapeutic strategies for affected patients.

Common Child and Adolescent Cutaneous Infestations and Fungal Infections.

Cutaneous infections and infestations are common among children and adolescents. Ectoparasitic infestations affect individuals across the globe. Head lice, body lice, scabies, and infestations with bed bugs are seen in individuals who reside in both resource poor areas and in developed countries. Superficial cutaneous and mucosal candida infections occur throughout the life cycle. Dermatophyte infections of keratin-containing skin and skin structures result in tinea capitis (scalp), tinea corporis (body), tinea pedis (foot), and tinea unguium (nails). Less frequent endemic fungal infections such as blastomycosis, coccidiodomycosis, and histoplasmosis may present with skin findings. This article will describe the epidemiology and transmission of these conditions as well as their clinical manifestations. The approach to diagnosis will be addressed as well as primary prevention and current therapies.

[Nail susceptibility to fungal infection in patients with type 1 and 2 diabetes under long term poor glycaemia control]. / Podatnosc paznokci na zakazenie grzybicze u chorych na cukrzyce typu 1 i 2 z dlugoterminowa zla kontrola glikemii.

Onychomycosis is a common disorder in adults. Its prevalence increases also in diabetics. The objective of the study was: 1) evaluation of finger and toe nail susceptibility to Candida albicans and Trichophyton mentagrophytes infection in patients with type 1 and type 2 diabetes with long term glycaemia under poor control as compared with healthy persons, and 2) checking whether or not various aetiology of type 1 and type 2 diabetes may influence the intensity of fungal nail infection. The materials comprised finger and toe nails sampled from 26 patients with type 1 diabetes (20 females and 6 males at average age 51 +/- 10 years), 25 patients with type 2 diabetes (17 females and 8 males at average age 58 +/- 4 years). Twenty two healthy volunteers (18 females and 4 males at average age 47 +/- 14 years) served as controls. All of the diabetics (except one with type 1 diabetes and four with type 2 diabetes) had increased fasting glycaemia; moreover, all of them had poor controlled long term glycaemia because the concentration of glycated haemoglobin HbAlc exceeded 7.5%. The patients with type 1 diabetes were treated with insulin while those with type 2 diabetes with diet only (one person), with gliclazide (sixteen persons), with glimepirid (five persons), and with metformin (four persons). Enhanced fingernail susceptibility to Candida albicans infection was detected in 38.5% of the patients with type 1 diabetes, in 28% of those with type 2 diabetes, and in 22.7% of the controls. Intensive toenail infection was found in 34.6%, 20%, and 22.7% respectively. Enhanced fingernail susceptibility to Trichophyton mentagrophytes infection was found in 30.8% of the patients with type 1 diabetes, in 48% of those with type 2 diabetes, and in 4.54% of the controls while intensive toenail infection in 15.4%, 20%, and 18,2% respectively. Statistical analysis gave evidence of statistically significant higher susceptibility to infection of finger and toe nails with T. mentagrophytes but not with C. albicans in both type 1 and type 2 diabetics, as compared with the controls. In the diabetics, no significant correlation was found between the susceptibility to C. albicans and T. mentagrophytes infection and the age of the patients, metabolic diabetes control (evaluated on the basis of serum glucose level and blood HbAlc concentration), as well as the duration of diabetes.

Preventive effects of topical washing with miconazole nitrate-containing soap to diaper candidiasis in hospitalized elderly patients: A prospective, double-blind, placebo-controlled study.

The objective of the present randomized, double-blind trial was to evaluate the efficacy and safety of daily washing with miconazole nitrate-containing soap for candidiasis at diaper-covered sites in elderly subjects under long-term inpatient care. To confirm the onset and disappearance of candidiasis, we microscopically evaluated the existence of the pseudohyphae and/or blastoconidia of Candida spp. We enrolled 75 elderly patients who wore diapers all day in the hospital or nursing home. Patients were randomly assigned to receive treatment with either miconazole soap or miconazole-free placebo soap, and 28 patients in the miconazole group and 27 patients in the placebo group were followed for 4 weeks. Although washing with miconazole soap did not affect the frequency of pseudohyphae/blastoconidia-positive patients, it significantly inhibited the positive conversion of pseudohyphae/blastoconidia compared with the placebo group. As a result, the frequency of patients positive for pseudohyphae/blastoconidia was significantly lower in the miconazole group than in the control group at 4 weeks (17.9% vs 44.4%). Clinically apparent diaper candidiasis did not develop in either group. Washing with miconazole soap was a significant independent factor for reducing the cases positive for pseudohyphae/blastoconidia, while diarrhea and heart failure were significant factors associated with an increase in the positive rate at the end-point. Severe adverse effects were not found in any patients. Thus, washing with miconazole soap is well-tolerated and can inhibit the positive conversion of Candida in patients wearing diapers. Therefore, maintenance of genital hygiene using this soap may prophylactically decrease the overall prevalence of patients with diaper candidiasis.

[Etiological agents of dermatomycoses isolated in a hospital of Santa Fe City, Argentina]. / Agentes etiológicos de micosis superficiales aislados en un hospital de Santa Fe, Argentina.

Superficial mycoses are limited to skin, hair, nails and mucous membranes. The most common etiological agents are dermatophytes and yeasts of Candida genus. The aim of this work was to know the etiological agents of dermatomycoses and their clinical presentation. Were analized 2073 samples of skin, hair, nails, and oral mucous membranes obtained from 1817 patients who attended the Microbiology Branch of the Central Laboratory at Dr. J. M. Cullen Hospital, since September 1999 to September 2003. The samples were examined and identified according to the localization and type of lesion. Out of the total samples 55.67% were positive; 63% were recovered from females, and 37% from males. The most common localization was the skin. Trichophyton rubrum was the most frequent dermatophyte, and among yeasts, Candida albicans was the prevalent species. Fourteen non-dermatophytic fungi (Fusarium spp. and Aspergillus spp.) were isolated, and considered emergent pathogens from superficial mycoses.

SIXTEEN YEARS OF DERMATOMYCOSIS CAUSED BY Candida spp. IN THE METROPOLITAN AREA OF PORTO ALEGRE, SOUTHERN BRAZIL.

The yeasts of the genus Candida infect skin, nails, and mucous membranes of the gastrointestinal and the genitourinary tract. The aim of this study was to determine the prevalence of dermatomycoses caused by Candida spp., and their etiological aspects in the metropolitan area of Porto Alegre, Brazil. A retrospective study with data obtained from tertiary hospital patients, from 1996 to 2011, was performed. The analyzed parameters were date, age, gender, ethnicity, anatomical region of lesions, and the direct examination results. For all the statistical analyses, a = 0.05 was considered. Among positive results in the direct mycological examination, 12.5% of the total of 4,815 cases were positive for Candida spp. The angular coefficient (B) was -0.7%/ year, showing a decrease over the years. The genus Candida was more prevalent in women (15.9% of women versus 5.84% of men), and in addition, women were older than men (54 versus 47 years old, respectively). There was no difference between ethnic groups. The nails were more affected than the skin, with 80.37% of the infections in the nails (72.9% in fingernails and 7.47% in toenails). Our study corroborates the literature regarding the preference for gender, age, and place of injury. Moreover, we found a decrease in infection over the studied period.

Epidemiological study of Candida species in cutaneous candidiasis based on PCR using a primer mix specific for the DNA topoisomerase II gene.

BACKGROUND: We have previously reported a PCR-based identification system for pathogenic fungi by targeting the DNA topoisomerase II gene, in which primer mixes specific for this gene were used for the PCR amplifications. OBJECTIVE: To test the potential of the PCR using primer mix that is specific for the DNA topoisomerase II gene and are designated as PsVIc, for rapid identification of Candida species involved in cutaneous candidiasis, and to define the relation between Candida species and the infection lesion. METHODS: Scales from 48 patients with cutaneous candidiasis were cultured on GYEP agar plates, and the genomic DNAs were purified from the colonies and used as DNA templates for PCR amplifications. Candida was identified as individual species based on the sizes of the PCR products generated in the PCR amplifications using PsVlc. RESULTS: Four Candida species (five genotypes; Candida albicans, Candida glabrata, Candida parapsilosis I, Candida parapsilosis II and Candida tropicalis II) were identified in the patients' scales. In 19 of the patients (39.6%), multiple PCR products (two or three bands) were amplified in a DNA sample, especially derived from scales at the groin of bed-ridden older patients using napkins. CONCLUSION: The PCR-based identification using the primer mix was useful for an epidemiological study of Candida species in cutaneous candidiasis.

Diaper dermatitis: a review and brief survey of eruptions of the diaper area.

Eruptions in the diaper area are the most common dermatologic problem in infancy. Such eruptions can be subdivided into primary diaper dermatitis, an acute inflammation of the skin in the diaper area with an ill-defined and multifactorial etiology, and secondary diaper dermatitis, a term which encompasses eruptions in the diaper area with defined etiologies. The most important factors in the development of primary diaper dermatitis are: (i) water/moisture, (ii) friction, (iii) urine, (iv) feces, and (v) microorganisms (sometimes). Possible treatments include minimizing diaper use and using disposable diapers, barrier creams, mild topical cortisones, and antifungal agents. A variety of other inflammatory and infectious processes can occur in the diaper area and an awareness of these secondary types of diaper dermatitis aids in the accurate diagnosis and treatment of patients.

Fungal infection of the feet in soccer players and non-athlete individuals.

This study was conducted to evaluate the occurrence of mycoses affecting the feet of soccer players and to compare this results with those in non-athlete individuals of the same age and sex. Initial evaluation consisted of a dermatological examination of the foot in 22 Chinese athletes, 83 Brazilian athletes and 24 Brazilian non-athletes. Scales of plantar skin, interdigital and subungual areas of the foot were collected for mycological examination (direct and culture). Nail clippings were obtained for histopathologic analysis. Tinea pedis was diagnosed more frequently among the non-athlete individuals. None of the Chinese athletes had tinea pedis alone. However, in this group onychomycosis was frequently higher when compared to the other groups. The fungal microbiota comprised Trichophyton rubrum (40%), Trichophyton mentagrophytes (36.4%) and Candida spp (20%). Candida spp was isolated only from Brazilian athletes. Results obtained with KOH wet mounts agreed with the results obtained in culture and with histopathologic examinations (50.5% vs 40.9%). The frequency of tinea pedis among soccer players was lower than the other groups in this study, possibly due to health education and professional feet care.

Superficial fungal infections seen at the National Skin Centre, Singapore.

UNLABELLED: Cutaneous fungal infections are common in Singapore. The National Skin Centre is a tertiary referral centre for dermatological diseases in the country, and sees more than 2,500 cases of superficial fungal infections annually. AIM: This study analyses data collated from the centre's medical record office as well as fungal culture results from the mycology laboratory. RESULTS: From 1999 to 2003, there were a total of 12,903 cases of superficial fungal infections seen at the centre. The majority of patients (n=9335) (72.3%) were males. The most common infection was tinea pedis (n=3516) (27.3%), followed by pityriasis versicolor (n=3249) (25.2%) and tinea cruris (n=1745) (13.5%). Candidal infections were also common (n=1430), the majority of which were cases of candidal intertrigo. There were very few cases of tinea capitis, which is uncommon in Singapore. The number of cases of onychomycosis has shown a rising trend over the past 5 years. Trichophyton rubrum was the most prevalent fungal pathogen isolated from all cases of superficial fungal infections of the skin, except for tinea pedis, where Trichophyton interdigitale was the most frequently isolated organism. Dermatophytes remain the most commonly isolated fungal pathogens isolated in toenail onychomycosis, whilst Candida species accounted for the majority of isolates in fingernail onychomycosis. CONCLUSION: Current epidemiologic trends of superficial fungal infections in Singapore show some similarities to recent studies from the United Kingdom and United States.

[2011 Epidemiological Survey of Dermatomycoses in Japan].

An epidemiological survey of dermatomycoses and their causative fungus flora in Japan for 2011 was conducted in accordance with methods and criteria of the past four surveys. The survey covered a total number of 36,052 outpatients who visited 12 dermatological clinics throughout Japan. The results were as follows. 1）Dermatophytosis was the most prevalent cutaneous fungal infection (2,980 cases) seen in these clinics, followed by candidiasis (378 cases) and then Malassezia infections (152 cases). 2）Among dermatophytoses, tinea pedis was the most frequent (1,930 cases : male, 980 ; female, 950), then in decreasing order, tinea unguium (780 cases : male, 409 ; female, 371), tinea corporis (203 cases : male, 132 ; female, 71), tinea cruris (112 cases : male, 86 ; female, 26), tinea manuum (43 cases : male, 25 ; female, 18), and tinea capitis including kerion (16 cases : male, 13 ; female, 3). 3）Tinea pedis and tinea unguium were seen to increase in the summer season and occur mostly among the aged population. Compared to the last survey, by clinical form, there was a marked decrease in dermatophytosis patients. 4）As the causative dermatophyte species, Trichophyton rubrum was the most frequently isolated at about 80 % among all dermatophyte infections excluding tinea capitis. T. mentagrophytes was about 10 %. Microsporum canis was isolated in five cases. M. gypseum was isolated in three cases, and Epidermophyton floccosum was isolated in only one case. T. tonsurans was isolated in 13 cases. 5）Cutaneous candidiasis was seen in 378 cases (305, male ; 537, female). Intertrigo (298 cases) was the most frequent clinical form, followed by diaporcandidiasis (79 cases), erosion interdigitalis (62 cases), genital candidiasis (46 cases). 6）Tinea versicolor was seen in 97 cases. Malassezia folliculitis was isolated in 55 cases.