Disseminated dermatophytosis caused by Microsporum gypseum in two patients with the acquired immunodeficiency syndrome

Tinea Incognito: Challenges in Diagnosis and Management

Tinea incognito is a dermatophyte infection with atypical features, due to the use of topical or systemic steroids or other immunosuppressive medications. Delayed diagnosis, spread of the infection to critical body surfaces, resistance to antifungal drugs, and increased costs due to prolonged hospitalization and multiple treatment regimens often complicate tinea incognito. It can affect individuals of all ages and genders, but it is more common in children. Atypical clinical appearance often necessitates differentiation from other diseases such as eczema, seborrheic dermatitis, lupus erythematosus, psoriasis, or other non-fungal skin conditions. The treatment of tinea incognito usually involves discontinuation of topical steroids or other immunosuppressive medications. Preventive measures and management of the underlying fungal infection are necessary and can be achieved with antifungal drugs. Patients should wear loose cotton clothes, use boiling water for laundry, and iron their clothing before wearing them. Additionally, they should avoid sharing bed linens, towels, clothes, and shoes. This review aims to raise awareness of tinea incognito among health practitioners, provide tips for detecting the disorder, include it in the differentials, and evaluate the available diagnostic procedures.

Molecular and Phenotypic Characterization of Nannizzia (Arthrodermataceae)

Phylogenetic studies of the family Arthrodermataceae have revealed seven monophyletic dermatophyte clades representing the genera Trichophyton, Epidermophyton, Nannizzia, Lophophyton, Paraphyton, Microsporum, and Arthroderma. Members of the genus Nannizzia are geo- or zoophiles that occasionally infect humans. With the newly proposed taxonomy, the genus Nannizzia comprises thirteen species, i.e., Nannizzia aenigmatica, N. corniculata, N. duboisii, N. fulva, N. graeserae, N. gypsea, N. nana, N. incurvata, N. perplicata, N. persicolor, N. praecox, and two novel species. Nannizzia polymorpha sp. nov. was isolated from a skin lesion of a patient from French Guiana. For the strain originally described as Microsporum racemosum by Borelli in 1965, we proposed Nannizzia lorica nom. nov. The species are fully characterized with five sequenced loci (ITS, LSU, TUB2, RP 60S L1 and TEF3), combined with morphology of the asexual form and physiological features. A key to the species based on phenotypic and physiological characters is provided.

Antifungal activity of Mongolian medicinal plant extracts

The in vitro antifungal activity of extracts obtained from 14 medicinal plants of the mongolian flora were investigated by measuring their minimal inhibitory concentration (MIC) against fungi cause of cutaneous diseases such as Candida species, dermatophytes and Malassezia furfur. Among the species examined, Stellaria dichotoma L., Scutellaria scordifolia L. Aquilegia sibirica Fisch. Et Schrenk. and Hyoscyamus niger L. extracts demonstrated antifungal activity against all studied fungi. In particular, S. scordifolia L. methanol extract, obtained at room temperature, showed the best activity against Candida spp., Malassezia furfur and dermatophytes with GMMIC₅₀ values of 22 µg/mL, 64 µg/mL and 32 µg/mL, respectively. The flavones, luteolin and apigenin, identified in S. scordifolia extracts, and rutin identified in S. dichotoma and Hyoscyamus niger L. extracts, could be responsible of the observed antifungal activity.

Dermatophytes and dermatophytosis in the eastern and southern parts of Africa

Dermatophytosis is currently a disease of global importance and a public health burden. It is caused by dermatophytes, which attack and grow on dead animal keratin. Dermatophytes belong to three genera, namely, Epidermophyton, Microsporum, and Trichophyton. The predominant clinical forms and causative agents vary from one region of the world to another. Poor socioeconomic status, high population densities, and poor sanitary conditions are some of the factors responsible for the high prevalence of dermatophytosis in many developing countries, which include countries in southern and eastern Africa, the focus of this review. To the best of our knowledge, there is currently no review article on published findings on dermatophytosis in the eastern and southern parts of Africa. This information will be of interest to the medical and research community since the world has become a global village. This review covers published research findings in eastern and southern regions of Africa until this date. The countries covered in the current review include Kenya, Ethiopia, Tanzania, South Africa, Mozambique, Madagascar, Malawi, Rwanda, Burundi, Uganda, Zambia, Zimbabwe, and Botswana. T. violaceum is the most common human etiological agent in all the countries under review with prevalence ranging from 56.7% to 95%, except for Madagascar (M. langeronii, reclassified as M. audouinii), Uganda (M. gypseum) and Malawi (M. audouinii). Tinea capitis was the most clinical type, followed by tinea corporis. Etiological agents of animal dermatophytoses were variable in the countries where they were reported. Major risk factors for dermatophytoses are age, climatic, and socioeconomic factors.

Severe Dermatophytosis and Acquired or Innate Immunodeficiency: A Review

Dermatophytes are keratinophilic fungi responsible for benign and common forms of infection worldwide. However, they can lead to rare and severe diseases in immunocompromised patients. Severe forms include extensive and/or invasive dermatophytosis, i.e., deep dermatophytosis and Majocchi’s granuloma. They are reported in immunocompromised hosts with primary (autosomal recessive CARD9 deficiency) or acquired (solid organ transplantation, autoimmune diseases requiring immunosuppressive treatments, HIV infection) immunodeficiencies. The clinical manifestations of the infection are not specific. Lymph node and organ involvement may also occur. Diagnosis requires both mycological and histological findings. There is no consensus on treatment. Systemic antifungal agents such as terbinafine and azoles (itraconazole or posaconazole) are effective. However, long-term outcome and treatment management depend on the site and extent of the infection and the nature of the underlying immunodeficiency.

Dermatophytosis in patients with human immunodeficiency virus infection: clinical aspects and etiologic agents

Dermatophytosis in individuals with human immunodeficiency virus infection seems to manifest with atypical, multiple, or extensive lesions more frequently. In addition, there are reports of presentations with little inflammation, called anergics. Less common etiologic agents have been isolated in these individuals, such as Microsporum species. To describe clinical aspects and etiologic agents of dermatophytosis in individuals with human immunodeficiency virus (HIV) infection. Patients with clinical diagnosis of dermatophytosis underwent scarification for mycological diagnosis through direct microscopic examination and fungal isolation in culture on Sabouraud dextrose agar. Sixty individuals had a clinical hypothesis of dermatophytosis. In 20 (33.3%) of the 60 patients, dermatophytosis was confirmed through a mycological study. Tinea corporis, diagnosed in 14 patients, was the most frequent clinical form, followed by tinea unguium in 7, tinea cruris in 5, and tinea pedis in 1 patient. Most of the lesions of tinea corporis were anergic. Five patients with tinea unguium had involvement of multiple nails, with onychodystrophy as the predominant subtype. Multiple cutaneous lesions occurred in 3 patients and extensive cutaneous lesions in 4. Regarding the agent, Trichophyton rubrum was the most commonly isolated. The high occurrence of anergic skin lesions and involvement of multiple nails, especially as onychodystrophy, corroborates the hypothesis that atypical, disseminated, and more severe presentations are common in individuals with HIV infection. However, no Microsporum species was isolated even in atypical, extensive, or disseminated cases, in disagreement with previous reports. Therefore, the approach of squamous lesions in HIV-positive patients must include a mycological study, in view of the possibility of anergic dermatophytosis, to promote the introduction of a suitable therapeutic agent.

Microsporum aenigmaticum sp. nov. from M. gypseum complex, isolated as a cause of tinea corporis

An undescribed Microsporum species was isolated from skin scales recovered from a 40-mm large, annular, scaling lesion on the wrist of a 46-year-old woman. The risk factors for dermatophyte infection in the patient were frequent work in the garden, hunting, and contact with dogs and horses. Direct microscopic examination of the scales revealed the presence of dermatophyte hyphae; when the samples were cultured, a morphologically similar fungus grew on all slants in pure culture. Both of these findings strongly suggested that the isolate was the true causal agent of infection. The possible geophilic nature of the species was based on phylogenetic analysis (internal transcribed spacer region of rDNA and β-tubulin gene) that placed it in between species of the M. gypseum complex. However, its divergencies from all other Microsporum species exceeded 4% base pairs. Based on β-tubulin phylogeny, the isolated species is a sister to M. gypseum. The species produces abundant chlamydospores and clumps of hyphae similar to those of ascomatal primordia but no conidia and ascospores. The species was unable to grow at 37°C and does not grow on T6 basal medium, which is unlike other Microsporum species; hair perforation and urease tests were positive. The addition of histidine to the T6 medium resulted in rapid growth of the fungus. The phylogenetic evidence, morphology, growth parameters, and physiology justified the proposal that the isolate is a new species, M. aenigmaticum, sp. nov.

In vitro antifungal activity of epigallocatechin 3-O-gallate against clinical isolates of dermatophytes

Previously, we reported that epigallocatechin 3-O-gallate (EGCg) has growth-inhibitory effect on clinical isolates of Candida species. In this study, we investigated the antifungal activity of EGCg and antifungal agents against thirty-five of dermatophytes clinically isolated by the international guidelines (M38-A2). All isolates exhibited good susceptibility to EGCg (MIC₅₀, 2-4 μg/mL, MIC₉₀, 4-8 μg/mL, and geometric mean (GM) MICs, 3.36-4 μg/mL) than those of fluconazole (MIC₅₀, 2-16 μg/mL, MIC₉₀, 4-32 μg/mL, and GM MICs, 3.45-25.8 μg/mL) and flucytosin (MIC₅₀, MIC₉₀, and GM MICs, >64 μg/mL), although they were less susceptible to other antifungal agents, such as amphotericin B, itraconazole, and miconazole. These activities of EGCg were approximately 4-fold higher than those of fluconazole, and were 4 to 16-fold higher than flucytosin. This result indicates that EGCg can inhibit pathogenic dermatophyte species. Therefore, we suggest that EGCg may be effectively used solely as a possible agent or combined with other antifungal agents for antifungal therapy in dermatophytosis.

Tinea incognito Caused by Microsporum gypseum in a Patient with Advanced HIV Infection: A Case Report

The prevalence and the clinical relevance of dermatophytoses in HIV-infected patients are poorly documented, particularly for those caused by tinea incognito. Here, we report a case of widespread facial tinea incognito occurring in an Italian patient with advanced HIV infection, showing both skin and brain lesions. Second-line treatment with liposomal amphotericin B and cotrimoxazole, administered after a microbiological characterization of the skin scrapings, led to complete clearance of all lesions.

Extracellular protease expression in Microsporum gypseum complex, its regulation and keratinolytic potential

Two soil isolates of Microsporum gypseum were studied for the production of extracellular proteases. Both the strains secreted protease on glucose-gelatin medium. The enzyme activity peaked on day 15 at 28 °C. Asparagine repressed protease yield. Sugars caused catabolite repression of protease formation. Protease activities of both the isolates were significantly affected by incubation period, culture media and carbohydrates used. Both the strains grew on the skin bait and caused a gravimetrically measurable loss of the substrate. Despite less pronounced differences in the keratinase levels, great variations occurred in the amount of keratin degraded by two isolates. Keratinase production as well as loss in substrate mass was better in glucose-lacking flasks than those containing the sugar. Although the rate of keratin degradation was independent of enzyme production, statistically positive correlations were recorded between loss in substrate mass: yielded dry mycelial weight and substrate degradation: keratinase levels.

Trichophyton species susceptibility to green and red propolis from Brazil

AIMS

The in vitro antifungal activity of Brazilian green and red propolis was tested against different species of Trichophyton.

METHODS AND RESULTS

The antifungal activity of the Brazilian aqueous and alcoholic extracts of the green propolis and the alcoholic extract of red propolis was observed against Trichophyton rubrum, Trichophyton tonsurans and Trichophyton mentagrohytes samples, using as controls itraconazole and terbinafine. The minimal inhibitory concentration was determined following the microdilution method indicated by the 'Clinical and Laboratory Standards Institute'. The minimal fungicide concentration was determined by the absence of growth in liquid sabouraud culture medium. The data obtained showed that the green propolis alcoholic extract's antifungal activity was from 64 to 1024 microg ml(-1), whereas the red propolis alcoholic extract was from 8 to 1024 microg ml(-1).

CONCLUSIONS

The antifungal activity of the red propolis alcoholic extract was more efficient than the green propolis alcoholic extract for all three species studied. The T. rubrum samples were shown to be more sensitive to the antifungal activity of the alcoholic extracts of the propolis.

SIGNIFICANCE AND IMPACT OF THE STUDY

The antifungal potential of the alcoholic extracts of green and red propolis demonstrated suggest an applicable potential as an alternative treatment for dermatophytosis caused by these species.

Immunoprophylaxis of dermatophytosis in animals

Dermatophytosis is a relatively common disease in many countries occurring endemically both in companion and food animals. Fungi belonging to the genera Trichophyton and Microsporum are most often isolated from clinical cases. Measures to control and prevent dermatophytosis include sanitation, hygienic measures and treatment. In some countries, successful control and eradication have been achieved by mass vaccination of cattle and fur-bearing animals. Vaccines containing live attenuated cells of the fungus stimulate a cell-mediated immune response conferring long-lasting protection against subsequent challenge by the homologous fungus. A delayed type hypersensitivity (DTH) skin test using appropriate dermatophyte antigens is suitable to assess the response. Inactivated dermatophyte vaccines are available for use in cattle, horse, dog, and cat in some countries. However, the scientific literature is scarce making it difficult to conclude on efficacy and appropriate use. Current vaccines are all first generation vaccines. Attempts have been made to prepare subunit vaccines based on new knowledge about virulence factors like the keratinases, so far with limited success. Candidate antigens must be able to stimulate a strong T helper 1 cell response and future research should focus on identification of major T-cell epitopes that specifically elicit a DTH reaction. Dermatophytosis is a zoonotic disease. In Norway and a few other countries, systematic vaccination against cattle ringworm has almost eliminated the disease, and ringworm in man caused by T. verrucosum is almost nonexistent. A similar benefit could be expected if a safe and efficacious vaccine was available for Microsporum canis infection in cats and dogs.

Epidemiology of dermatophytoses in a rural community in Eastern Nigeria and review of literature from Africa

A total of 4,287 primary school children, comprising 1,740 males and 2,547 females in Arochukwu local government area of Abia state Nigeria were examined for clinical signs of dermatophytoses. About 873 (20.4%), consisting of 505 males and 368 females had lesions consistent with dermatophytoses. The disease was more prevalent in males (29%) than females (14.4%) in a ratio of approximately 2:1 (P < 0.05). The infection rate increased from 16.8% in the 4-6 year age group to a peak of 28.1% in the 10-12 year age bracket and dropped sharply to 5.6% in the 16-18 year group. The highest prevalence (39%) was observed among males aged 10-12 years while females 16-18 years had the lowest prevalence (2.5%). Tinea capitis was the predominant clinical type of dermatophytoses, and occurred in 13.7% of the total population studied and 67% of lesion positive cases. Trichophyton soudanense and Trichophyton tonsurans the predominant aetiological agents of dermatophytoses with a prevalence of 26.2% and 21.6%, respectively. Others include Trichophyton mentagrophytes (18.8%), Epidermophyton floccosum (8.3%), Microsporum audouinii (6.4%), Microsporum gypseum (6.0%), Trichophyton rubrum (5.5%) and Microsporum ferrugineum (7.3%), which was isolated for the first time in Nigeria.

Species distribution and antifungal susceptibilities of dermatophytes during a one year period at a university hospital in Turkey

Dermatophyte infections have been considered to be a major public health problem in many parts of the world. The aim of this study was to determine the causative agents of dermatophytoses and their antifungal susceptibilities in a Turkish University Hospital, west of Turkey. A total of 926 patients suspected to have dermatophytic lesions were examined over a period of 1 year (2001-2002). Samples collected from skin, hair and nails were submitted to direct microscopical examination using KOH and Calcofluor white stain, cultured on Sabouraud dextrose agar and Mycosel agar. The prevalence of dermatophytoses was 7.34% (68/926). Trichophyton rubrum was the most frequent dermatophyte isolated (56%) followed by T. mentagrophytes (38%), T. violaceum (1.5%), T. verrucosum (1.5%), Microsporum canis (1.5%) and Epidermophyton floccosum (1.5%). Tinea pedis (47%) was the most common type of infection, followed by tinea unguium (29%), tinea inguinalis (15%), tinea corporis (7.4%) and tinea capitis (1.6%). Secondary, we have tested 68 strains of dermatophytes against four antifungal agents following mainly the National Committee for Clinical Laboratory Standards M38-P standard for filamentous fungi. In general, all antifungals were shown to be highly effective and itraconazole and naftifine appeared more active than ketoconazole and oxiconazole.

Concentric rings: an unusual presentation of tinea corporis caused by Microsporum gypseum

A case of tinea corporis with the unusual presentation of concentric erythematous rings on the abdomen is reported. The pathogen was identified as Microsporum gypseum. While a number of unusual lesions have been described in M. gypseum infections, we are unaware of any reports on concentric rings.

Antifungal activities of extracts from Thai medicinal plants against opportunistic fungal pathogens associated with AIDS patients

Summary In this study, 36 extracts derived from 10 plant species were selected to screen for their antifungal activity against clinical isolates of Candida albicans, Cryptococcus neoformans and Microsporum gypseum. Selection was based on their use by traditional Thai healers or their reported antimicrobial activities in an attempt to find bioactive medicines for use in the treatment of opportunistic fungal infections in AIDS patients. The disc diffusion and hyphal extension-inhibition assays were primarily used to test for inhibition of growth. Minimum inhibitory concentration was determined by dilution methods. The chloroform extracts of Alpinia galanga and Boesenbergia pandurata had pronounced antifungal activity against C. neoformans and M. gypseum, but exhibited weak activity against C. albicans. Alpinia galanga and B. pandurata are excellent candidates for the development of a remedy for opportunistic fungal infections in AIDS patients.

AIDS and HIV infections: uncommon presentations

Infection with HIV or AIDS has a great impact on skin diseases, not only by affecting the immune system and thereby host defense against bacterial, viral, or mycotic infection, but also by changing tumor immune response and autoimmune reactivity. In the present review, emphasis will be made on infectious diseases, including sexually transmitted disease, inflammatory skin disease, and neoplasias. Knowledge of changing disease pattern with HIV/AIDS may help the clinical dermatologist and venerologist to identify dermatoses and act in the most appropriate manner to support the patient.

Scutular tinea of the scrotum: report of two cases

Infections caused by dermathophytes in the scrotal skin are uncommon especially due to Microsporum gypseum, which may form scutular or favus-like lesions. We report two patients with this type of tinea: one immune suppressed by HIV infection and another immunocompetent without comorbidity. In the literature we found only two reports in immunocompetent patients and some in immune suppressed with similar symptoms.

In vitro susceptibility testing of Microsporum gypseum isolated from healthy cattle and soil samples against itraconazole, terbinafine, fluconazole and topical veterinarian drugs

The present study evaluated in vitro susceptibility testing of dermatophytes isolates from healthy cattle and soil samples against three antifungal agents and three topical veterinarian drugs. Itraconazole and terbinafine showed a higher in vitro fungicidal activity than fluconazole. The veterinarian drugs LEPECID and iodine 5% were more active in vitro than the UNGUENTO spray. All drugs showed fungicidal activity against Microsporum gypseum, and they may be considered as efficient agents for the topical treatment of dermatophytoses in cattle.

Widespread and invasive Trichophyton rubrum infection mimicking Kaposi's sarcoma in a patient with AIDS

Opportunistic fungal infections are commonly encountered in AIDS patients. Candidiasis, tinea pedis, onychomycosis, and deep mycotic infections have been the fungal infections most frequently reported in these patients. Dermatophyte infections can appear to be atypical and aggressive in these patients and may lead to a misdiagnosis. We report a Trichophyton rubrum infection in a 44-year-old man with AIDS that presented as a widespread and multiple tumor-like appearance. After the patient was treated with terbinafine for 21 weeks, the lesions cleared completely. We think that this type of dermatophyte infection is very unusual in patients with AIDS and could lead to inappropriate diagnostic processes and treatments.

Dermatophytosis on the eyelid caused by Microsporum gypseum

We report a case of tinea on the eyelid in a woman with psoriasis. Due to the history of psoriasis and clinical aspect of the lesion the diagnosis of psoriasis was suggested in the first place; however, laboratory examination revealed Microsporum gypseum. The patient was treated with oral itraconazole resulting in clinical and mycological cure. We emphasize the uncommon location of tinea caused by M. gypseum and the importance of searching for fungal infection on scaly lesions.

Disseminated dermatophytosis caused by Microsporum gypseum in an AIDS patient: response to terbinafine and amorolfine. Fallbericht. Disseminierte Dermatophytose durch Microsporum gypseum bei einem AIDS- Patienten mit Ansprechen auf Terbinafin und Amorolfin

A 51-year-old white male, native of Rio de Janeiro, Brazil, with advanced AIDS and in chronic use of imidazoles for oral candidosis, presented erythematous, desquamative, pruriginous plaques of 1 month evolution on the trunk, inguinal/crural region, and lower limbs. The diagnosis of dermatophytosis was based on the isolation of Microsporum gypseum from scales scraped from the skin lesions. The lesions regressed after 30 days treatment with itraconazole, 100 mg day(-1). After interruption of this antifungal, the mycosis recurred 2 months later, along with a toe onychomycosis also caused by M. gypseum. Attempted reintroduction of itraconazole at higher dose was unsuccessful. Patient responded well to treatment with terbinafine 250 mg day(-1) for 45 days. However, the medication had to be interrupted as a result of the emergence of a disseminated erythematous/papulous rash. Topical treatment with amorolfine cream was then performed, with a good clinical and mycological response.

Interlaboratory evaluation of the Etest for antifungal susceptibility testing of dermatophytes

A three-site interlaboratory reproducibility evaluation of the Etest concentration gradient strip method for testing antifungal susceptibilities was conducted using 30 strains of dermatophytes exposed to strips loaded with ketoconazole (KTZ), itraconazole (ITZ), amphotericin B (AMB) and fluconazole (FCZ). Etest minimal inhibitory concentrations were compared with those obtained using a broth microdilution method. All isolates produced clearly detectable growth at 28 degrees C within 72-96 h for reading with the Etest method. The highest interlaboratory agreement between Etest and the microdilution method was shown with FCZ (94%), and the lowest was seen with KTZ (60%). Overall, agreement between the Etest and microdilution method was variable. It was excellent for AMB (97%), good for ITZ (80%) and KTZ (77%), and low for fluconazole (27%).

Collaborative evaluation of optimal antifungal susceptibility testing conditions for dermatophytes

A multicenter study was conducted to define the most suitable testing conditions for antifungal susceptibility of dermatophytes. Broth microdilution MICs of clotrimazole, itraconazole, and terbinafine were determined in three centers against 60 strains of dermatophytes. The effects of inoculum density (ca. 10(3) and 10(4) CFU/ml), incubation time (3, 7, and 14 days), endpoint criteria for MIC determination (complete [MIC-0] and prominent [MIC-2] growth inhibition), and incubation temperature (28 and 37 degrees C) on intra- and interlaboratory agreement were analyzed. The optimal testing conditions identified were an inoculum of 10(4) CFU/ml, a temperature of incubation of 28 degrees C, an incubation period of 7 days, and MIC-0.

Case Report. Widespread tinea corporis due to Trichophyton rubrum

We report the case of a 36-year-old man who presented large erythematous plaques involving the trunk, face and extremities, since one month. Some of these lesions had a psoriasis-like aspect, with abundant superficial scaling. Direct microscopic examination of scales removed from the plaques revealed numerous hyphae. Cultural examination lead to the identification of Trichophyton rubrum species. Our case of tinea corporis presented some peculiarities related both to the extension of the lesions and their clinical aspects.

Subcutaneous infection by Microsporum gypseum

We report a case of subcutaneous infection caused by the dermatophyte Microsporum gypseum in an immunocompetent host. The patient acquired the infection in the knee through a traumatic inoculation of a splinter. To our knowledge this is the first case of subcutaneous infection caused by this fungus.

Epidemiology and prevalence of onychomycosis in HIV-positive individuals

BACKGROUND

Patients who are human immunodeficiency virus (HIV) positive are predisposed to the development of infections including tinea pedis and onychomycosis. While smaller studies have been reported, there has been no large study evaluating the prevalence of onychomycosis in HIV-positive individuals, or comparing the development of onychomycosis in a typical temperate area with that in a typical tropical area.

METHODS

HIV-positive individuals were evaluated at five clinics: four in Ontario, Canada and one in Sao Paulo, Brazil. The subjects were asked questions to determine the epidemiology of onychomycosis in HIV-positive individuals. The feet were examined and nail material was obtained for mycologic examination to determine the causative organism of onychomycosis.

RESULTS

A total of 500 subjects were examined (415 men and 85 women; age (mean +/- SE), 39 +/- 0.4 years; 400 Canadian, 100 Brazilian). The racial origins of the Canadian patients were: Caucasian, 83.8%; Asian, 4.3%; African-American, 8.1%; Hispanic, 3.3%; American Indian, 0.3%. The Brazilian origins were: Caucasian, 68.7%; African, 18.1%; mixed race, 13.3%. Abnormal appearing nails and mycologic evidence of onychomycosis were present in 200 (40.0%) and 116 (23.2%), respectively, of 500 subjects. The prevalence of onychomycosis in the Canadian and Brazilian samples was 24.0% (96 of 400) and 20.0% (20 of 100), respectively. The projected prevalence of onychomycosis in HIV-positive individuals in Canada was 19.9% (95% CI: 16.0-23.9%) after taking into account the age and sex distribution of HIV-positive individuals in the population. When nails appeared clinically abnormal, the prevalence of onychomycosis was 50.5% (Canada, 51.3%; Brazil, 45.5%). For comparison, published data indicate that the prevalence of onychomycosis in immunocompetent individuals living in Canada is 6.9%. The clinical presentation of onychomycosis for the whole sample (n=500) was: distal and lateral subungual onychomycosis (DLSO), 20.0%; white superficial onychomycosis (WSO), 3.6%; proximal subungual onychomycosis (PSO), 1.8% (Canadian and Brazilian samples: DLSO 21.2% vs. 15.0%, WSO 3.3% vs. 5.0%, and PSO 1.5% vs. 3.0%). The distribution of the causative fungal organisms was: dermatophytes: Candida species: nondermatophyte molds, 73:2:2 (Canadian and Brazilian samples: dermatophytes 95.5% vs. 90.9%, Candida species 3.0% vs. 0%, and nondermatophyte molds 1.5% vs. 9.0%). The use of protease inhibitors, reverse transcriptase inhibitors, or oral antifungal agents did not make a significant difference in the prevalence of onychomycosis for both the Canadian and Brazilian groups. Patients with onychomycosis were aware of their abnormal appearing nails (chi2(1)=69.7, P<0.001), embarrassed by the appearance of their nails (chi2(1)=29.7, P<0.001), and took measures to hide their nails from other individuals. A higher proportion of individuals with onychomycosis experienced discomfort compared with those without the disease (chi2(1)=9.0, P=0.003). Also, individuals who experienced pain in the nail unit were more likely to have onychomycosis (risk odds ratio (ROR), 2.2; 95% CI: 1.0-4.7, P=0.05).

CONCLUSIONS

The prevalence of onychomycosis in HIV-positive individuals in the sample of 500 patients was 23.2%. In the Canadian (n=400) and Brazilian (n=100) samples, the corresponding figures were 24% and 20%, respectively, with the predominant causative organisms being dermatophytes. The projected prevalence of onychomycosis in HIV-positive Canadians is 19.9%. Predisposing factors include a CD4 count of approximately 370, a positive family history of onychomycosis, a history of tinea pedis, and walking barefoot around pools. Onychomycosis can be symptomatic, a source of embarrassment, and a potential cause of morbidity.

Tinea incognito due to Microsporum gypseum in three children

Tinea incognito is a dermatophytosis of atypical clinical character due to the absence of classic features of ringworm. It is caused by prolonged use of topical steroids, sometimes prescribed as a result of incorrect diagnosis. The cases reported in the literature have different clinical presentations and have generally been in adults. We report three children with tinea incognito in whom the lesions were psoriasis-like, eczema-like, and lichenoid, respectively. Diagnosis was confirmed by mycologic examination, which led to the identification of Microsporum gypseum, a geophilic dermatophyte which is an infrequent agent of mycotic infection in humans.