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Bishnoi A, Narang T, Das L, Chatterjee D, Singh V, Shah S, Shah R, Dogra S. Itraconazole-induced adrenal insufficiency in a patient with exogenous Cushing's syndrome. Indian J Dermatol Venereol Leprol 2024; 90:703. [PMID: 38031683 DOI: 10.25259/ijdvl_295_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/30/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Anuradha Bishnoi
- Department of Dermatology, Venereology and Leprology, PGIMER, Chandigarh, India
| | - Tarun Narang
- Department of Dermatology, Venereology and Leprology, PGIMER, Chandigarh, India
| | - Liza Das
- Department of Endocrinology, PGIMER, Chandigarh, India
| | | | - Vaneet Singh
- Department of Ophthalmology, Chesterfield Royal Hospital, Calow, Chesterfield, Derbyshire, United Kingdom
| | - Shikha Shah
- Department of Dermatology, Venereology and Leprology, PGIMER, Chandigarh, India
| | - Ravi Shah
- Department of Endocrinology, PGIMER, Chandigarh, India
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leprology, PGIMER, Chandigarh, India
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Khurana A, Sharath S, Sardana K, Chowdhary A. Clinico-mycological and therapeutic updates on cutaneous dermatophytic infections in the era of Trichophyton indotineae. J Am Acad Dermatol 2024; 91:315-323. [PMID: 38574764 DOI: 10.1016/j.jaad.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 04/06/2024]
Abstract
Trichophyton indotineae has emerged as a novel dermatophyte species resulting in treatment recalcitrant skin infections. While the earliest reports came from India, T. indotineae has now spread to many parts of the world and is rapidly becoming a global health concern. Accurate identification of T. indotineae requires elaborate mycological investigations which is beyond the domain of routine microbiology testing. Extensive, non-inflammatory and atypical presentations are commonly seen with this novel species. T. indotineae shows an alarmingly high rate of mutations in the squalene epoxidase gene leading to lowered in vitro susceptibility to terbinafine. This has also translated into a lowered clinical response and requirement of a higher dose and much longer durations of treatment with the drug. Although the species remains largely susceptible to itraconazole, prolonged treatment durations are required to achieve cure with itraconazole. Fluconazole and griseofulvin do not have satisfactory in vitro or clinical activity. Apart from requirement of prolonged treatment durations, relapse postsuccessful treatment is a distressing and yet unexplained consequence of this "species-shift." Use of third generation azoles and combinations of systemic antifungals is unwarranted as both have not demonstrated clear superiority over itraconazole given alone, and the former is an important class of drugs for invasive mycoses.
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Affiliation(s)
- Ananta Khurana
- Department of Dermatology, Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India.
| | - Savitha Sharath
- Department of Dermatology, Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Kabir Sardana
- Department of Dermatology, Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Anuradha Chowdhary
- Medical Mycology Unit, Department of Microbiology, National Reference Laboratory for Antimicrobial Resistance in Fungal Pathogens, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi, India
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Shaw D, Dogra S, Singh S, Shah S, Narang T, Kaur H, Walia K, Ghosh A, Handa S, Chakrabarti A, Rudramurthy SM. Prolonged treatment of dermatophytosis caused by Trichophyton indotinea with terbinafine or itraconazole impacts better outcomes irrespective of mutation in the squalene epoxidase gene. Mycoses 2024; 67:e13778. [PMID: 39086026 DOI: 10.1111/myc.13778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 07/18/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Over the past decades, the increasing incidence of recurrent dermatophytosis associated with terbinafine-resistant Trichophyton has posed a serious challenge in management of dermatophytosis. Independent reports of failure of treatment and high minimum inhibitory concentrations (MIC) of antifungals are available, but data correlating MIC and clinical outcomes is still sparse. Therefore, the present study was conducted to evaluate the outcomes of systemic treatment of dermatophytosis and its correlation with MIC of the etiological agents isolated from such patients. METHODS Retrospective analysis of 587 consecutive patients with dermatophytosis was done from March 2017 to March 2019. Demographic and clinical details of the patients were noted, along with the results of direct microscopy and fungal culture. The isolates were identified by sequencing the internal transcribed spacer region of rDNA. Antifungal susceptibility testing was performed following the CLSI M38 protocol. Mutation in the squalene epoxidase (SE) gene was detected by DNA sequencing and ARMS-PCR. Based on the culture-positivity and prescribed systemic antifungal, patients were categorised into Group I culture-positive cases treated with systemic terbinafine and Group II culture-positive cases treated with systemic itraconazole, each for a total period of 12 weeks. RESULTS In the present study, 477 (81.39%) were culture-positive; however, 12 weeks follow-up was available for 294 patients (Group I-157 and Group II-137) who were included for statistical analysis. In both groups [Group I-37/63 (51.4%) and Group II-14/54 (58.3%)], a better cure rate was observed if the initiation of therapy was performed within <6 months of illness. Treatment outcome revealed that if therapy was extended for 8-12 weeks, the odds of cure rate are significantly better (p < .001) with either itraconazole (Odd Ratio-15.5) or terbinafine (Odd Ratio-4.34). Higher MICs for terbinafine were noted in 41 cases (cured-18 and uncured-23) in Group I and 39 cases (cured-16 and uncured-23) in Group II. From cured (Group I-17/18; 94.4% and Group II-14/16; 87.5%) and uncured (Group I-20/23; 86.9% and Group II-21/23; 91.3%) cases had F397L mutation in the SE gene. No significant difference in cure rate was observed in patients with Trichophyton spp. having terbinafine MIC ≥ 1or <1 μg/mL (Group I-p = .712 and Group II-p = .69). CONCLUSION This study revealed that prolonging terbinafine or itraconazole therapy for beyond 8 weeks rather than the standard 4 weeks significantly increases the cure rate. Moreover, no correlation has been observed between antifungal susceptibility and clinical outcomes. The MIC remains the primary parameter for defining antifungal activity and predicting the potency of antifungal agents against specific fungi. However, predicting therapeutic success based solely on the MIC of a fungal strain is not always reliable, as studies have shown a poor correlation between in vitro data and in vivo outcomes. To address this issue, further correlation of antifungal susceptibility testing (AFST) data with clinical outcomes and therapeutic drug monitoring is needed. It also highlights that initiation of the treatment within <6 months of illness increases cure rates and reduces recurrence. Extensive research is warranted to establish a better treatment regime for dermatophytosis.
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Affiliation(s)
- Dipika Shaw
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Department of Microbiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India
| | - Sunil Dogra
- Department of Dermatology, Venerology & Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shreya Singh
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shikha Shah
- Department of Dermatology, Venerology & Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Tarun Narang
- Department of Dermatology, Venerology & Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harsimran Kaur
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kamini Walia
- Indian Council of Medical Research, New Delhi, India
| | - Anup Ghosh
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjeev Handa
- Department of Dermatology, Venerology & Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Baron A, Hamane S, Gits-Muselli M, Legendre L, Benderdouche M, Mingui A, Ghelfenstein-Ferreira T, Alanio A, Dellière S. Dual quantitative PCR assays for the rapid detection of Trichophyton indotineae from clinical samples. Med Mycol 2024; 62:myae067. [PMID: 38977869 DOI: 10.1093/mmy/myae067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 06/24/2024] [Accepted: 07/05/2024] [Indexed: 07/10/2024] Open
Abstract
Trichophyton indotineae is an emerging species of the Trichophyton mentagrophytes complex (TMC), responsible for an epidemic of widespread hairless skin infections that is frequently (50-70%) resistant to terbinafine. In order to initiate appropriate treatment as quickly as possible without waiting for culture positivity (10-15 days) and molecular identification from the strain, we developed a dual quantitative PCR (qPCR) for the direct detection of T. indotineae in clinical samples. We first designed a T. indotineae-specific qPCR assay (TI-qPCR) targeting a single specific polymorphism in the internal transcribed spacer region. Although none of the 94 non-dermatophyte and 7 dermatophyte species were amplified, this TI-qPCR allowed amplification of other TMC species at a lower yield. With equal amounts (0.1 ng) of DNA per reaction, the mean quantitative cycle (Cq) values for T. indotineae and non-indotineae TMC were 27.9 (±0.1) and 38.9 (±0.3), respectively. Therefore, we normalized this assay against a previously validated pan-dermatophyte qPCR assay (PD-qPCR) and relied on the ΔCq [(TI-qPCR) - (PD-qPCR)] to identify T. indotineae versus other TMC species. Dual assay was validated using 86 clinical samples of culture-confirmed T. indotinea and 19 non-indotineae TMC cases. The mean ΔCq for non-indotineae TMC was 9.6 ± 2.7, whereas the ΔCq for T. indotinea was -1.46 ± 2.1 (P < .001). Setting the ΔCq at 4.5 as a cutoff value resulted in 100% specificity for the detection of T. indotineae. This dual qPCR assay quickly detects T. indotineae from skin scrapings, aiding in early diagnosis and treatment for patients with suspected infection.
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Affiliation(s)
- Audrey Baron
- Laboratoire de parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, F-75010 Paris, France
| | - Samia Hamane
- Laboratoire de parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, F-75010 Paris, France
| | - Maud Gits-Muselli
- Laboratoire de microbiologie, AP-HP, Hôpital Robert-Debré, F-75019 Paris, France
| | - Lina Legendre
- Laboratoire de parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, F-75010 Paris, France
| | - Mazouz Benderdouche
- Laboratoire de parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, F-75010 Paris, France
| | - Anselme Mingui
- Laboratoire de parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, F-75010 Paris, France
| | - Théo Ghelfenstein-Ferreira
- Laboratoire de parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, F-75010 Paris, France
- Institut Pasteur, Université de Paris Cité, CNRMA, Unité de Mycologie Translationnelle, F-75015 Paris, France
| | - Alexandre Alanio
- Laboratoire de parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, F-75010 Paris, France
- Institut Pasteur, Université de Paris Cité, CNRMA, Unité de Mycologie Translationnelle, F-75015 Paris, France
| | - Sarah Dellière
- Laboratoire de parasitologie-mycologie, AP-HP, Hôpital Saint-Louis, F-75010 Paris, France
- Institut Pasteur, Université de Paris Cité, Unité Immunobiologie d'Aspergillus, F-75015 Paris, France
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Sonego B, Corio A, Mazzoletti V, Zerbato V, Benini A, di Meo N, Zalaudek I, Stinco G, Errichetti E, Zelin E. Trichophyton indotineae, an Emerging Drug-Resistant Dermatophyte: A Review of the Treatment Options. J Clin Med 2024; 13:3558. [PMID: 38930086 PMCID: PMC11204959 DOI: 10.3390/jcm13123558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 06/11/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Dermatophytosis is a prevalent superficial infection caused by filamentous fungi, primarily affecting the skin and/or its appendages. In recent years, there has been a notable increase in mycotic strains resistant to standard antifungal therapies, including Trichophyton indotineae, a dermatophyte of the Trichophyton mentagrophytes complex. This review aims to provide a comprehensive overview of the treatment options for T. indotineae, elucidating their effectiveness in managing this challenging mycotic infection. Methods: For this review, a search was conducted in the PubMed, Scopus, Web of Science, Embase, and Google Scholar databases, encompassing all published data until March 2024. English-language articles detailing therapy outcomes for patients confirmed to be affected by T. indotineae, identified through molecular analysis, were included. Results: Itraconazole was shown to be a good therapeutic choice, particularly when administered at a dosage of 200 mg/day for 1-12 weeks. Voriconazole was also demonstrated to be effective, while terbinafine exhibited a reduced response rate. Griseofulvin and fluconazole, on the other hand, were found to be ineffective. Although topical treatments were mostly ineffective when used alone, they showed promising results when used in combination with systemic therapy. Mutational status was associated with different profiles of treatment response, suggesting the need for a more tailored approach. Conclusions: When managing T. indotineae infections, it is necessary to optimize therapy to mitigate resistances and relapse. Combining in vitro antifungal susceptibility testing with mutational analysis could be a promising strategy in refining treatment selection.
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Affiliation(s)
- Benedetta Sonego
- Dermatology Clinic, Maggiore Hospital, University of Trieste, 34125 Trieste, Italy; (B.S.); (A.C.); (A.B.); (N.d.M.); (I.Z.)
| | - Andrea Corio
- Dermatology Clinic, Maggiore Hospital, University of Trieste, 34125 Trieste, Italy; (B.S.); (A.C.); (A.B.); (N.d.M.); (I.Z.)
| | - Vanessa Mazzoletti
- Institute of Dermatology, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy;
| | - Verena Zerbato
- Infectious Diseases Unit, Trieste University Hospital (ASUGI), 34125 Trieste, Italy;
| | - Alessandro Benini
- Dermatology Clinic, Maggiore Hospital, University of Trieste, 34125 Trieste, Italy; (B.S.); (A.C.); (A.B.); (N.d.M.); (I.Z.)
| | - Nicola di Meo
- Dermatology Clinic, Maggiore Hospital, University of Trieste, 34125 Trieste, Italy; (B.S.); (A.C.); (A.B.); (N.d.M.); (I.Z.)
| | - Iris Zalaudek
- Dermatology Clinic, Maggiore Hospital, University of Trieste, 34125 Trieste, Italy; (B.S.); (A.C.); (A.B.); (N.d.M.); (I.Z.)
| | - Giuseppe Stinco
- Institute of Dermatology, Department of Medicine, University of Udine, 33100 Udine, Italy; (G.S.); (E.E.)
| | - Enzo Errichetti
- Institute of Dermatology, Department of Medicine, University of Udine, 33100 Udine, Italy; (G.S.); (E.E.)
| | - Enrico Zelin
- Institute of Dermatology, Santa Maria della Misericordia University Hospital, 33100 Udine, Italy;
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Haghani I, Babaie M, Hoseinnejad A, Rezaei-Matehkolaei A, Mofarrah R, Yahyazadeh Z, Kermani F, Javidnia J, Shokohi T, Azish M, Kamyab Hesari K, Saeedi M, Ghasemi Z, Khojasteh S, Hajheydari Z, Mosayebi E, Valadan R, Seyedmousavi S, Abastabar M, Hedayati MT. High Prevalence of Terbinafine Resistance Among Trichophyton mentagrophytes/T. interdigitale Species Complex, a Cross-Sectional Study from 2021 to 2022 in Northern Parts of Iran. Mycopathologia 2024; 189:52. [PMID: 38864945 DOI: 10.1007/s11046-024-00855-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/18/2024] [Indexed: 06/13/2024]
Abstract
Treatment-resistant dermatophytosis caused by the members of the Trichophyton mentagrophytes/Trichophyton interdigitale species group (TMTISG) is increasing worldwide. We aimed to determine the prevalence of TMTISG in patients with dermatophytosis in two centers from north of Iran and detect the possible mutations in the squalene epoxidase (SQLE) gene in relevant terbinafine (TRB) resistant pathogenic isolates. From November 2021 to December 2022, 1960 patients suspected to dermatophytosis and referred to two mycology referral laboratories in the north of Iran were included in the study. Identification of all dermatophyte isolates was confirmed by RFLP of rDNA internal transcribed spacer (ITS) regions. Antifungal susceptibility testing against five common antifungals using the CLSI-M38-A3 protocol was performed. The TMTISG isolates resistant to TRB, were further analyzed to determine the possible mutations in the SQLE gene. Totally, 647 cases (33%) were positive for dermatophytosis of which 280 cases (43.3%) were identified as members of TMTISG. These were more frequently isolated from tinea corporis 131 (44.56%) and tinea cruris 116 (39.46%). Of 280 TMTISG isolates, 40 (14.3%) were resistant to TRB (MIC ≥ 4 µg/mL), all found to be T. indotineae in ITS sequencing. In SQLE sequencing 34 (85%) of TRB-resistant isolates had coincident mutations of Phe397Leu and Ala448Thr whereas four and two isolates had single mutations of Phe397Leu and Leu393Ser, respectively. Overall, the resistance of Iranian TMTISG isolates to TRB greatly occurred by a mutation of Phe397Leu in the SQLE gene as alone or in combination with Ala448Thr. Nevertheless, for the occurrence of in vitro resistance, only the presence of Phe397Leu mutation seems to be decisive.
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Affiliation(s)
- Iman Haghani
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Maryam Babaie
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Akbar Hoseinnejad
- Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Department of Medical Mycology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Rezaei-Matehkolaei
- Department of Medical Mycology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ramin Mofarrah
- Department of Dermatology, Faculty of Medicine, Sari Branch, Islamic Azad University, Sari, Iran
| | - Zahra Yahyazadeh
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Firoozeh Kermani
- Department of Parasitology and Mycology, Infectious Diseases and Tropical Medicine Research Center, Health Research Center, School of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Javad Javidnia
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Tahereh Shokohi
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Maryam Azish
- Department of Parasitology and Medical Mycology, School of Medicine, Dezful University of Medical Sciences, Dezful, Iran
| | - Kambiz Kamyab Hesari
- Department of Dermatopathology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Majid Saeedi
- Department of Pharmaceutics, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Zeinab Ghasemi
- Department of Dermatopathology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shaghayegh Khojasteh
- Molecular Medicine Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, 7916613885, Iran
| | - Zohreh Hajheydari
- Department of Dermatology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Elham Mosayebi
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Reza Valadan
- Molecular and Cell Biology Research Center (MCBRC), Mazandaran University of Medical Sciences, Sari, Iran
| | - Seyedmojtaba Seyedmousavi
- Microbiology Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Mahdi Abastabar
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran.
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
| | - Mohammad Taghi Hedayati
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran.
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
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Dellière S, Jabet A, Abdolrasouli A. Current and emerging issues in dermatophyte infections. PLoS Pathog 2024; 20:e1012258. [PMID: 38870096 PMCID: PMC11175395 DOI: 10.1371/journal.ppat.1012258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Affiliation(s)
- Sarah Dellière
- Service de Parasitologie-Mycologie, Hôpital Saint-Louis, AP-HP, Paris, France
- Institut Pasteur, Immunobiology of Aspergillus, Université Paris-Cité, Paris, France
| | - Arnaud Jabet
- Service de Parasitologie-Mycologie, Hôpital La Pitié-Salpêtrière, AP-HP, Paris, France
- Service de Parasitologie-Mycologie, Hôpital Saint-Antoine, AP-HP, Paris, France
- Institut Pierre Louis d’Epidémiologie et de Santé Publique, Sorbonne Université, Paris, France
| | - Alireza Abdolrasouli
- Department of Medical Microbiology, King’s College Hospital, London, United Kingdom
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
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Tamimi P, Fattahi M, Firooz A, Ghaderi A, Ayatollahi A, Nasiri Kashani M, Alkhen A. Recalcitrant dermatophyte infections: identification and risk factors. Int J Dermatol 2024. [PMID: 38712801 DOI: 10.1111/ijd.17145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/03/2024] [Accepted: 03/04/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Recalcitrant dermatophytosis is an emerging phenomenon that occurs worldwide, and Trichophyton indotineae is currently the prominent cause. MATERIALS AND METHODS Skin specimens from patients with tinea infection were obtained by scrubbing and then sectioned into three fragments. Two fragments were subjected to direct microscopic examination and culture, while the third portion was utilized in the PCR method. RESULTS Isolates were morphologically identified as Trichophyton mentagrophytes/interdigitale complex (n = 60 [83.33%]), Microsporum canis (n = 8 [11.11%]), Trichophyton rubrum (n = 3 [4.16%]), and Epidermophyton floccosum (n = 1 [1.38%]). Among 60 T. mentagrophytes complex isolates, 53 (88.33%) were classified as T. indotineae and seven as T. interdigitale genotype II. The disease duration was longer in the T. indotineae group (P = 0.035). Both Gradient PCR and skin-sampling methods yield similar results in terms of positive and negative cases (P = 1.0000). The time patients stopped their medication did not impact the positive case numbers (P = 0.803). Gender had no effects on the frequency (P = 0.699). Familial contamination, dermatologic disorder, and other underlying conditions did not differ in the two group infections (P > 0.05). Steroid usage is strongly associated with the emergence of tinea infection (P < 0.04). The duration of antifungal administration had a substantial effect on the emergence of resistant organisms (P = 0.05). CONCLUSIONS Steroid usage, T. indotineae involvement, and prolonged exposure to antifungals were the solid and influential factors in recalcitrant involvement. Regarding quick and suitable diagnosis and treatment, which is essential in preventing recalcitrant cases, we suggest that direct skin sample PCR can meet the demands.
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Affiliation(s)
- Pegah Tamimi
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsa Fattahi
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Firooz
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Aliasghar Ghaderi
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Azin Ayatollahi
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mansour Nasiri Kashani
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
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Saraswat A, Dogra S, Shenoy M, Verma S, K S, Ghate S, Ganjoo A, Aurangabadkar S, Tiwari A, Poojary S, Inamdar A, Majid I, Girdhar M, Shah B, Varma S, Ramamoorthy R, Dhoot D, Barkate H. Clinical Use of Super-Bioavailable Itraconazole for the Management of Dermatophytosis: Consensus Statement by Dermatologists from India via the Modified Delphi Technique. Dermatology 2024; 240:671-683. [PMID: 38697027 DOI: 10.1159/000538080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 02/26/2024] [Indexed: 05/04/2024] Open
Abstract
Super-bioavailable itraconazole (SB ITZ) overcomes the limitations of conventional itraconazole (CITZ) such as interindividual variability and reduced bioavailability. It has been approved for systemic mycoses in Australia and Europe as 50 mg and the USA as 65 mg and in India as 50 mg, 65 mg, 100 mg, and 130 mg. However, data on the ideal dose and duration of SB ITZ treatment in managing dermatophytosis are insufficient. This consensus discusses the suitability, dosage, duration of treatment, and relevance of using SB ITZ in managing dermatophytosis in different clinical scenarios. Sixteen dermatologists (>15 years of experience in the field and ≥2 years clinical experience with SB ITZ), formed the expert panel. A modified Delphi technique was employed, and a consensus was reached if the concordance in response was >75%. A total of 26 consensus statements were developed. The preferred dose of SB ITZ is 130 mg once daily and if not tolerated, 65 mg twice daily. The preferred duration for treating naïve dermatophytosis is 4-6 weeks and that for recalcitrant dermatophytosis is 6-8 weeks. Moreover, cure rates for dermatophytosis are a little better with SB ITZ than with CITZ with a similar safety profile as of CITZ. Better patient compliance and efficacy are associated with SB ITZ than with CITZ, even in patients with comorbidities and special needs such as patients with diabetes, extensive lesions, corticosteroid abuse, adolescents, and those on multiple drugs. Expert clinicians reported that the overall clinical experience with SB ITZ was better than that with CITZ.
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Affiliation(s)
- Abir Saraswat
- Department of Dermatology, Indushree Skin Clinic, Lucknow, India
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leprology Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Manjunath Shenoy
- Department of Dermatology, Yenepoya Medical College, Mangalore, India
| | - Shyam Verma
- Department of Dermatology, Nirvan Skin Clinic, Vadodara, India
| | - Seetharam K
- Department of Dermatology, GSL Medical College, Rajamundry, India
| | - Sunil Ghate
- Department of Dermatology, Dr Ghate's Skin, Hair and LASER Centre, Mumbai, India
| | - Anil Ganjoo
- Department of Dermatology, Skinnovation Clinics, New Delhi, India
| | - Sanjeev Aurangabadkar
- Department of Dermatology, Dr. Aurangabadkar's Skin and Laser Clinics, Hyderabad, India
| | - Anurag Tiwari
- Department of Dermatology, Center for Skin Diseases and Laser Treatment, Bhopal, India
| | - Shital Poojary
- Department of Dermatology, K J Somaiya Medical College, Mumbai, India
| | - Arun Inamdar
- Department of Dermatology, Sri B M Patil Medical College, BLDE Deemed University, Vijayapur, India
| | - Imran Majid
- Department of Dermatology, Cutis Institute of Dermatology, Srinagar, India
| | - Mukesh Girdhar
- Department of Dermatology, Max Super Specialty Hospital, Ppg, Delhi, India
| | - Bela Shah
- Department of Dermatology, BJ Medical College and Civil Hospital, Ahmedabad, India
| | - Sachin Varma
- Department of Dermatology, Skinvita Clinic, Kolkata, India
| | | | - Dhiraj Dhoot
- Department of Global Medical Affairs, Glenmark Pharmaceuticals Ltd., Mumbai, India
| | - Hanmant Barkate
- Department of Global Medical Affairs, Glenmark Pharmaceuticals Ltd., Mumbai, India
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Hill RC, Caplan AS, Elewski B, Gold JAW, Lockhart SR, Smith DJ, Lipner SR. Expert Panel Review of Skin and Hair Dermatophytoses in an Era of Antifungal Resistance. Am J Clin Dermatol 2024; 25:359-389. [PMID: 38494575 PMCID: PMC11201321 DOI: 10.1007/s40257-024-00848-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/19/2024]
Abstract
Dermatophytoses are fungal infections of the skin, hair, and nails that affect approximately 25% of the global population. Occlusive clothing, living in a hot humid environment, poor hygiene, proximity to animals, and crowded living conditions are important risk factors. Dermatophyte infections are named for the anatomic area they infect, and include tinea corporis, cruris, capitis, barbae, faciei, pedis, and manuum. Tinea incognito describes steroid-modified tinea. In some patients, especially those who are immunosuppressed or who have a history of corticosteroid use, dermatophyte infections may spread to involve extensive skin areas, and, in rare cases, may extend to the dermis and hair follicle. Over the past decade, dermatophytoses cases not responding to standard of care therapy have been increasingly reported. These cases are especially prevalent in the Indian subcontinent, and Trichophyton indotineae has been identified as the causative species, generating concern regarding resistance to available antifungal therapies. Antifungal-resistant dermatophyte infections have been recently recognized in the United States. Antifungal resistance is now a global health concern. When feasible, mycological confirmation before starting treatment is considered best practice. To curb antifungal-resistant infections, it is necessary for physicians to maintain a high index of suspicion for resistant dermatophyte infections coupled with antifungal stewardship efforts. Furthermore, by forging partnerships with federal agencies, state and local public health agencies, professional societies, and academic institutions, dermatologists can lead efforts to prevent the spread of antifungal-resistant dermatophytes.
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Affiliation(s)
| | - Avrom S Caplan
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, NY, USA
| | - Boni Elewski
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeremy A W Gold
- Centers for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, USA
| | - Shawn R Lockhart
- Centers for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, USA
| | - Dallas J Smith
- Centers for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, 1305 York Avenue, New York, NY, 10021, USA.
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Kaur T, Bassan MS, Bisht M, Kumar N, Saini P, Hazarika N. Hypothalamus-pituitary-adrenal axis (HPA axis) suppression with inappropriate use of steroids in recalcitrant dermatophytosis - A cross-sectional study. J Family Med Prim Care 2024; 13:2026-2031. [PMID: 38948600 PMCID: PMC11213414 DOI: 10.4103/jfmpc.jfmpc_1330_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 12/04/2023] [Accepted: 12/08/2023] [Indexed: 07/02/2024] Open
Abstract
Background Improper use of over-the-counter (OTC) steroid medication has been linked to recalcitrant dermatophytosis. There is proven evidence of HPA axis suppression by the use of long-term oral steroids. This study aims to determine the prevalence and pattern of inappropriate OTC steroid use and its effects on the hypothalamus-pituitary-adrenal (HPA) axis in adults with recalcitrant dermatophytosis. Materials and Methods This cross-sectional study of 2 months was conducted in a hospital setting and included patients of recalcitrant dermatophytosis with a history of OTC steroid use. Clinico-demographic details and basal serum cortisol levels were recorded in all and analyzed. Result Of a total of 103 patients, 59.22% (n = 61/103) were males, and the mean duration of steroid abuse was 17.78 months. About 48.54% (n = 50/103), 3.88% (n = 4/103), and 47.57% (n = 49/103) patients reported the use of topical steroids, oral steroids, and both oral and topical steroids, respectively. Among all the topical steroid users (n = 99), clobetasol propionate 48.48% (n = 48/99), while among oral steroid users (n = 53), prednisolone 45.28% (n = 24/53) were the most commonly used agents, respectively. The morning serum cortisol levels (8-9 AM) were found to be decreased in 42.7% (n = 44/103), with a mean value of 44.28 ± 17.34 μg/dL. Conclusion Improper OTC steroid use in recalcitrant dermatophytosis leads to HPA axis suppression. This highlights the need for intervention from apex health officials.
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Affiliation(s)
- Tanureet Kaur
- Department of Pharmacology, AIIMS Rishikesh, Virbhadra Road, Rishikesh, Uttarakhand, India
| | - Manbir S. Bassan
- Department of Pharmacology, AIIMS Rishikesh, Virbhadra Road, Rishikesh, Uttarakhand, India
| | - Manisha Bisht
- Department of Pharmacology, AIIMS Rishikesh, Virbhadra Road, Rishikesh, Uttarakhand, India
| | - Nitish Kumar
- Department of Dermatology, AIIMS Rishikesh, Virbhadra Road, Rishikesh, Uttarakhand, India
| | - Poonam Saini
- Department of Dermatology, AIIMS Rishikesh, Virbhadra Road, Rishikesh, Uttarakhand, India
| | - Neirita Hazarika
- Department of Dermatology, AIIMS Rishikesh, Virbhadra Road, Rishikesh, Uttarakhand, India
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Rao MKP, Siddananjappa L, Sidana N, Deshmukh A, Diwari B, Podder I, Kumar S, Mittal R, Daultani P, Jaiswal A, Chinda M. Efficacy and Safety of Amorolfine Lotion 0.25% w/v Compared to Amorolfine Cream 0.25% w/w in Patients With Superficial Fungal Infections of the Skin: A Multi-center, Randomized, Open-Label, Active-Controlled, Non-inferiority Phase III Clinical Trial. Cureus 2024; 16:e60162. [PMID: 38868264 PMCID: PMC11166603 DOI: 10.7759/cureus.60162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Dermatophytosis, a major cause of superficial fungal infections, requires topical and systemic antifungals. Amorolfine, a morpholine derivative, is a new topical antifungal available in cream and lotion formulations. OBJECTIVE To evaluate the efficacy and safety of amorolfine lotion 0.25% compared to amorolfine cream 0.25% in patients with dermatophytosis. METHODS A multi-center randomized, two-arm, active-controlled, parallel, non-inferiority phase III clinical trial involving 284 dermatophytosis patients was conducted, with the test arm using amorolfine lotion and the reference arm using amorolfine cream. The study drugs were applied once daily in the evening for four weeks and patients were followed up for another two weeks. The primary endpoint was clinical cure, while secondary endpoints included mycological cure, composite cure, global efficacy assessment, and post-treatment relapse. Safety and tolerability were assessed. RESULTS Amongst the enrolled patients, 69.9% and 68.1% of patients had tinea corporis, while 30.1% and 31.9% had tinea cruris. The majority of patients in both groups (99.3% test and 97% reference) achieved a clinical cure at the end of treatment. Mycological cure was achieved by 98.6% and 96.3% respectively. A composite cure was achieved by 98.6% in the test arm versus 96.3% in the reference arm. A total of two AEs were reported in two (1.4%) patients in the test group and three AEs were reported in three (2.1%) patients in the reference group, all of the AEs were mild and resolved within three days without supportive medication. No severe adverse effects were reported in any of the study subjects. CONCLUSION Amorolfine lotion 0.25% w/v showed a non-inferior clinical, mycological, and composite cure in dermatophytosis patients, was well-tolerated, and had a similar safety profile to amorolfine cream 0.25% w/w.
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Affiliation(s)
- M Kanaka Prasad Rao
- General Medicine, Rajiv Gandhi Institute of Medical Sciences, Srikakulam, IND
| | | | - Neetu Sidana
- Dermatology, Apex Hospitals Pvt. Ltd., Jaipur, IND
| | - Ashish Deshmukh
- Dermatology, Mahatma Gandhi Mission Medical College, Aurangabad, IND
| | - Binayak Diwari
- Skin and Venereal Diseases, Hi-Tech Medical College and Hospital, Bhubaneswar, IND
| | - Indrasish Podder
- Dermatology and Veneriology, College of Medicine and Sagore Dutta Hospital, Kolkata, IND
| | - Surendra Kumar
- Skin, Venereal Diseases and Leprosy, Sawai Man Singh (SMS) Medical College and Hospital, Jaipur, IND
| | - Ravindra Mittal
- New Product Development, Zydus Healthcare Ltd., Ahmedabad, IND
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13
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Belmokhtar Z, Djaroud S, Matmour D, Merad Y. Atypical and Unpredictable Superficial Mycosis Presentations: A Narrative Review. J Fungi (Basel) 2024; 10:295. [PMID: 38667966 PMCID: PMC11051100 DOI: 10.3390/jof10040295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 04/07/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
While typically exhibiting characteristic features, fungal infections can sometimes present in an unusual context, having improbable localization (eyelid, face, or joint); mimicking other skin diseases such as eczema, psoriasis, or mycosis fungoides; and appearing with unexpected color, shape, or distribution. The emergence of such a challenging clinical picture is attributed to the complex interplay of host characteristics (hygiene and aging population), environment (climate change), advances in medical procedures, and agent factors (fungal resistance and species emergence). We aim to provide a better understanding of unusual epidemiological contexts and atypical manifestations of fungal superficial diseases, knowing that there is no pre-established clinical guide for these conditions. Thus, a literature examination was performed to provide a comprehensive analysis on rare and atypical superficial mycosis as well as an update on certain fungal clinical manifestations and their significance. The research and standard data extraction were performed using PubMed, Medline, Scopus, and EMBASE databases, and a total of 222 articles were identified. This review covers published research findings for the past six months.
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Affiliation(s)
- Zoubir Belmokhtar
- Department of Environmental Sciences, Faculty of Natural Sciences, Djilali Liabes University of Sidi-Bel-Abbes, Sidi Bel Abbes 22000, Algeria;
- Laboratory of Plant and Microbial Valorization (LP2VM), University of Science and Technology of Oran, Mohamed Boudiaf (USTOMB), Oran 31000, Algeria
| | - Samira Djaroud
- Department of Chemistry, Djilali Liabes University of Sidi-Bel-Abbes, Sidi Bel Abbes 22000, Algeria
| | - Derouicha Matmour
- Central Laboratory, Djilali Liabes University of Medicine of Sidi-Bel-Abbes, Sidi Bel Abbes 22000, Algeria
| | - Yassine Merad
- Central Laboratory, Djilali Liabes University of Medicine of Sidi-Bel-Abbes, Sidi Bel Abbes 22000, Algeria
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14
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Ojha AK, Albert V, Sharma S, Hallur V, Singh G, Pamidimukkala U, Singh KJ, Kaur H, Karuna T, Savio J, Nath R, Xess I, Gupta P, Shetty A, Das M. Pan-Indian Clinical Registry of Invasive Fungal Infections Among Patients in the Intensive Care Unit: Protocol for a Multicentric Prospective Study. JMIR Res Protoc 2024; 13:e54672. [PMID: 38363632 PMCID: PMC10907932 DOI: 10.2196/54672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Fungal infections are now a great public health threat, especially in those with underlying risk factors such as neutropenia, diabetes, high-dose steroid treatment, cancer chemotherapy, prolonged intensive care unit stay, and so on, which can lead to mycoses with higher mortality rates. The rates of these infections have been steadily increasing over the past 2 decades due to the increasing population of patients who are immunocompromised. However, the data regarding the exact burden of such infection are still not available from India. Therefore, this registry was initiated to collate systematic data on invasive fungal infections (IFIs) across the country. OBJECTIVE The primary aim of this study is to create a multicenter digital clinical registry and monitor trends of IFIs and emerging fungal diseases, as well as early signals of any potential fungal outbreak in any region. The registry will also capture information on the antifungal resistance patterns and the contribution of fungal infections on overall morbidity and inpatient mortality across various conditions. METHODS This multicenter, prospective, noninterventional observational study will be conducted by the Indian Council of Medical Research through a web-based data collection method from 8 Advanced Mycology Diagnostic and Research Centers across the country. Data on age, gender, clinical signs and symptoms, date of admission, date of discharge or death, diagnostic tests performed, identified pathogen details, antifungal susceptibility testing, outcome, and so on will be obtained from hospital records. Descriptive and multivariate statistical methods will be applied to investigate clinical manifestations, risk variables, and treatment outcomes. RESULTS These Advanced Mycology Diagnostic and Research Centers are expected to find the hidden cases of fungal infections in the intensive care unit setting. The study will facilitate the enhancement of the precision of fungal infection diagnosis and prompt treatment modalities in response to antifungal drug sensitivity tests. This registry will improve our understanding of IFIs, support evidence-based clinical decision-making ability, and encourage public health policies and actions. CONCLUSIONS Fungal diseases are a neglected public health problem. Fewer diagnostic facilities, scanty published data, and increased vulnerable patient groups make the situation worse. This is the first systematic clinical registry of IFIs in India. Data generated from this registry will increase our understanding related to the diagnosis, treatment, and prevention of fungal diseases in India by addressing pertinent gaps in mycology. This initiative will ensure a visible impact on public health in the country. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/54672.
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Affiliation(s)
| | | | - Saurabh Sharma
- Indian Council of Medical Research-National Institute of Medical Statistics, New Delhi, India
| | - Vinaykumar Hallur
- All India Institute of Medical Sciences, Bhubaneswar (AIIMS, Bhubaneswar), Bhubaneswar, Odisha, India
| | - Gagandeep Singh
- All India Institute of Medical Sciences, New Delhi (AIIMS-New Delhi), New Delhi, India
| | | | - Kh Jitenkumar Singh
- Indian Council of Medical Research-National Institute of Medical Statistics, New Delhi, India
| | - Harleen Kaur
- Indian Council of Medical Research-National Institute of Medical Statistics, New Delhi, India
| | - Tadepalli Karuna
- All India Institute of Medical Sciences, Bhopal (AIIMS-Bhopal), Bhopal, Madhya Pradesh, India
| | - Jayanthi Savio
- St John's Medical College and Hospital, Bangalore, Karnataka, India
| | - Reema Nath
- Assam Medical College and Hospital, Dibrugarh, Assam, India
| | - Immaculata Xess
- All India Institute of Medical Sciences, New Delhi (AIIMS-New Delhi), New Delhi, India
| | - Prashant Gupta
- King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Anjali Shetty
- Parmanand Deepchand Hinduja Hospital (PD Hinduja Hospital), Mumbai, Maharashtra, India
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Oliveira TF, Valeriano CAT, Buonafina-Paz MDS, Souza-Motta CM, Machado AR, Neves RP, Bezerra JDP, Arantes TD, de Hoog S, Magalhães OMC. Molecular Verification of Trichophyton in the Brazilian URM Culture Collection. Mycopathologia 2024; 189:2. [PMID: 38217794 DOI: 10.1007/s11046-023-00811-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/11/2023] [Indexed: 01/15/2024]
Abstract
Trichophyton species cause dermatophytosis in humans, with a high, worldwide frequency of reports and important public health relevance. We evaluated 61 Trichophyton strains from different sources deposited in the University Recife Mycology (URM) culture collection of the Universidade Federal de Pernambuco, Brazil. Strains were phenotypically identified and confirmed by sequencing Internal Transcribed Spacers rDNA and partial beta-tubulin 2-exon. Additionally, we evaluated their susceptibility to terbinafine and itraconazole. Physiological analyses included urease activity and growth in casein medium. Phenotypic methods allowed the reliable identification of T. rubrum only, whereas, for other species, molecular methods were mandatory. All Trichophyton species exhibited susceptibility profiles to itraconazole (0.04-5.33 μg/mL) and terbinafine (0.17-3.33 μg/mL). Our analyses revealed a heterogeneous distribution of T. mentagrophytes, which does not support the current distribution within the species complex of T. mentagrophytes and its genotypes.
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Affiliation(s)
- Tatiana F Oliveira
- Departamento de Micologia Prof. Chaves Batista, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Carlos A T Valeriano
- Departamento de Micologia Prof. Chaves Batista, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - M Daniela S Buonafina-Paz
- Departamento de Micologia Prof. Chaves Batista, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Cristina M Souza-Motta
- Departamento de Micologia Prof. Chaves Batista, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Alexandre R Machado
- Departamento de Micologia Prof. Chaves Batista, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Rejane P Neves
- Departamento de Micologia Prof. Chaves Batista, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Jadson D P Bezerra
- Laboratório de Micologia (LabMicol), Departamento de Biociências e Tecnologia, Instituto de Patologia Tropical e Saúde Pública (IPTSP), Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil.
| | - Thales D Arantes
- Laboratório de Micologia (LabMicol), Departamento de Biociências e Tecnologia, Instituto de Patologia Tropical e Saúde Pública (IPTSP), Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil
| | - Sybren de Hoog
- Center of Expertise in Mycology of Radboud University Medical Center, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Oliane M C Magalhães
- Departamento de Micologia Prof. Chaves Batista, Universidade Federal de Pernambuco, Recife, PE, Brazil
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16
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Song G, Kong X, Li X, Liu W, Liang G. Prior selection of itraconazole in the treatment of recalcitrant Trichophyton indotineae infection: Real-world results from retrospective analysis. Mycoses 2024; 67:e13663. [PMID: 37882456 DOI: 10.1111/myc.13663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/08/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The number of terbinafine-resistant Trichophyton indotineae is increasing in recent years while the treatment is still a matter to discuss. OBJECTIVES To explore the best therapeutic approach, we present real-world treatment of T. indotineae infection by analysing publicly available data. METHODS We have reviewed all published articles, mainly including case reports and case series, on the drug-resistant T. mentagrophytes complex by using the key search terms to search the databases. RESULTS We enrolled 25 articles from 14 countries, including 203 times of treatment information for 113 patients. The cure rate of itraconazole 200 mg per day at the fourth, eighth and the twelfth week were 27.27%, 48.48% and 54.55%, respectively, which was significantly higher than terbinafine 250 mg per day (8.77%, 24.56% and 28.07%) and even 500 mg/d terbinafine. Griseofulvin 500-1000 mg for 2-6 months may be effective while fluconazole had no record of successful treatment. Voriconazole and ravuconazole had potential therapeutic efficacy. Topical therapy alone showed limited therapeutic efficacy, but the combination with oral antifungals can be alternative. CONCLUSION Oral itraconazole 200 mg per day for 4-8 weeks was the most effective treatment out of these commonly used antifungal drugs, and can be prior selection.
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Affiliation(s)
- Ge Song
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- Department of Dermatology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xue Kong
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- Department of Dermatology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xiaofang Li
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- Department of Dermatology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Weida Liu
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- Department of Dermatology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Guanzhao Liang
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- Department of Dermatology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Kruithoff C, Gamal A, McCormick TS, Ghannoum MA. Dermatophyte Infections Worldwide: Increase in Incidence and Associated Antifungal Resistance. Life (Basel) 2023; 14:1. [PMID: 38276250 PMCID: PMC10817648 DOI: 10.3390/life14010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/15/2023] [Accepted: 12/15/2023] [Indexed: 01/27/2024] Open
Abstract
The increase in incidence of superficial fungal infections combined with the emergence of antifungal resistance represents both a global health challenge and a considerable economic burden. Recently, dermatophytes, the main culprit causing superficial fungal infections, have started to exhibit antifungal resistance. This can be observed in some of the most common species such as Trichophyton rubrum and Trichophyton mentagrophytes. Importantly, the new subspecies, known as Trichophyton indotineae, has been reported to show high resistance to terbinafine, a first-line treatment for dermatophyte infections. Compounding these issues is the realization that diagnosing the causative infectious agents requires using molecular analysis that goes beyond the conventional macroscopic and microscopic methods. These findings emphasize the importance of conducting antifungal susceptibility testing to select the appropriate antifungal necessary for successful treatment. Implementing these changes may improve clinical practices that combat resistant dermatophyte infections.
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Affiliation(s)
- Caroline Kruithoff
- Heritage College of Osteopathic Medicine, Ohio University, Cleveland, OH 44122, USA;
| | - Ahmed Gamal
- Center for Medical Mycology and Integrated Microbiome Core, Department of Dermatology, Case Western Reserve University, Cleveland, OH 44106, USA; (A.G.); (T.S.M.)
| | - Thomas S. McCormick
- Center for Medical Mycology and Integrated Microbiome Core, Department of Dermatology, Case Western Reserve University, Cleveland, OH 44106, USA; (A.G.); (T.S.M.)
| | - Mahmoud A. Ghannoum
- Center for Medical Mycology and Integrated Microbiome Core, Department of Dermatology, Case Western Reserve University, Cleveland, OH 44106, USA; (A.G.); (T.S.M.)
- Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
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Dashti Y, Alobaid K, Al-Rashidi S, Dashti M, AbdulMoneim MH, Al-Enezi M, Abou-Chakra N, Jørgensen KM. Autochthonous case of Trichophyton indotineae in Kuwait. J Mycol Med 2023; 33:101432. [PMID: 37666031 DOI: 10.1016/j.mycmed.2023.101432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/26/2023] [Accepted: 08/28/2023] [Indexed: 09/06/2023]
Abstract
Trichophyton indotineae is an emerging dermatophyte that has remarkable impact on public health worldwide. In addition to producing severe extensive skin lesions, this species is frequently resistant to terbinafine, used as a first line agent. As a result, the infection is often refractory, making treatment very challenging. The current report describes the first case of Trichophyton indotineae infection in Kuwait. The infected woman had no recent travel history. She failed to respond to several courses of antifungals, but finally responded to voriconazole. The report suggests that T. indotineae is under recognised, hence, active surveillance of dermatophytes is warranted.
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Affiliation(s)
- Yousef Dashti
- Department of Dermatology, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | - Khaled Alobaid
- Department of Mycology, Mycology Reference Laboratory, Mubarak Al-Kabeer Hospital, Block 4, Street Number: 103, Post code 46304, Jabriya, Kuwait.
| | - Shahad Al-Rashidi
- Department of Dermatology, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | - Maryam Dashti
- Department of Dermatology, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | | | - Manar Al-Enezi
- Department of Dermatology, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
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19
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Bristow IR, Joshi LT. Dermatophyte resistance - on the rise. J Foot Ankle Res 2023; 16:69. [PMID: 37794415 PMCID: PMC10552281 DOI: 10.1186/s13047-023-00665-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023] Open
Abstract
Dermatophytes are group of filamentous fungi which have adapted to living on the skin of humans and other animals. In the last decade, reports have emerged from Asia of new dermatophyte strains showing resistance to the commonly used antifungal agent terbinafine and others. The spread of these resistant strains has been noted in many other countries globally. Little is known about the mechanisms or management of this emerging problem. Urgent research and changes to current practice are required if the spread of the infection is to be contained and managed effectively.
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Affiliation(s)
- Ivan R Bristow
- AECC University College, Parkwood Campus, Parkwood Road, Bournemouth, BH5 2DF, UK.
| | - Lovleen Tina Joshi
- Molecular Microbiology, Peninsula Dental School, University of Plymouth, Drake Circus, Plymouth, PL4 8AA, UK
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20
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Blanchard G, Amarov B, Fratti M, Salamin K, Bontems O, Chang YT, Sabou AM, Künzle N, Monod M, Guenova E. Reliable and rapid identification of terbinafine resistance in dermatophytic nail and skin infections. J Eur Acad Dermatol Venereol 2023; 37:2080-2089. [PMID: 37319111 DOI: 10.1111/jdv.19253] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 05/05/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Fungal infections are the most frequent dermatoses. The gold standard treatment for dermatophytosis is the squalene epoxidase (SQLE) inhibitor terbinafine. Pathogenic dermatophytes resistant to terbinafine are an emerging global threat. Here, we determine the proportion of resistant fungal skin infections, analyse the molecular mechanisms of terbinafine resistance, and validate a method for its reliable rapid identification. METHODS Between 2013 and 2021, we screened 5634 consecutively isolated Trichophyton for antifungal resistance determined by hyphal growth on Sabouraud dextrose agar medium containing 0.2 μg/mL terbinafine. All Trichophyton isolates with preserved growth capacity in the presence of terbinafine underwent SQLE sequencing. Minimum inhibitory concentrations (MICs) were determined by the broth microdilution method. RESULTS Over an 8-year period, the proportion of fungal skin infections resistant to terbinafine increased from 0.63% in 2013 to 1.3% in 2021. Our routine phenotypic in vitro screening analysis identified 0.83% (n = 47/5634) of Trichophyton strains with in vitro terbinafine resistance. Molecular screening detected a mutation in the SQLE in all cases. Mutations L393F, L393S, F397L, F397I, F397V, Q408K, F415I, F415S, F415V, H440Y, or A398 A399 G400 deletion were detected in Trichophyton rubrum. Mutations L393F and F397L were the most frequent. In contrast, all mutations detected in T. mentagrophytes/T. interdigitale complex strains were F397L, except for one strain with L393S. All 47 strains featured significantly higher MICs than terbinafine-sensitive controls. The mutation-related range of MICs varied between 0.004 and 16.0 μg/mL, with MIC as low as 0.015 μg/mL conferring clinical resistance to standard terbinafine dosing. CONCLUSIONS Based on our data, we propose MIC of 0.015 μg/mL as a minimum breakpoint for predicting clinically relevant terbinafine treatment failure to standard oral dosing for dermatophyte infections. We further propose growth on Sabouraud dextrose agar medium containing 0.2 μg/mL terbinafine and SQLE sequencing as fungal sporulation-independent methods for rapid and reliable detection of terbinafine resistance.
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Affiliation(s)
- Gabriela Blanchard
- Department of Dermatology, Lausanne University Hospital, CHUV, Lausanne, Switzerland
| | - Boyko Amarov
- Institute of Statistics and Econometrics, Sofia University "St. Kliment Ohridski," Faculty of Economics and Business Administration, Sofia, Bulgaria
| | - Marina Fratti
- Department of Dermatology, Lausanne University Hospital, CHUV, Lausanne, Switzerland
| | - Karine Salamin
- Department of Dermatology, Lausanne University Hospital, CHUV, Lausanne, Switzerland
| | - Olympia Bontems
- Department of Dermatology, Lausanne University Hospital, CHUV, Lausanne, Switzerland
| | - Yun-Tsan Chang
- Department of Dermatology, Lausanne University Hospital, CHUV, Lausanne, Switzerland
| | - Alina Marcela Sabou
- Laboratoire de Parasitologie et Mycologie Médicale, Plateau Technique de Microbiologie, University Hospital of Strasbourg, Strasbourg, France
| | | | - Michel Monod
- Department of Dermatology, Lausanne University Hospital, CHUV, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Emmanuella Guenova
- Department of Dermatology, Lausanne University Hospital, CHUV, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Department of Dermatology, Hospital 12 de octubre, Medical School, University Complutense, Madrid, Spain
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21
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Dev PP, Bansal S, Bhargava A. Revisiting the pathogenesis of dermatophytosis: A cross-sectional analytic study of serum levels of interleukins-2, 8, 10 and 17. Mycoses 2023; 66:876-881. [PMID: 37309232 DOI: 10.1111/myc.13625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/27/2023] [Accepted: 06/02/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Given the current epidemic-like scenario of dermatophyte infections, it is prudent to revisit the immunopathogenesis of dermatophytosis. Comprehending the intricate interactions among interleukins can aid in understanding the recent trends in infection. There is a paucity of literature on the various cytokine levels observed in the serum of patients suffering from various dermatophytoses. AIM To study serum cytokine levels of interleukins 2, 8, 10 and 17 in patients with dermatophytosis. METHODS A cross-sectional analytic study was conducted on 64 cases of clinical dermatophyte infections (KOH confirmed) and 64 controls. The clinico-epidemiological profile of the cases was studied. By using a solid phase sandwich ELISA (enzyme-linked immunosorbent assay), the serum levels of interleukins 2, 8, 10 and 17 were measured and compared between cases and controls. Serum interleukin-2, 8, 10 and 17 levels were studied among cases based on mode of onset, duration of illness, treatment history, site of infection and multiple other morphological characteristics of the infection. RESULTS The cases had statistically higher levels of interleukins-8, 10 and 17 in comparison with controls. The levels of interleukin-8 were significantly lower (p < .05) among those who had received oral antifungals. In cases where the lesion had scaling, the serum levels of interleukin-10 were significantly higher (p < .05). The lesional hyperpigmentation was significantly (p < .05) associated with low levels of interleukin-17. Also, interleukin-17 was significantly (p < .05) elevated in patients with lesions in the abdomen. CONCLUSION It is the first time that serum interleukin levels are studied in dermatophytosis. There is an immunological dysfunction specific to dermatophytoses initiated by their infection. Key factor in this dysfunction is the elevation of IL-10, contributing to persistent infection. In turn, causing an increase in IL-17, promoting inflammation and tissue damage. This cycle of elevated IL-10 and IL-17 can further exacerbate the infection and lead to chronicity. The activity of IL-2 and the Th1 immune pathway is reduced by two opposing immune pathways: the Th17 and Th2 axes.
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Affiliation(s)
- Prabin P Dev
- Department of Dermatology and STD, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Shikha Bansal
- Department of Dermatology and STD, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Aradhana Bhargava
- Apex Regional STD Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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22
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Shenoy MM, De A, Shah B, Das A, Saraswat A, Lahiri K, Yadav S, Sarda A, Chakraborty D, J D, Kamat S, Doshi Y, Gonsalves N, Choudhary A, Dhoot D, Mahadkar N, Bhushan S, Gadkari R, Barkate H. Efficacy of Super-Bioavailable Itraconazole and Conventional Itraconazole at Different Dosing Regimens in Glabrous Tinea Infection - A Randomized Clinical Trial. Drug Des Devel Ther 2023; 17:2899-2908. [PMID: 37766823 PMCID: PMC10520254 DOI: 10.2147/dddt.s421583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023] Open
Abstract
Introduction Itraconazole follows non-linear pharmacokinetics and hence is recommended once daily, but in real-world practice, is commonly prescribed as twice daily. Hence, this study aimed to evaluate the efficacy and safety of super-bioavailable-itraconazole-130 mg (SB-130) and conventional-itraconazole-200 mg (CITZ-200) once daily compared with conventional-itraconazole-100 mg (CITZ-100) twice daily in glabrous tinea. Methods A total of 261 eligible patients were enrolled in this prospective, randomized, clinical study from December-2021 to August-2022 at seven centers in India. Efficacy and safety assessments were done at week-3 and 6, with follow-up at week-10 for relapse. The primary objective was to assess the proportion of patients who achieved complete cure at week-6 following treatment in all itraconazole groups. The secondary outcomes were safety and clinical and mycological cure rates. Results Of 261 patients, 240 were included in the analysis. At week-6, 140 patients were completely cured; thus, overall cure rate was 58.33%. Fifty-five patients (69%) in SB-130 while 47/77 (61%) and 38/83 (46%) patients were completely cured in CITZ-200 and CITZ-100 groups respectively (p<0.05; SB-130: CITZ-100, p=0.32; SB-130: CITZ-200, p=0.058; CITZ-200: CITZ-100). There was no statistical difference in the mycological cure rate and area clearance rate between any of the groups (p=0.14); however, a statistically significant difference was noted for OD dosing over BD dosing in achieving clinical cure rates (p<0.05). A total of 13/140 patients (9%) relapsed following complete cure, with no statistically significant difference between any of the groups (p=0.50). All treatments were safe and well-tolerated, with no discontinuation. Conclusion In this clinical study, moderate efficacy with all doses of ITZ was reported but was better with OD dosing. Although there was no statistical difference between SB-130 and CITZ-200, SB-130 may be preferred over CITZ-200 owing to the advantage of SB over the conventional ITZ.
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Affiliation(s)
| | - Abhishek De
- Department of Dermatology, Wizderm Specialty Skin and Hair Clinic, Kolkata, West Bengal, India
| | - Bela Shah
- Department of Dermatology, BJ Medical College and Civil Hospital, Ahmedabad, Gujarat, India
| | - Anupam Das
- Department of Dermatology, Iris Multispecialty Hospital, Kolkata, West Bengal, India
| | - Abir Saraswat
- Department of Dermatology, Indushree Skin Clinic, Lucknow, Uttar Pradesh, India
| | - Koushik Lahiri
- Department of Dermatology, Wizderm Specialty Skin and Hair Clinic, Kolkata, West Bengal, India
| | - Sheetal Yadav
- Department of Dermatology, ABVIMS and Dr. RML Hospital, New Delhi, India
| | - Aarti Sarda
- Department of Dermatology, Wizderm Specialty Skin and Hair Clinic, Kolkata, West Bengal, India
| | - Disha Chakraborty
- Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India
| | - Dharmender J
- Department of Dermatology, Wizderm Specialty Skin and Hair Clinic, Kolkata, West Bengal, India
| | - Shruti Kamat
- Department of Dermatology, Wizderm Specialty Skin and Hair Clinic, Kolkata, West Bengal, India
| | - Yashika Doshi
- Department of Dermatology, Wizderm Specialty Skin and Hair Clinic, Kolkata, West Bengal, India
| | - Nelry Gonsalves
- Department of Dermatology, Wizderm Specialty Skin and Hair Clinic, Kolkata, West Bengal, India
| | - Ankita Choudhary
- Department of Dermatology, Wizderm Specialty Skin and Hair Clinic, Kolkata, West Bengal, India
| | - Dhiraj Dhoot
- Department of Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Namrata Mahadkar
- Department of Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Sumit Bhushan
- Department of Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Rujuta Gadkari
- Department of Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Hanmant Barkate
- Department of Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
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23
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Crotti S, Cruciani D, Spina S, Piscioneri V, Natalini Y, Pezzotti G, Sabbatucci M, Papini M. A Terbinafine Sensitive Trichophyton indotineae Strain in Italy: The First Clinical Case of tinea corporis and onychomycosis. J Fungi (Basel) 2023; 9:865. [PMID: 37754973 PMCID: PMC10532841 DOI: 10.3390/jof9090865] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 09/28/2023] Open
Abstract
Trichophyton indotineae is an emerging dermatophyte species that plays a relevant role in human healthcare. It has been associated with severe chronic skin infections and a high level of terbinafine resistance. T. indotineae is endemic to India, Iran, and Iraq but several cases have been reported in Europe, recently. In this manuscript, the authors report the first clinical description of a tinea corporis and onychomycosis due to T. indotineae. The patient was a 42-year-old female from India that has lived in Umbria (Central Italy) for the last two years. Firstly, a dermatological examination suggested dermatophytosis: mycology isolation from cultures and macro- and microscopical features identified the colonies as belonging to the T. mentagrophytes/T. interdigitale species complex. Subsequently, ITS1/ITS4 end-point PCR and Sanger sequencing identified the strain as T. indotineae. Lastly, a DermaGenius® Resistance Multiplex real-time PCR assay was carried out, targeting the mutations in the SQLE gene to establish terbinafine resistance or susceptibility of the strain. The melting curve observed was compatible with wild-type positive control, identifying the strain as T. indotineae terbinafine-sensitive. An oral terbinafine treatment was associated with a topical ciclopirox nail solution, resulting in remission in its clinical manifestation. On 3 July 2023, the local Prevention Service notified the case to the Ministry of Health that then reported the information at national and international levels.
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Affiliation(s)
- Silvia Crotti
- Centro Specialistico Patologie Micotiche, Istituto Zooprofilattico Sperimentale dell’Umbria e delle Marche “Togo Rosati” (IZSUM), 06126 Perugia, Italy; (S.C.); (S.S.); (V.P.); (G.P.)
| | - Deborah Cruciani
- Centro Specialistico Patologie Micotiche, Istituto Zooprofilattico Sperimentale dell’Umbria e delle Marche “Togo Rosati” (IZSUM), 06126 Perugia, Italy; (S.C.); (S.S.); (V.P.); (G.P.)
| | - Sara Spina
- Centro Specialistico Patologie Micotiche, Istituto Zooprofilattico Sperimentale dell’Umbria e delle Marche “Togo Rosati” (IZSUM), 06126 Perugia, Italy; (S.C.); (S.S.); (V.P.); (G.P.)
| | - Vincenzo Piscioneri
- Centro Specialistico Patologie Micotiche, Istituto Zooprofilattico Sperimentale dell’Umbria e delle Marche “Togo Rosati” (IZSUM), 06126 Perugia, Italy; (S.C.); (S.S.); (V.P.); (G.P.)
| | - Ylenia Natalini
- Clinica Dermatologica di Terni, Università degli Studi di Perugia, 06123 Perugia, Italy; (Y.N.); (M.P.)
| | - Giovanni Pezzotti
- Centro Specialistico Patologie Micotiche, Istituto Zooprofilattico Sperimentale dell’Umbria e delle Marche “Togo Rosati” (IZSUM), 06126 Perugia, Italy; (S.C.); (S.S.); (V.P.); (G.P.)
| | - Michela Sabbatucci
- Department of Infectious Diseases, Istituto Superiore di Sanità, 00161 Roma, Italy;
- Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi di Pisa, 56126 Pisa, Italy
| | - Manuela Papini
- Clinica Dermatologica di Terni, Università degli Studi di Perugia, 06123 Perugia, Italy; (Y.N.); (M.P.)
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24
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Kong X, Song G, Mei H, Zheng H, Tang C, de Hoog S, Li X, She X, Liu W, Liang G. The Domestic Isolation of Terbinafine- and Itraconazole-Resistant Trichophyton indotineae in Chinese Mainland. Mycopathologia 2023; 188:383-393. [PMID: 37335400 DOI: 10.1007/s11046-023-00761-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/03/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Trichophyton indotineae, a new species of dermatophytes, has become a significant concern in treating dermatophytosis due to the high level of terbinafine resistance reported in India and even worldwide. OBJECTIVES This study aimed to report the terbinafine- and itraconazole-resistant T. indotineae in Chinese mainland, by identifying the phylogenetic classification of the isolate strain, and detecting the drug resistance, gene mutation and expression. PATIENTS/METHODS The skin scales of the patient were cultured on SDA and the isolate was authenticated by DNA sequencing and MALDI-TOF MS. Antifungal susceptibility testing was performed following the M38-A2 CLSI protocol to examine the MICs values of terbinafine, itraconazole, fluconazole, etc. The strain was screened for mutations in the squalene epoxidase (SQLE) gene by Sanger sequencing and detected the expression of CYP51A and CYP51B by qRT-PCR. RESULTS A multi-resistant ITS genotype VIII sibling of the T. mentagrophytes complex (T. indotineae) was isolated in Chinese mainland. The strain harbored high terbinafine MIC of > 32 μg/mL and itraconazole MIC of 1.0 μg/mL, which was identified a mutation in the squalene epoxidase gene with amino acid substitution (Phe397Leu, mutation 1191C > A). In addition, overexpression of CYP51A and CYP51B was observed. With multiple relapses, the patient finally achieved clinical cure by itraconazole pulse therapy and topical clotrimazole cream for 5 weeks. CONCLUSIONS The first domestic strain of terbinafine- and itraconazole-resistant T. indotineae from a patient in Chinese mainland was isolated. Itraconazole pulse therapy can be an effective method for the treatment of T. indotineae.
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Affiliation(s)
- Xue Kong
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, 210042, China
- Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, 210042, China
| | - Ge Song
- Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Huan Mei
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, 210042, China
| | - Hailin Zheng
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, 210042, China
| | - Chao Tang
- Center of Expertise in Mycology, Radboud University Medical Center, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Sybren de Hoog
- Center of Expertise in Mycology, Radboud University Medical Center, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Xiaofang Li
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, 210042, China
- Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, 210042, China
| | - Xiaodong She
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, 210042, China
- Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, 210042, China
| | - Weida Liu
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, 210042, China.
- Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, 210042, China.
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 21166, China.
| | - Guanzhao Liang
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, 210042, China.
- Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, 210042, China.
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25
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Jabet A, Normand AC, Brun S, Dannaoui E, Bachmeyer C, Piarroux R, Hennequin C, Moreno-Sabater A. Trichophyton indotineae, from epidemiology to therapeutic. J Mycol Med 2023; 33:101383. [PMID: 37031652 DOI: 10.1016/j.mycmed.2023.101383] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 03/25/2023] [Accepted: 03/28/2023] [Indexed: 03/31/2023]
Abstract
Trichophyton indotineae is a newly described dermatophyte species. This fungal pathogen has recently emerged in India and is responsible for chronic or recurrent widespread superficial infections. Resistance to terbinafine is frequently associated to this pathogen and is related to point mutations in the gene encoding the squalene epoxidase. T. indotineae infections have been reported outside India, highlighting the risk of worldwide diffusion of this microorganism. Species identification and antifungal susceptibility determination are key points for infection control but still remain challenging. Systemic treatment is usually required and itraconazole is frequently prescribed in case of terbinafine resistance. This review summarizes main features of T. indotineae taxonomy, epidemiology, clinical manifestations, identification, antifungal profile, treatment and prevention.
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Affiliation(s)
- Arnaud Jabet
- Service de Parasitologie-Mycologie, Hôpital Saint-Antoine, AP-HP, 75012 Paris, France; Service de Parasitologie-Mycologie, Hôpital La Pitié-Salpêtrière, AP-HP, 75013 Paris, France.
| | - Anne-Cécile Normand
- Service de Parasitologie-Mycologie, Hôpital La Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Sophie Brun
- Service de Parasitologie-Mycologie, Hôpital Avicenne, AP-HP, 93009 Bobigny, France
| | - Eric Dannaoui
- Unité de Parasitologie-Mycologie, Service de Microbiologie, Hôpital Necker, AP-HP, 75015 Paris, France; UR Dynamic 7380, UPEC, EnvA, USC ANSES, Faculté de Santé, 94000 Créteil, France; Faculté de Médecine, Université Paris Cité, 75006 Paris, France
| | - Claude Bachmeyer
- Service de Médecine interne, Hôpital Tenon, AP-HP, 75020 Paris, France
| | - Renaud Piarroux
- Service de Parasitologie-Mycologie, Hôpital La Pitié-Salpêtrière, AP-HP, 75013 Paris, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique, Inserm, Sorbonne Université, 75013 Paris, France
| | - Christophe Hennequin
- Service de Parasitologie-Mycologie, Hôpital Saint-Antoine, AP-HP, 75012 Paris, France; Centre de Recherche Saint-Antoine, CRSA, Inserm, Sorbonne Université, 75012 Paris, France
| | - Alicia Moreno-Sabater
- Service de Parasitologie-Mycologie, Hôpital Saint-Antoine, AP-HP, 75012 Paris, France; Centre d'Immunologie et des Maladies Infectieuses, (CIMI-PARIS), Inserm U1135, Sorbonne, 75013 Paris, France
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26
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Russo G, Toutous Trellu L, Fontao L, Ninet B. Towards an Early Clinical and Biological Resistance Detection in Dermatophytosis: About 2 Cases of Trichophyton indotineae. J Fungi (Basel) 2023; 9:733. [PMID: 37504722 PMCID: PMC10381761 DOI: 10.3390/jof9070733] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 06/03/2023] [Accepted: 06/19/2023] [Indexed: 07/29/2023] Open
Abstract
Trichophyton indotineae causes resistant dermatophytosis to terbinafine. The global spread of terbinafine-resistant Trichophyton indotineae strains with mutations in the squalene epoxidase gene is a major issue. This emerging species is now more frequently isolated in Europe and we report here two cases of T. indotineae tinea corporis in Switzerland, one with in vitro resistance to terbinafine and a second with in vitro susceptibility but a clinical resistance. Mycology isolation from cultures and sequencing ITS gene were used to confirm T. indotineae infection. In vitro antifungal susceptibility was tested in a microplate with a colorimetric detection of fungal viability for the determination of the minimal inhibitory concentration (MIC). Facing these emerging resistances and since there are a limited number of antifungal agents available to treat dermatophytosis, the early detection of terbinafine resistance should be a prerequisite in the management of T. indotineae infections.
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Affiliation(s)
- Giuseppe Russo
- Division of Dermatology and Venereology, University Hospital of Geneva, CH-1205 Geneva, Switzerland
| | - Laurence Toutous Trellu
- Division of Dermatology and Venereology, University Hospital of Geneva, CH-1205 Geneva, Switzerland
| | - Lionel Fontao
- Division of Dermatology and Venereology, University Hospital of Geneva, CH-1205 Geneva, Switzerland
- Laboratory of Dermatology, Division of Laboratory Medicine, University Hospital of Geneva, CH-1205 Geneva, Switzerland
| | - Béatrice Ninet
- Laboratory of Dermatology, Division of Laboratory Medicine, University Hospital of Geneva, CH-1205 Geneva, Switzerland
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Naseem S, Nawab M, Fatima SH, Minhajuddin A, Khan AA. Assessing the efficacy and safety of Unani pharmacopoeial formulations in dermatophytosis (quba) - a randomized controlled trial. Drug Metab Pers Ther 2023; 38:169-177. [PMID: 36194619 DOI: 10.1515/dmpt-2022-0125] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/30/2022] [Indexed: 06/07/2023]
Abstract
OBJECTIVES The recent trends of rising unresponsive cases of dermatophytosis to conventional therapies pose a challenge in clinical practice. Unani medicine offers effective treatment for dermatophytosis. This study aimed to evaluate the efficacy and safety of the Unani herbo-mineral preparations Qurs-e-Asfar (QA) and Rogan-e-Narjeel (RN) in dermatophytosis. METHODS This was a randomized, active-controlled and open-label clinical study. The participants diagnosed with dermatophytosis (n=78) randomized into treatment group (n=40) receiving oral QA (778 mg twice a day) and topical RN and control group (n=38) receiving oral Itraconazole (100 mg/day) and topical Terbinafine hydrochloride (1%) for 6 weeks. RESULTS We found post-treatment improvement in itching by 86.3% vs. 78% (treatment vs. control group), erythema by 96.4% vs. 94.3%, scaling by 93% vs. 92.2% and peripheral raised margins by 82.3% vs. 81%. Furthermore, this study showed that the differences in the mean Total Signs and Symptoms Score (TSSS) and positive KOH mount were clinically and statistically significant (p<0.05) in both the groups. On comparing inter group, the differences in mean TSSS (p=0.07) and positive KOH mount (p=0.717) were found statistically insignificant. CONCLUSIONS This study concludes that the formulations QA and RN were effective and safe in the treatment of dermatophytosis.
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Affiliation(s)
- Saima Naseem
- Department of Moalajat (Medicine), National Research Institute of Unani Medicine for Skin Disorders, Opp. ESI Hospital, Eragadda, Hyderabad, India
| | - Mohammad Nawab
- Department of Moalajat (Medicine), National Research Institute of Unani Medicine for Skin Disorders, Opp. ESI Hospital, Eragadda, Hyderabad, India
| | - Syeda Hajra Fatima
- Department of Pathology, National Research Institute of Unani Medicine for Skin Disorders, Opp. ESI Hospital, Eragadda, Hyderabad, India
| | - Ahmed Minhajuddin
- National Research Institute of Unani Medicine for Skin Disorders, Opp. ESI Hospital, Eragadda, Hyderabad, India
| | - Asif Ahmad Khan
- Department of Moalajat (Medicine), National Research Institute of Unani Medicine for Skin Disorders, Opp. ESI Hospital, Eragadda, Hyderabad, India
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Haghani I, Akhtari J, Yahyazadeh Z, Espahbodi A, Kermani F, Javidnia J, Hedayati MT, Shokohi T, Badali H, Rezaei-Matehkolaei A, Aghili SR, Al-Rawahi A, Al-Harrasi A, Abastabar M, Al-Hatmi AMS. Potential Inhibitory Effect of Miltefosine against Terbinafine-Resistant Trichophyton indotineae. Pathogens 2023; 12:pathogens12040606. [PMID: 37111492 PMCID: PMC10146699 DOI: 10.3390/pathogens12040606] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 04/29/2023] Open
Abstract
Several prolonged and significant outbreaks of dermatophytosis caused by Trichophyton indotineae, a new emerging terbinafine-resistant species, have been ongoing in India in recent years, and have since spread to various countries outside Asia. Miltefosine, an alkylphosphocholine, is the most recently approved drug for the treatment of both visceral and cutaneous leishmaniasis. Miltefosine in vitro activity against terbinafine-resistant and susceptible T. mentagrophytes/T. interdigitale species complex, including T. indotineae, is limited. The current study aimed to assess miltefosine's in vitro activity against dermatophyte isolates, which are the most common causes of dermatophytosis. Miltefosine, terbinafine, butenafine, tolnaftate, and itraconazole susceptibility testing was performed using Clinical and Laboratory Standards Institute broth microdilution methods (CLSI M38-A3) against 40 terbinafine-resistant T. indotineae isolates and 40 terbinafine-susceptible T. mentagrophytes/T. interdigitale species complex isolates. Miltefosine had MIC ranges of 0.063-0.5 µg/mL and 0.125-0.25 µg/mL against both terbinafine-resistant and susceptible isolates. In terbinafine-resistant isolates, the MIC50 and MIC90 were 0.125 µg/mL and 0.25 µg/mL, respectively, and 0.25 µg/mL in susceptible isolates. Miltefosine had statistically significant differences in MIC results when compared to other antifungal agents (p-value 0.05) in terbinafine-resistant strains. Accordingly, the findings suggest that miltefosine has a potential activity for treating infections caused by terbinafine-resistant T. indotineae. However, further studies are needed to determine how well this in vitro activity translates into in vivo efficacy.
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Affiliation(s)
- Iman Haghani
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Javad Akhtari
- Immunogenetics Research Center, Department of Medical Nanotechnology, School of Advanced Technologies in Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Zahra Yahyazadeh
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Amirreza Espahbodi
- Student Research Committee, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Firoozeh Kermani
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Javad Javidnia
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Mohammad Taghi Hedayati
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Tahereh Shokohi
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Hamid Badali
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Molecular Microbiology & Immunology, South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX 78249-0600, USA
| | - Ali Rezaei-Matehkolaei
- Department of Medical Mycology, School of Medicine, Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 61357-15794, Iran
| | - Seyed Reza Aghili
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Ahmed Al-Rawahi
- Natural & Medical Sciences Research Centre, University of Nizwa, Nizwa 616, Oman
| | - Ahmed Al-Harrasi
- Natural & Medical Sciences Research Centre, University of Nizwa, Nizwa 616, Oman
| | - Mahdi Abastabar
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Abdullah M S Al-Hatmi
- Natural & Medical Sciences Research Centre, University of Nizwa, Nizwa 616, Oman
- Center of Expertise in Mycology, Radboud University Medical Center/Canisius Wilhelmina Hospital, 6532 SZ Nijmegen, The Netherlands
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Bhalavi H, Shaw D, Mehta H, Narang T, Sachdeva N, Shafiq N, Rudramurthy SM, Dogra S. Correlation of plasma levels of itraconazole with treatment response at 4 weeks in chronic dermatophytosis: Results of a randomised controlled trial. Mycoses 2023; 66:281-288. [PMID: 36457207 DOI: 10.1111/myc.13551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/19/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Itraconazole in varying doses and duration is being frequently used for the management of dermatophytosis. There is a scarcity of studies on the bioavailability of various itraconazole brands available in the market. AIMS AND OBJECTIVES The aim of this study was to determine the plasma concentration of itraconazole of various brands and its correlation with clinical efficacy in chronic dermatophytosis. MATERIALS AND METHODS One hundred patients with chronic dermatophytosis with age >18 years were studied at the outpatient clinic of our tertiary care hospital. Plasma itraconazole level was estimated on Week 2 and Week 4 after randomly dividing the patients into Groups A, B and C who received cap itraconazole 100 mg twice a day of innovator, multinational and local generic brands, respectively, for 4 weeks. Both efficacy (cure, partial cure or no cure), safety and recurrence were compared between the three groups. RESULTS At 4 weeks, number of patients classified as 'cured' were 10/26 (38.4%) in Group A, 5/22 in Group B (22.7%) and 3/21 (14.2%) in Group C (p = .002). Mycological cure rates at Week 4 in Groups A, B and C were 21 (80.8%), 17 (81.0%) and 5 (26.3%), respectively (p = .006). Plasma levels of itraconazole were comparable between the three groups at Week 2 and Week 4. No statistically significant correlation was found between itraconazole levels and treatment response in any of the groups at 4 weeks. Incidence of adverse effects and recurrence rates was also similar among the three groups. CONCLUSION Cure rates for chronic dermatophytosis were poor with all three itraconazole brands at 4 weeks of treatment. Higher cure rates were obtained with innovator drug as compared to multinational and local generic brands at 4 weeks. Plasma levels of the three drugs were however similar, indicating that factors other than serum bioavailability are at play in determining response of chronic dermatophyte infections to oral itraconazole.
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Affiliation(s)
- Hitesh Bhalavi
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Dipika Shaw
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Hitaishi Mehta
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Tarun Narang
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Naresh Sachdeva
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nusrat Shafiq
- Department of Clinical Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Dogra
- Department of Dermatology, Venereology and Leprology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Bhattacharyya A, Sadhasivam S, Sinha M, Gupta S, Saini S, Singh H, Khurana A, Sachdeva S, Sardana K, Ghosh S. Treatment of recalcitrant cases of tinea corporis/cruris caused by T. mentagrophytes - interdigitale complex with mutations in ERG11 ERG 3, ERG4, MDR1 MFS genes & SQLE and their potential implications. Int J Dermatol 2023; 62:637-648. [PMID: 36929499 DOI: 10.1111/ijd.16622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 01/10/2023] [Accepted: 02/07/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Recalcitrant dermatophyte infections are being reported from various parts of the world due to varied causes including strain variation, steroid misuse, SQLE mutations, and variable quality of itraconazole pellet formulations. The oral drug preferred in endemic areas is itraconazole, to which MIC levels remain low, and clinical failures to itraconazole reported defy a sound scientific explanation. OBJECTIVES The objective of the study was to conduct a proteomic and genomic analysis on isolates from therapeutically recalcitrant case with isolation of gene mutations and enzymatic abnormalities to explain azole failures. METHODS Trichophyton mentagrophyte interdigitale complex strains were isolated from seven clinically non-responding tinea corporis/cruris patients, who had failed a sequential course of 6 weeks of terbinafine 250 mg QD and itraconazole 100 mg BID. After AFST 1 strain, KA01 with high MIC to most drugs was characterized using whole genome sequencing, comparative proteomic profiling, and total sterol quantification. RESULTS Sterol quantification showed that the standard strain of Trichophyton mentagrophytes (MTCC-7687) had half the ergosterol content than the resistant KA01 strain. Genomic analysis revealed mutations in SQLE, ERG4, ERG11, MDR1, MFS genes, and a novel ERG3 mutation. Proteomic analysis established the aberrant expression of acetyl Co-A transferase in the resistant strain and upregulation of thioredoxin reductase and peroxiredoxin. CONCLUSION Our findings demonstrate possible reasons for multidrug resistance in the prevalent strain with mutations in genes that predict terbinafine (SQLE) and azole actions (ERG4, ERG11, ERG3) apart from efflux pumps (MDR1, MFS) that can explain multidrug clinical failures.
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Affiliation(s)
| | | | - Mau Sinha
- Vyome Therapeutics Limited, New Delhi, India
| | - Swati Gupta
- Vyome Therapeutics Limited, New Delhi, India
| | | | | | - Ananta Khurana
- Department of Dermatology, Venereology and Leprosy, Dr. Ram Manohar Lohia Hospital, Atal Bihari Vajpayee Institute of Medical Sciences, New Delhi, India
| | - Soumya Sachdeva
- Saraswathi Institute of Medical Sciences, Anwarpur, Uttar Pradesh, India
| | - Kabir Sardana
- Department of Dermatology, Venereology and Leprosy, Dr. Ram Manohar Lohia Hospital, Atal Bihari Vajpayee Institute of Medical Sciences, New Delhi, India
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Normand AC, Moreno-Sabater A, Jabet A, Hamane S, Cremer G, Foulet F, Blaize M, Dellière S, Bonnal C, Imbert S, Brun S, Packeu A, Bretagne S, Piarroux R. MALDI-TOF Mass Spectrometry Online Identification of Trichophyton indotineae Using the MSI-2 Application. J Fungi (Basel) 2022; 8:1103. [PMID: 36294668 PMCID: PMC9604624 DOI: 10.3390/jof8101103] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/17/2022] Open
Abstract
Trichophyton indotineae is an emerging pathogen which recently spread from India to Europe and that is more prone than other species of the Trichophyton mentagrophytes complex to show resistance to terbinafine, resulting in the necessity of rapid identification. Here, we improved the online MSI-2 MALDI-TOF identification tool in order to identify T. indotineae. By multiplying the culture conditions (2 culture media and 6 stages of growth) prior to protein extractions for both test isolates and reference strains, we added 142 references corresponding to 12 strains inside the T. mentagrophytes complex in the online MSI-2 database, of which 3 are T. indotineae strains. The resulting database was tested with 1566 spectra of 67 isolates from the T. mentagrophytes complex, including 16 T. indotineae isolates. Using the newly improved MSI-2 database, we increased the identification rate of T. indotineae from 5% to 96%, with a sensitivity of 99.6%. We also identified specific peaks (6834/6845 daltons and 10,634/10,680 daltons) allowing for the distinction of T. indotineae from the other species of the complex. Our improved version of the MSI-2 application allows for the identification of T. indotineae. This will improve the epidemiological knowledge of the spread of this species throughout the world and will help to improve patient care.
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Affiliation(s)
- Anne-Cécile Normand
- Service de Parasitologie-Mycologie, Hôpital La Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Alicia Moreno-Sabater
- Service de Parasitologie-Mycologie, Hôpital Saint-Antoine, AP-HP, 75012 Paris, France
- Centre d’Immunologie et des Maladies Infectieuses, (CIMI-PARIS), Inserm U1135, Sorbonne Université, 75013 Paris, France
| | - Arnaud Jabet
- Service de Parasitologie-Mycologie, Hôpital La Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Samia Hamane
- Hôpital Saint Louis Laboratoire de Parasitologie-Mycologie, Assistance Publique des Hôpitaux de Paris, 75010 Paris, France
| | | | - Françoise Foulet
- Service de Parasitologie-Mycologie, Hôpitaux Universitaires Henri Mondor, AP-HP, 94000 Créteil, France
- UR Dynamic 7380, UPEC, EnvA, USC ANSES, Faculté de Santé, 94000 Créteil, France
| | - Marion Blaize
- Service de Parasitologie-Mycologie, Hôpital La Pitié-Salpêtrière, AP-HP, 75013 Paris, France
- Sorbonne Université, INSERM, CNRS, Centre d’Immunologie et des Maladies Infectieuses, Cimi-Paris, 75013 Paris, France
| | - Sarah Dellière
- Hôpital Saint Louis Laboratoire de Parasitologie-Mycologie, Assistance Publique des Hôpitaux de Paris, 75010 Paris, France
| | - Christine Bonnal
- Service de Parasitologie-Mycologie, Hôpital Bichat-Claude Bernard, AP-HP, 75018 Paris, France
| | - Sébastien Imbert
- Univ Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, Inserm UMR 1045, 33600 Bordeaux, France
- CHU Bordeaux, Département de Parasitologie-Mycologie, CIC 1401, 33000 Bordeaux, France
| | - Sophie Brun
- Service de Parasitologie-Mycologie, Hôpital Avicenne, AP-HP, 93009 Bobigny, France
- Faculté de Médecine, Université Sorbonne Paris Nord, 93009 Bobigny, France
| | - Ann Packeu
- Sciensano, BCCM/IHEM Collection, Mycology and Aerobiology Unit, 1000 Brussels, Belgium
| | - Stéphane Bretagne
- Hôpital Saint Louis Laboratoire de Parasitologie-Mycologie, Assistance Publique des Hôpitaux de Paris, 75010 Paris, France
| | - Renaud Piarroux
- Service de Parasitologie-Mycologie, Hôpital La Pitié-Salpêtrière, AP-HP, 75013 Paris, France
- Institut Pierre Louis d’Épidémiologie et de Santé Publique, Inserm, Sorbonne Université, 75013 Paris, France
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Langfeldt A, Gold JAW, Chiller T. Emerging Fungal Infections: from the Fields to the Clinic, Resistant Aspergillus fumigatus and Dermatophyte Species: a One Health Perspective on an Urgent Public Health Problem. CURRENT CLINICAL MICROBIOLOGY REPORTS 2022; 9:46-51. [PMID: 36188157 PMCID: PMC9512973 DOI: 10.1007/s40588-022-00181-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2022] [Indexed: 11/27/2022]
Abstract
Purpose of Review For this review, we use a One Health approach to examine two globally emerging public health threats related to antifungal drug resistance: triazole-resistant Aspergillus fumigatus infections, which can cause a life-threatening illness in immunocompromised hosts, and antifungal-resistant dermatophytosis, which is an aggressive skin infection caused by dermatophyte molds. We describe the state of current scientific knowledge and outline necessary public health actions to address each issue. Recent Findings Recent evidence has identified the agricultural use of triazole fungicides as an important driver of triazole-resistant A. fumigatus infections. Antifungal-resistant dermatophyte infections are likely driven by the inappropriate use of antifungal drugs and antibacterial and corticosteroid creams. Summary This review highlights the need for a One Health approach to address emerging antifungal resistant infections, emphasizing judicious antifungal use to preserve available treatments; strengthened laboratory capacity to identify antifungal resistance; and improved human, animal, and environmental surveillance to detect emerging resistance, monitor trends, and evaluate the effectiveness of efforts to decrease spread.
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Affiliation(s)
- Antonia Langfeldt
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Jeremy A. W. Gold
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Tom Chiller
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA USA
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Batvandi A, Pchelin IM, Kiasat N, Kharazi M, Mohammadi R, Zomorodian K, Rezaei‐Matehkolaei A. Time and Cost‐efficient Identification of
Trichophyton indotineae. Mycoses 2022; 66:75-81. [DOI: 10.1111/myc.13530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Abolfazl Batvandi
- Cellular and Molecular Research Center Medical Basic Sciences Research Institute, Ahvaz Jundishapur University of Medical Sciences Ahvaz Iran
- Department of Medical Mycology School of Medicine, Ahvaz Jundishapur University of Medical Sciences Ahvaz Iran
| | - Ivan M. Pchelin
- Laboratory of Innovative Methods in Microbiological Monitoring Research Centre for Personalized Medicine, Institute of Experimental Medicine Saint Petersburg Russia
| | - Neda Kiasat
- Cellular and Molecular Research Center Medical Basic Sciences Research Institute, Ahvaz Jundishapur University of Medical Sciences Ahvaz Iran
- Department of Medical Mycology School of Medicine, Ahvaz Jundishapur University of Medical Sciences Ahvaz Iran
| | - Mahboobeh Kharazi
- Department of Parasitology and Mycology School of Medicine, Shiraz University of Medical Sciences Shiraz Iran
| | - Rasoul Mohammadi
- Department of Medical Parasitology and Mycology School of Medicine, Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences Isfahan Iran
| | - Kamiar Zomorodian
- Department of Parasitology and Mycology School of Medicine, Shiraz University of Medical Sciences Shiraz Iran
| | - Ali Rezaei‐Matehkolaei
- Cellular and Molecular Research Center Medical Basic Sciences Research Institute, Ahvaz Jundishapur University of Medical Sciences Ahvaz Iran
- Department of Medical Mycology School of Medicine, Ahvaz Jundishapur University of Medical Sciences Ahvaz Iran
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Bieber K, Harder M, Ständer S, Boch K, Kridin K, Köhler B, Anemüller W, Ernst AL, Zillikens D, Cavalar M, Ludwig RJ. DNA-Chip-basierte Diagnose der Onychomykose und Tinea pedis. J Dtsch Dermatol Ges 2022; 20:1112-1122. [PMID: 35971577 DOI: 10.1111/ddg.14819_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/22/2022] [Indexed: 11/28/2022]
Abstract
HINTERGRUND UND ZIELE Onychomykose (OM) und Tinea pedis (TP) sind häufige Pilzinfektionen der Haut. Aktuell basiert die Diagnose vornehmlich auf mikroskopischem Direktnachweis und/oder Kultur. Beide Methoden haben jedoch eine geringe bis mäßige Sensitivität und benötigen teilweise mehrere Wochen, bis endgültige Laborergebnisse vorliegen. Um die Diagnose kutaner Pilzinfektionen zu verbessern, wurden PCR-basierte Methoden entwickelt. Hier haben wir hier die Sensitivität und Spezifität einer Chip-basierten Multiplex-PCR mit mikroskopischen Direktnachweis und verglichen. PATIENTEN UND METHODIK In einer monozentrischen, prospektiven Studie wurden bei Patienten mit Verdacht auf OM (n = 67) oder TP (n = 73) Schuppenpräparate entnommen und mittels mikroskopischem Direktnachweis, Kultur und DNA-Chip-Technologie der Erregernachweis durchgeführt. In einem weiteren Ansatz wurde überprüft, ob Abstriche als Alternative zur Entnahme eines Schuppenpräparates verwendet werden können. Hierfür wurden 24 weitere OM/TP-Patienten rekrutiert und die Ergebnisse der DNA-Chip-Technologie aus Abstrichen mit denen aus den Schuppenpräparaten verglichen. ERGEBNISSE Im Vergleich aller Methoden hatte die DNA-Chip-Technologie die höchste Sensitivität, eine Kombination von DNA-Chip-Technologie mit mikroskopischem Direktnachweis erhöhte dies weiter. Ergebnisse dieser kombinierten Labordiagnostik sind innerhalb von 24 Stunden verfügbar. Der Vergleich der Probenentnahmetechniken (Abstrich beziehungsweise Schuppenpräparat) zeigte vergleichbare Ergebnisse. SCHLUSSFOLGERUNGEN Die molekulare Diagnostik (mittels DNA-Chip-Technologie) hat eine hohe Sensitivität für die OM- und TP-Diagnostik, insbesondere in Kombination mit dem mikroskopischen Direktnachweis.
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Affiliation(s)
- Katja Bieber
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | | | - Sascha Ständer
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Katharina Boch
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Khalaf Kridin
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Birgit Köhler
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | | | - Anna Lara Ernst
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Detlef Zillikens
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | | | - Ralf J Ludwig
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
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Bieber K, Harder M, Ständer S, Boch K, Kridin K, Köhler B, Anemüller W, Ernst AL, Zillikens D, Cavalar M, Ludwig RJ. DNA chip‐based diagnosis of onychomycosis and tinea pedis. J Dtsch Dermatol Ges 2022; 20:1112-1121. [DOI: 10.1111/ddg.14819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/22/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Katja Bieber
- Lübeck Institute of Experimental Dermatology University of Lübeck Lübeck Germany
| | | | - Sascha Ständer
- Department of Dermatology University of Lübeck Lübeck Germany
| | - Katharina Boch
- Department of Dermatology University of Lübeck Lübeck Germany
| | - Khalaf Kridin
- Lübeck Institute of Experimental Dermatology University of Lübeck Lübeck Germany
- Azrieli Faculty of Medicine Bar‐Ilan University Safed Israel
| | - Birgit Köhler
- Department of Dermatology University of Lübeck Lübeck Germany
| | | | - Anna Lara Ernst
- Lübeck Institute of Experimental Dermatology University of Lübeck Lübeck Germany
| | | | | | - Ralf J. Ludwig
- Lübeck Institute of Experimental Dermatology University of Lübeck Lübeck Germany
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Madarasingha NP, Eriyagama S, Jayasekera PI, de Silva Weliange S, Gunasekera S, Munasingha DM, Rajendran P, Ekanayaka SMB, Liyanange J, Thamilvannan N, Sumanasena B, Srisaravanabavanathan F, Wijenayake B. Characterization of Recalcitrant Dermatophytosis in a Multicenter Study in Sri Lanka. Am J Trop Med Hyg 2022; 107:117-121. [PMID: 35895368 PMCID: PMC9294678 DOI: 10.4269/ajtmh.21-1022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/09/2021] [Indexed: 03/14/2024] Open
Abstract
A changing clinical scenario of dermatophytosis has been observed in Sri Lanka during the past few years. In keeping with the trend described in India, an increase in the number of chronic, relapsing, and recalcitrant infections has been noted. The objective of our study was to assess the therapeutic response of dermatophytosis to standard antifungal treatment in Sri Lanka and to identify possible contributory factors in cases showing inadequate therapeutic response. A descriptive, observational, cross-sectional study was carried out in nine hospitals, representing each province. Over 6 months, patients with dermatophytosis on glabrous skin were included. All subjects underwent skin scrapings for mycological studies and were treated with a standard course of antifungals for a specific period. In those patients who achieved complete clearance, recurrences were noted. The study included 796 patients, of whom 191 (24%) had symptoms for more than 3 months at presentation. A total of 519 patients (65.2%) had multiple-site involvement, and 503 (63.2%) had evidence of prior use of topical steroids. Skin scrapings were positive for fungal elements in the direct smears of 659 patients (82.8%), and the predominant dermatophyte isolated was Trichophyton mentagrophytes (65.6%). Partial responders after 10 weeks of treatment and recurrences after complete clearance were significantly greater in the group that used topical steroids before presentation (P < 0.001). This study highlights the magnitude of the threat of an inadequate therapeutic response in dermatophytosis in Sri Lanka, and identifies steroid misuse, and the shift of the predominant fungal species to T. mentagrophytes as possible causative factors.
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Khurana A, Agarwal A, Agrawal D, Sardana K, Singh A, Chowdhary A. Multidrug resistant tinea corporis/cruris: response to voriconazole. J Mycol Med 2022; 32:101306. [DOI: 10.1016/j.mycmed.2022.101306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 05/09/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022]
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Terbinafine Resistance in Dermatophytes: A French Multicenter Prospective Study. J Fungi (Basel) 2022; 8:jof8030220. [PMID: 35330222 PMCID: PMC8948947 DOI: 10.3390/jof8030220] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 02/06/2023] Open
Abstract
In recent years, we have moved from the sporadic description of terbinafine-resistant (TerR) Trichophyton spp. isolates to the Indian outbreak due to T. indotineae. Population flows have spread TerR worldwide, altering local epidemiology. We conducted a prospective multicentric study to determine the relative frequency of TerR isolates in France (Paris area) and of the newly introduced T. indotineae species. TerR isolates were screened by the terbinafine-containing-agar-medium (TCAM) method and confirmed by EUCAST. Sequencing methods were used to identify isolates to the species/genotype level and to analyze substitutions in the squalene epoxidase gene (SQLE). In total, 3 isolates out of 580 (T. rubrumn = 1; T. interdigitalen = 1; T. indotineaen = 1) grew on TCAM, showed terbinafine resistance by EUCAST and harbored the Phe397Leu (n = 2) or Leu393Ser (n = 1) substitution in the SQLE. ITS-sequencing of isolates of the T. mentagrophytes/interdigitale complex (n = 125) revealed a relative frequency of 4.8% for T. indotineae and the presence of T. mentagrophytes genotype VII. Despite the detection of terbinafine resistance, isolates from this complex remained susceptible to itraconazole, voriconazole and amorolfine. Terbinafine resistance is present in France and the dermatophyte epidemiology is changing. Efficient systems must be implemented to survey the evolution of newly introduced species and to identify TerR isolates.
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Posso-De Los Rios CJ, Tadros E, Summerbell RC, Scott JA. Terbinafine Resistant Trichophyton Indotineae Isolated in Patients with Superficial Dermatophyte Infection in Canadian Patients. J Cutan Med Surg 2022; 26:371-376. [PMID: 35144480 DOI: 10.1177/12034754221077891] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Trichophyton mentagrophytes type VIII (segregated as Trichophyton indotineae) is a new strain of antifungal resistant Trichophyton spp. that has been found in different countries around the world. This new strain has been found to be resistant to terbinafine. OBJECTIVES We present the clinical characteristics, diagnosis and treatment approach of Canadian patients with mycology and molecular confirmation of superficial mycosis caused by T. indotineae. METHODS Mycology testing from cultures and PCR were used to confirm T. indotineae. We collected clinical information from patients with a confirmed diagnosis. RESULTS We report eight Canadian patients mainly presenting with extensive superficial mycosis due to T. indotineae. Three patients presented lesions on the face in addition to lesions on their body. Four patients were initially started on itraconazole or fluconazole, one patient was started on topical therapy, and three patients were referred to infectious disease. CONCLUSIONS This new strain represents a dermatology and public health concern. Treatment guidelines are lacking. We include a practical approach and treatment recommendations for clinicians who will be encountering these emerging cases in Canada while waiting for evidence-based treatment guidelines.
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Affiliation(s)
| | - Enas Tadros
- Dermatology Clinic, DermCare. 1065 Canadian Pl Unit 206, Mississauga, ON, Canada
| | - Richard C Summerbell
- 7938274071 Dalla Lana School of Public Health, University of Toronto, ON, Canada.,Dynacare Laboratories. 115 Midair Court, Brampton, ON, Canada.,Sporometrics. 219 Dufferin Street, Suite 20C, Toronto, ON, Canada
| | - James A Scott
- 7938274071 Dalla Lana School of Public Health, University of Toronto, ON, Canada.,Dynacare Laboratories. 115 Midair Court, Brampton, ON, Canada.,Sporometrics. 219 Dufferin Street, Suite 20C, Toronto, ON, Canada
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Jabet A, Brun S, Normand AC, Imbert S, Akhoundi M, Dannaoui E, Audiffred L, Chasset F, Izri A, Laroche L, Piarroux R, Bachmeyer C, Hennequin C, Sabater AM. Extensive Dermatophytosis Caused by Terbinafine-Resistant Trichophyton indotineae, France. Emerg Infect Dis 2022; 28:229-233. [PMID: 34932456 PMCID: PMC8714191 DOI: 10.3201/eid2801.210883] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Extensive dermatophytosis caused by terbinafine-resistant Trichophyton indotineae harboring Phe397Leu and Leu393Ser substitutions in the squalene epoxidase enzyme was diagnosed in France. Analysis of internal transcribed spacer sequences revealed the wide spread of this species in Asia and Europe. Detection of T. indotineae in animals suggests their possible role as reservoirs.
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Jartarkar S, Kadnur M, Narayanaswamy G, Manoj Kumar A, Arora S, Balakrishnan T. A clinico-mycological study of dermatophytoses and their in-vitro sensitivity to antifungal drugs. INDIAN JOURNAL OF DERMATOPATHOLOGY AND DIAGNOSTIC DERMATOLOGY 2022. [DOI: 10.4103/ijdpdd.ijdpdd_41_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Patel MA, Aliporewala VM, Patel DA. Common Antifungal Drugs in Pregnancy: Risks and Precautions. J Obstet Gynaecol India 2021; 71:577-582. [PMID: 34898894 PMCID: PMC8617216 DOI: 10.1007/s13224-021-01586-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 10/21/2021] [Indexed: 02/02/2023] Open
Abstract
Fungal skin infections are on the rise in India, and pregnant women are not immune to them. They are one of the commonest causes of secondary pruritus in pregnancy and can worsen the quality of life. Cutaneous dermatophytic infections have seen a recent emergence as a public health problem in India with increasing incidence as well as failure to appropriately respond to treatment. Vaginal candidiasis may cause obstetric and perinatal complications such as chorioamnionitis, premature rupture of membranes, preterm labor and neonatal candidiasis. Antifungal drugs are commonly prescribed in pregnancy. The common oral antifungals used are fluconazole, ketoconazole, itraconazole, terbinafine and griseofulvin; whereas the common topical antifungals are azoles, ciclopirox oleamine, terbinafine, amongst others. There have been reports of congenital abnormalities in the fetus and spontaneous abortions attributed to oral antifungals. Prescribing antifungal drugs in pregnancy needs careful consideration. In this article, we discuss the safety profile and recommendations regarding the use of these drugs during gestation. We have performed a literature search of recent large-scale cohort, case-control, and meta-analysis studies and presented them in this review. Antifungals such as echinocandins, amphotericin B, flucytosine, etc. which are indicated for systemic mycoses are beyond the scope of this article. Finally, we have given authors' perspective regarding the justifiable use of these antifungals in pregnant women.
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Affiliation(s)
- Madhuri A. Patel
- N. Wadia Hospital, Parel, Mumbai, India
- Police Hospital, Mumbai, India
- Sion, Mumbai, India
| | | | - Disha A. Patel
- Department of Community Medicine at TNMC, BYL Nair Charitable Hospital, Mumbai, India
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Gnat S, Łagowski D, Nowakiewicz A, Dyląg M. A global view on fungal infections in humans and animals: opportunistic infections and microsporidioses. J Appl Microbiol 2021; 131:2095-2113. [PMID: 33556223 DOI: 10.1111/jam.15032] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 02/03/2021] [Accepted: 02/03/2021] [Indexed: 12/12/2022]
Abstract
After cardiovascular diseases, infectious diseases are the second most common cause of death worldwide. Although these infections are caused mainly by viruses or bacteria, a systematically growing prevalence of human and animal opportunistic fungal infections is noticeable worldwide. More attention is being paid to this problem, especially due to the growing frequency of recalcitrant and recurrent mycoses. The latter are classically divided into superficial, which are the most common type, subcutaneous, and systemic. This work discusses opportunistic fungal pathogens without proven horizontal transmission between different animal species including humans and microsporidia as spore-forming unicellular parasites related to fungi; however, with a yet undetermined taxonomic position. The review also mentions aetiological agents, risk factors, epidemiology, geographical distribution, and finally symptoms characteristic for individual disease entities. This paper provides insight into fungal infections from a global perspective and simultaneously draws attention to emerging pathogens, whose prevalence is continuously increasing. Finally, this work also takes into consideration the correct nomenclature of fungal disease entities and the importance of secondary metabolites in the pathogenesis of fungal infections.
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Affiliation(s)
- S Gnat
- Department of Veterinary Microbiology, Faculty of Veterinary Medicine, Institute of Preclinical Veterinary Sciences, University of Life Sciences, Lublin, Poland
| | - D Łagowski
- Department of Veterinary Microbiology, Faculty of Veterinary Medicine, Institute of Preclinical Veterinary Sciences, University of Life Sciences, Lublin, Poland
| | - A Nowakiewicz
- Department of Veterinary Microbiology, Faculty of Veterinary Medicine, Institute of Preclinical Veterinary Sciences, University of Life Sciences, Lublin, Poland
| | - M Dyląg
- Department of Mycology and Genetics, Faculty of Biological Sciences, Institute of Genetics and Microbiology, University of Wroclaw, Wroclaw, Poland
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Gnat S, Łagowski D, Nowakiewicz A, Trościańczyk A, Dyląg M. New Reference Genes for qRT-PCR Analysis as a Potential Target for Identification of Trichophyton verrucosum in Different Culture Conditions. Pathogens 2021; 10:pathogens10111361. [PMID: 34832515 PMCID: PMC8618703 DOI: 10.3390/pathogens10111361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/09/2021] [Accepted: 10/18/2021] [Indexed: 11/17/2022] Open
Abstract
Dermatophytes are a group of filamentous fungi infecting skin, hair, and nails that raise great diagnostic difficulties. qRT-PCR is a reliable technique for quantifying gene expression with increasingly frequent use in mycological diagnostics. Knowledge of genes and molecular markers with potential to be used in the identification of dermatophytes is of great importance for the development of this branch of diagnostics. In this article, the suitability of six candidate reference genes (TUBB, ACTB, ADPRF, RPL2, SDHA, and EEF1A1) was investigated for gene expression analysis in the dermatophyte Trichophyton verrucosum, which was cultured in various mycological media that are commonly used in a diagnostic laboratory, i.e., Sabouraud, potato dextrose, and keratin-supplemented MM-Cove. The different culture conditions are extremely important factors for the growth and physiology of dermatophytes. Gene expression stability was evaluated using geNorm, NormFinder, BestKeeper, and RefFinder algorithms. Regarding the stability of expression, SDHA was the most stable housekeeping gene; hence, this gene is recommended for future qRT-PCR studies on T. verrucosum strains. These results allow us to conclude that the SDHA gene can be an additional good candidate as an identification target in the qRT-PCR technique.
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Affiliation(s)
- Sebastian Gnat
- Department of Veterinary Microbiology, Faculty of Veterinary Medicine, University of Life Sciences, Akademicka 12, 20-033 Lublin, Poland; (A.N.); (A.T.)
- Correspondence: (S.G.); (D.Ł.); Tel.: +48-81-445-60-93 (S.G.); +48-81-445-66-96 (D.Ł.)
| | - Dominik Łagowski
- Department of Veterinary Microbiology, Faculty of Veterinary Medicine, University of Life Sciences, Akademicka 12, 20-033 Lublin, Poland; (A.N.); (A.T.)
- Correspondence: (S.G.); (D.Ł.); Tel.: +48-81-445-60-93 (S.G.); +48-81-445-66-96 (D.Ł.)
| | - Aneta Nowakiewicz
- Department of Veterinary Microbiology, Faculty of Veterinary Medicine, University of Life Sciences, Akademicka 12, 20-033 Lublin, Poland; (A.N.); (A.T.)
| | - Aleksandra Trościańczyk
- Department of Veterinary Microbiology, Faculty of Veterinary Medicine, University of Life Sciences, Akademicka 12, 20-033 Lublin, Poland; (A.N.); (A.T.)
| | - Mariusz Dyląg
- Department of Mycology and Genetics, Faculty of Biological Sciences, University of Wroclaw, 51-148 Wroclaw, Poland;
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Answer to November 2021 Photo Quiz. J Clin Microbiol 2021; 59:e0316420. [PMID: 34664994 DOI: 10.1128/jcm.03164-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Gnat S, Łagowski D, Dyląg M, Zielinski J, Nowakiewicz A. In vitro evaluation of photodynamic activity of methylene blue against Trichophyton verrucosum azole-susceptible and -resistant strains. JOURNAL OF BIOPHOTONICS 2021; 14:e202100150. [PMID: 34185387 DOI: 10.1002/jbio.202100150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 06/13/2023]
Abstract
The intense search for the "Holy Grail" of antifungal therapy can be observed today. The searches are not limited only to discovery of potential antifungal drugs, but also new therapeutic strategies involving the use of chemosensitizers to achieve synergistic effect or physicochemical factors inducing stress conditions in fungal cells. In this study was examined in vitro effectiveness of photodynamic antifungal strategy with methylene blue using a light beam with a wavelength equal to 635 nm toward the Trichophyton verrucosum susceptible and itraconazole- and/or fluconazole-resistant strains. Methylene blue used at concentration equal to 5 μg/mL and in the presence of 40 J/cm2 of light energy showed fungicidal effect toward the susceptible strains. However, for azole-resistant isolates, only the energy dose equal to 60 J/cm2 at 5 μg/mL of methylene blue allowed to kill the pathogen. This study confirms that methylene blue induced by red light has a definite inhibitory effect on zoophilic dermatophytes.
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Affiliation(s)
- Sebastian Gnat
- Faculty of Veterinary Medicine, Department of Veterinary Microbiology, University of Life Sciences, Lublin, Poland
| | - Dominik Łagowski
- Faculty of Veterinary Medicine, Department of Veterinary Microbiology, University of Life Sciences, Lublin, Poland
| | - Mariusz Dyląg
- Faculty of Biological Sciences, Department of Mycology and Genetics, University of Wroclaw, Wroclaw, Poland
| | - Jessica Zielinski
- Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Aneta Nowakiewicz
- Faculty of Veterinary Medicine, Department of Veterinary Microbiology, University of Life Sciences, Lublin, Poland
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Sooriya S, Jayapalan S, Mini G, Manjusree S, Nandakumar L. Chronic Dermatophytosis: Clinico-Mycological Determinants and Antifungal Susceptibility Pattern. Indian J Dermatol 2021; 66:329. [PMID: 34446965 PMCID: PMC8375531 DOI: 10.4103/ijd.ijd_283_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Recent years have witnessed a dramatic increase in chronic unresponsive dermatophytosis. A study was conducted to quantify the proportion of patients with chronic dermatophytosis and to determine the clinico-mycological predictors of chronicity including antifungal susceptibility. Methods: Hospital-based cross-sectional study design was adopted. Four hundred and twenty-five patients were studied. The outcome variable was chronic dermatophytosis and the determinants were clinico-mycological characteristics. Chi-square and odds ratio (OR) with 95% confidence interval (CI) were calculated. Results: Chronic dermatophytosis was seen in 29.4%. Past history of dermatophytosis, OR 0.44 (95% CI 0.28–0.68); family history of dermatophytosis, OR 1.66 (95% CI 1.06–2.56); HIV infection, OR 9.88 (95% CI 1.09–89.33); treatment with topical antifungals, OR 2.4 (95% CI 1.5–3.9); systemic antifungals, OR 3.9 (95% CI 2.5–6.1); topical steroids, OR 2.02 (95% CI 1.25–3.25); multiple-site infection, OR 1.97 (95% CI 1.24–3.13); and tinea unguium, OR 6.52 (95% CI 2.89–14.7) were the significant determinants. Trichophyton mentagrophytes (73.6%) was the most common isolate followed by Trichophyton rubrum and Microsporum gypseum (13.2%) each. A percentage of 77.4 of the isolates were resistant—73.6% isolates to terbinafine and 3.8% isolates to fluconazole. None of the isolates were resistant to itraconazole. Conclusion: Significant determinants were host-related factors. Thorough history taking, patient examination, and education can improve the present scenario. Microbiological resistance was not a significant predictor. High proportion of resistant strains should be an eye opener. Developing and adopting a standard uniform treatment protocol throughout the country should be the need of the hour.
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Affiliation(s)
- S Sooriya
- Department of Dermatology and Venereology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Sabeena Jayapalan
- Department of Dermatology and Venereology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - G Mini
- Department of Dermatology and Venereology, Government Medical College, Kollam, Kerala, India
| | - S Manjusree
- Department of Microbiology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Lakshmy Nandakumar
- Department of Microbiology, Government Medical College, Thiruvananthapuram, Kerala, India
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Gnat S, Łagowski D, Dyląg M, Ptaszyńska A, Nowakiewicz A. Modulation of ERG gene expression in fluconazole-resistant human and animal isolates of Trichophyton verrucosum. Braz J Microbiol 2021; 52:2439-2446. [PMID: 34351602 PMCID: PMC8578519 DOI: 10.1007/s42770-021-00585-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 07/11/2021] [Indexed: 12/03/2022] Open
Abstract
Dermatophytes are a group of eukaryotic microorganisms characterized by high capacity to colonize keratinized structures such as the skin, hair, and nails. Over the past years, the incidence of infections caused by zoophilic species, e.g., Trichophyton verrucosum, has been increasing in some parts of the world, especially in Europe. Moreover, the emergence of recalcitrant dermatophytoses and in vitro resistant dermatophytes has become a cause of concern worldwide. Here, we analyzed the mechanisms underlying resistance to fluconazole among clinical isolates of T. verrucosum. Quantitative RT-PCR was carried out to determine the relative expression levels of mRNA transcripts of ERG3, ERG6, and ERG11 genes in the fungal samples using the housekeeping gene GAPDH as a reference. Our results showed that the upregulation of the ERG gene expression is a possible mechanism of resistance to fluconazole in this species. Furthermore, ERG11 is the most statistically significantly overexpressed gene in the pool of fluconazole-resistant T. verrucosum isolates. Additionally, we have demonstrated that exposure to fluconazole increases the levels of expression of ERG genes in fluconazole-resistant isolates of T. verrucosum. In conclusion, this study has shown one of the possible mechanisms of resistance to fluconazole among zoophilic dermatophytes, which involves the maintenance of high levels of expression of ERG genes after drug exposure.
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Affiliation(s)
- Sebastian Gnat
- Department of Veterinary Microbiology, Faculty of Veterinary Medicine, Institute of Preclinical Veterinary Sciences, University of Life Sciences, Akademicka 12, 20-033, Lublin, Poland
| | - Dominik Łagowski
- Department of Veterinary Microbiology, Faculty of Veterinary Medicine, Institute of Preclinical Veterinary Sciences, University of Life Sciences, Akademicka 12, 20-033, Lublin, Poland.
| | - Mariusz Dyląg
- Department of Mycology and Genetics, Faculty of Biological Sciences, Institute of Genetics and Microbiology, University of Wroclaw, Wroclaw, Poland
| | - Aneta Ptaszyńska
- Department of Imm, unobiology, Institute of Biological Sciences, Faculty of Biology and Biotechnology, Maria Curie-Skłodowska University, Lublin, Poland
| | - Aneta Nowakiewicz
- Department of Veterinary Microbiology, Faculty of Veterinary Medicine, Institute of Preclinical Veterinary Sciences, University of Life Sciences, Akademicka 12, 20-033, Lublin, Poland
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Antifungal Susceptibility and Mutations in the Squalene Epoxidase Gene in Dermatophytes of the Trichophyton mentagrophytes Species Complex. Antimicrob Agents Chemother 2021; 65:e0005621. [PMID: 33972254 PMCID: PMC8284460 DOI: 10.1128/aac.00056-21] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
During the past decade, a prolonged and serious outbreak of dermatophytosis due to a terbinafine-resistant novel species in the Trichophyton mentagrophytes-T. interdigitale complex has been ongoing in India, and it has spread to several European countries. The objective of this study was to investigate the molecular background of the squalene epoxidase (SQLE) gene in order to understand the risk of emergence and spread of multiresistance in dermatophytes. Antifungal susceptibility to fluconazole, griseofulvin, itraconazole, ketoconazole, miconazole, naftifine, sertaconazole, and terbinafine was tested in 135 isolates from India, China, Australia, Germany, and The Netherlands. Based on the latest taxonomic insights, strains were identified as three species: T. mentagrophytessensu stricto (n = 35), T. indotineae (n = 64, representing the Indian clone), and T. interdigitalesensu stricto (n = 36). High MICs of terbinafine (>16 mg/liter) were found in 34 (53%) T. indotineae isolates. These isolates showed an amino acid substitution in the 397th position of the SQLE gene. Elevated MICs of terbinafine (0.5 mg/liter) were noted in 2 (3%) T. indotineae isolates; these isolates lead to Phe415Val and Leu393Ser of the SQLE gene. The stability of the effect of the mutations was proven by serial transfer on drug-free medium. Lys276Asn and Leu419Phe substitutions were found in susceptible T. mentagrophytes strains. The Phe377Leu/Ala448Thr double mutant showed higher MIC values for triazoles. High MICs of terbinafine are as yet limited to T. indotineae and are unlikely to be distributed throughout the T. mentagrophytes species complex by genetic exchange.
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Verma SB, Panda S, Nenoff P, Singal A, Rudramurthy SM, Uhrlass S, Das A, Bisherwal K, Shaw D, Vasani R. The unprecedented epidemic-like scenario of dermatophytosis in India: III. Antifungal resistance and treatment options. Indian J Dermatol Venereol Leprol 2021; 87:468-482. [PMID: 34219433 DOI: 10.25259/ijdvl_303_20] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 08/01/2020] [Indexed: 02/03/2023]
Abstract
One of the canonical features of the current outbreak of dermatophytosis in India is its unresponsiveness to treatment in majority of cases. Though there appears to be discordance between in vivo and in vitro resistance, demonstration of in vitro resistance of dermatophytes to antifungals by antifungal susceptibility testing is essential as it may help in appropriate management. The practical problem in the interpretation of antifungal susceptibility testing is the absence of clinical breakpoints and epidemiologic cutoff values. In their absence, evaluation of the upper limit of a minimal inhibitory concentration of wild type isolates may be beneficial for managing dermatophytosis and monitoring the emergence of isolates with reduced susceptibility. In the current scenario, most of the cases are unresponsive to standard dosages and duration of treatment recommended until now. This has resulted in many ex-cathedra modalities of treatment that are being pursued without any evidence. There is an urgent need to carry out methodical research to develop an evidence base to formulate a rational management approach in the current scenario.
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Affiliation(s)
| | - Saumya Panda
- Department of Dermatology, Belle Vue Clinic, Kolkata, West Bengal, India, India
| | - Pietro Nenoff
- Department of Dermatology and Laboratory Medicine, Laboratory for Medical Microbiology, Moelbis, Germany
| | - Archana Singal
- Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, Delhi, India
| | - Shivprakash M Rudramurthy
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Silke Uhrlass
- Department of Dermatology and Laboratory Medicine, Laboratory for Medical Microbiology, Moelbis, Germany
| | - Anupam Das
- Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
| | - Kavita Bisherwal
- Department of Dermatology, Venereology and Leprosy, Lady Hardinge Medical College and SSK Hospital, Delhi
| | - Dipika Shaw
- Department of Medical Microbiology, PGI, Chandigarh, India
| | - Resham Vasani
- Department of Dermatology, Bhojani Clinic, Mumbai, Maharashtra, India
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