Dermatophyte infections in human immune deficiency virus (HIV) disease

Exploring the Co-occurrence of dermatophyte infection and ichthyosis: A report of 3 cases

Dermatophyte infections frequently pose diagnostic challenges, especially when occurring alongside ichthyosis, a genetic skin disorder characterized by dry, thickened, scaly skin. This case series outlines three cases where dermatophyte infections overlapped with ichthyosis, emphasizing the complexities in clinical identification and differential diagnosis. Atypical clinical presentations in these cases led to initial misdiagnoses. Ichthyosis, a genetic skin disorder characterized by thickened and scaly skin, creates an environment conducive to dermatophyte settlement, complicating the diagnostic process. The cases highlight the importance of considering fungal infections, even when clinical features deviate from the expected course. A vigilant diagnostic approach, including mycological examinations, is crucial for accurate identification and timely management.

Mucocutaneous mycoses in people living with human immunodeficiency virus in Indonesia

BACKGROUND

To date, integrated care for people living with human immunodeficiency virus (PLHIV) has improved. However, although the management of mucocutaneous mycosis cases has improved, disease progression might be different in immunocompromised patients, which leads to variable clinical manifestations.

OBJECTIVES

To describe the characteristics of mucocutaneous mycosis cases in the PLHIV population and its associated factors in Indonesia.

METHODS

This retrospective study was conducted from January 2014 to December 2018 in four academic hospitals. Data were acquired from medical records with the inclusion of mucocutaneous mycosis patients with concurrent HIV infection. Analysis with the chi-squared test was performed using Statistical Package for the Social Sciences (SPSS) version 20.0.

RESULTS

A total of 1,796 cases of mucocutaneous mycoses were identified in 1782 PLHIV. The most common types of infection were candidiasis (63%), followed by dermatophytosis (35.1%), and malasseziosis (1.9%), which were significantly higher in PLHIV with CD4 level <200 cells/mm³ . The proportions of male gender (78.6% vs. 56.3%, p < .001), high level of education (48.0% vs. 64.1%, p < .001), office workers (73.8% vs. 64.1%, p < .001), combination of topical and systemic antifungal agents (59.1% vs. 48.5%, p = .006) and not receiving antiretroviral therapy (63.2% vs. 7.8%, p < .001) were significantly higher in PLHIV with a CD4 level <200 cells/mm³ .

CONCLUSION

In Indonesia, the most common fungal infection in PLHIV is candidiasis. This study also addressed the important matters regarding mucocutaneous mycoses in PLHIV. Education is an important measure to prevent the incidence of cutaneous mycoses in PLHIV, especially in high-risk groups.

Clinicopathological Features of Seborrheic-Like Dermatitis in HIV-Infected Adults: A Single Institutional Descriptive Cross-Sectional Study

BACKGROUND

Atypical and severe clinical presentations of seborrheic-like dermatitis (SLD) are associated with HIV infection, correlating with advanced disease or low CD4 counts. Previous studies documented histological findings characteristic of seborrheic dermatitis in HIV-positive patients.

OBJECTIVE

To expand current knowledge of the clinicopathological characteristics of SLD in South African HIV-seropositive individuals.

METHODS

This prospective study included HIV-seropositive adult patients presenting with SLD to a dermatology clinic from March 2017 to April 2018. A dermatologist established the diagnosis of SLD and the severity of the disease. Detail about antiretroviral therapy (ART), the latest CD4 count, and the viral load was retrieved from the patients' clinical records. Histopathological assessment of the patients' skin biopsies was recorded using standardized data sheets and semiquantifiable grades.

RESULTS

This study included 13 women and 17 men. Fifty percent of patients showed severe or very severe SLD. Six (20.0%) patients presented with erythroderma. Statistical analysis did not show a significant correlation between severity of disease and CD4 count, viral load, or ART, respectively. This study confirmed that the presence of confluent parakeratosis, necrotic keratinocytes, plasma cells, neutrophils with leukocytoclasia, and leukoexocytosis are histopathological clues to SLD occurring in HIV-seropositive patients.

CONCLUSION

SLD in HIV patients may present with varying clinical severity, including erythroderma. The association between the prevalence and severity of SLD with CD4 count, viral load, and ART requires further studies with larger patient populations. The presence of specific histopathological features in a skin biopsy of SLD is a clue to the diagnosis of HIV.

Preparation, and Assessment of Antidermatophyte Activity of Miconazole-Urea Water-Soluble Film

Cutaneous mycoses, particularly tinea pedis caused by Trichophyton rubrum, are commonly known infections in humans. They are still considered as a major public health problem worldwide affecting the quality of life due to prolonged period of treatment and development of drug resistance, which leads to recurrence of infections. The objective of our study was to assess the effectiveness of miconazole in the presence and absence of urea, as a penetration enhancer, against T. rubrum and to formulate both of them in a water-soluble film to be applied topically for the purpose of treating tinea pedis caused by this fungus. Drug combination revealed synergism where miconazole minimum inhibitory concentration (MIC) and minimum fungicidal concentration (MFC) (0.5 and 1 mg/L) were considerably declined to 0.001 and 0.004 mg/L, respectively, when combined with 20% urea. This enhanced drug interaction activity against the test strain was explained by the alterations raised on the morphology and ultrastructures observed microscopically. Minimal fungicidal dose of miconazole/urea combination displayed plasmolysis and shrink cytoplasm; however, necrotic cells with punctured walls and degraded cytoplasmic content were observed at high fungicidal dose. Water-soluble films, prepared using increasing values of miconazole MFC and urea, were transparent, smooth, uniform, and flexible. Their physicochemical characters showed homogeneity in weight, thickness, drug content, and folding endurances with normal surface pH values, indicating the reproducibility of the preparation method. The novel simulation model for the film mechanism of action supported the idea and the suggested application method of the new dosage form. Evaluation of these films was carried in vitro using disk diffusion assay as well as in vivo using guinea pig dermatophytosis model. The in vitro assessment revealed an increase in the inhibition zone diameters in a concentration-dependent manner upon using 10 or 20% of urea combined with miconazole. In vivo test showed that combination of 0.004 mg/L miconazole with 20% urea (M + U20) showed the highest efficacy percentage (95.83%), which was statistically superior to the infected untreated control (p < 0.001) in fungal burden reduction as well as improvement in clinical scores (p < 0.001). This work supports the hypothesis and suggests a new promising dosage form for the treatment of T. rubrum infections.

Majocchi's granuloma: current perspectives

Majocchi’s granuloma (MG) is a rare fungal infection of the dermis that is mainly caused by dermatophytes (in ≥95% of cases); the most frequently identified cause is anthropophilic Trichophyton rubrum. In the rest of the cases, the causes are non-dermatophytic fungi such as Aspergillus species. This review aimed to provide information about the current perspectives on MG regarding its clinical characteristics, predisposing factors, laboratory diagnosis, and treatment strategies. Although the lower extremities were reported to be the most common site of infection, facial involvement has been predominant in the past 5 years. Our literature research showed that the most common predisposing factor (55%) is the use of topical steroid creams without potassium hydroxide examination during treatment of erythematous squamous dermatoses. A reliable diagnosis of MG is based on histopathological examination, including fungal culture and molecular analyses. MG should be treated not only with topical agents but also with systemic antifungal agents that are continued until the lesions are completely resolved. In systemic treatment, the most preferred drug is terbinafine, because of its efficacy, side effects, and safety.

Antifungal Activity of Ellagic Acid In Vitro and In Vivo

Ellagic acid (EA) has been shown to have antioxidant, antibacterial, and anti-inflammatory activities. In Uighur traditional medicine, Euphorbia humifusa Willd is used to treat fungal diseases, and recent studies suggest that it is the EA content which is responsible for its therapeutic effect. However, the effects of EA on antifungal activity have not yet been reported. This study aimed to investigate the inhibitory effect of EA on fungal strains both in vitro and in vivo. The minimal inhibitory concentration (MIC) was determined by the National Committee for Clinical Laboratory Standards (M38-A and M27-A2) standard method in vitro. EA had a broad spectrum of antifungal activity, with MICs for all the tested dermatophyte strains between 18.75 and 58.33 µg/ml. EA was also active against two Candida strains, with MICs between 25.0 and 75.0 µg/ml. It was inactive against Candida glabrata. The susceptibility of six species of dermatophytes to EA was comparable with that of the commercial antifungal, fluconazole. The most sensitive filamentous species was Trichophyton rubrum (MIC = 18.75 µg/ml). Studies on the mechanism of action using an HPLC-based assay and an enzyme linked immunosorbent assay showed that EA inhibited ergosterol biosynthesis and reduced the activity of sterol 14α-demethylase P450 (CYP51) in the Trichophyton rubrum membrane, respectively. An in vivo test demonstrated that topical administration of EA (4.0 and 8.0 mg/cm(2) ) significantly enhanced the cure rate in a guinea-pig infection model of Trichophyton rubrum. The results suggest that EA has the potential to be developed as a natural antifungal agent.

Lemon peels mediated synthesis of silver nanoparticles and its antidermatophytic activity

There is an increasing commercial demand for nanoparticles due to their wide applicability in various areas. Metallic nanoparticles are traditionally synthesized by wet chemical techniques, where the chemicals used are quite often toxic and flammable. In this work, The extract of lemon peel was prepared and mixed with 1 mM AgNO3 solution .The bioreduction of Ag(+) ion in solution was monitored using UV-visible spectrometer, FESEM and EDAX analysis. Skin scales were collected from patients with suspected dermatophytosis and the dermatophytes were isolated and identified. The AgNPs produced from lemon peels showed good activity against the isolated dermatophytes. The present research work emphasizes the use of lemon peels for the effective synthesize of AgNPs and could be used against the dermatophytes which are found to develop drug resistant towards broad-spectrum antibiotics. The biosynthesis of AgNPs using lemon peel extract is very simple and economic. The use of environmentally benign and renewable plant material offers enormous benefits of eco-friendliness.

Dermatophytosis and immunovirological status of HIV-infected and AIDS patients from Sao Paulo city, Brazil

Over the past decades, more people became infected with human immunodeficiency virus (HIV) and developed acquired immunodeficiency syndrome (AIDS). Because of that the incidence of fungal infections rose dramatically. It happened because this virus can modify the course of fungal diseases, leading to altered clinical pictures. The aim of this study was to evaluate epidemiological and biological aspects of dermatophytosis in HIV-positive and AIDS patients living in the city of São Paulo, Brazil. A total of 84 (44 HIV-positive and 40 AIDS) patients were enrolled in this study. The patients were tested for dermatophyte infections, as well as for the CD4(+) /CD8(+) and HIV viral load counts. Tinea unguium was most frequently observed in AIDS patients, whereas Tinea pedis was mostly observed in HIV-positive patients. The most frequent dermatophyte species was Trichophyton rubrum. CD4(+) counts and CD4(+) /CD8(+) ratios were not associated with a higher risk for dermatophytosis. On the other hand, viral load higher than 100 000 copies/ml was associated with a higher frequency of dermatophytosis. The results suggest to that although dermatophytosis is common in HIV-positive and AIDS patients, the degree of immunosuppression does not seems to correlate with increased risk of this fungal infection. In addition, high viral load as a predictive risk factor for dermatophyte infection should be subject of further evaluations.

The prevalence of dermatophyte infection in patients infected with human immunodeficiency virus

BACKGROUND

It is not known whether human immunodeficiency virus (HIV) infection is associated with an increased susceptibility to dermatophytes.

METHODS

In this study, we determined the prevalence of cutaneous fungal infection in a cohort of HIV-infected patients and HIV-negative controls, and examined the factors associated with an increased risk of infection.

RESULTS

Using a multiple regression analysis, we found that the strongest independent predictor of cutaneous fungal infection in both groups was a self-reported history of homosexual sex. There was no relationship between HIV infection or reduced CD4 count and the prevalence of dermatophyte infection.

CONCLUSIONS

HIV infection is not independently associated with an increased risk of cutaneous fungal disease.

Global gene expression of Trichophyton rubrum in response to PH11B, a novel fatty acid synthase inhibitor

AIMS

To determine the transcriptional responses of Trichophyton rubrum to the artificial substance, PH11B.

METHODS AND RESULTS

The broth microdilution assay for antifungal susceptibility testing of dermatophytes was used to measure the minimum inhibitory concentration (MIC) of PH11B. cDNA microarray technology and real-time RT-PCR were used to study the transcriptional responses of T. rubrum to PH11B. The MIC determined was 16 microg ml(-1). The analysis of microarray data revealed that 787 genes were affected. Transcript levels from 476 genes increased at least two times, while 311 gene transcript levels decreased at least two times.

CONCLUSIONS

PH11B has strong antifungal activity and the transcriptional response of T. rubrum to PH11B was determined.

SIGNIFICANCE AND IMPACT OF THE STUDY

This microarray data set provides an analysis of gene expression of T. rubrum under PH11B treatment. The data provide an insight into the various metabolic processes altered or activated by PH11B. This study provided an insight into the action mode of the PH11B on T. rubrum.

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.

Evaluation and management of Fungal infections in Immunocompromised patients

As the population of chronically immunosuppressed individuals continues to grow, the prevalence of fungal infections is increasing. Fungal infections in this patient population represent challenges in diagnosis and management. This article will review the common superficial and invasive mycoses that occur in the solid organ transplant and HIV-infected populations. Disease presentations are reviewed, but emphasis is placed on cutaneous manifestations. Recent advances in antifungal therapy and their direct application to specific diseases provide important new approaches to this complex and often seriously ill patient population.

The influence of surface carbohydrates during in vitro infection of mammalian cells by the dermatophyte Trichophyton rubrum

In order to better understand the role played by surface glycoconjugates during host cell adhesion and endocytosis of Trichophyton rubrum, we looked for the presence of carbohydrate-binding adhesins on the microconidia surface and their role on cellular interaction with epithelial and macrophages cells. The interaction of T. rubrum with chinese hamster ovary epithelial cells and their glycosylation-deficient mutants demonstrated a higher adhesion index in Lec1 and Lec2 mutants, that express mannose and galactose, respectively. Endocytosed fungi were shown preferentially in Lec2 cells. Addition of the carbohydrates to the interaction medium, pretreatment with lectins and with sodium periodate decreased the adhesion and endocytic index for all mutants. The ability of the fungus to penetrate into mammalian cells was confirmed in experiments using macrophages treated with cytochalasin D. Flow cytometric analysis showed that this fungus recognizes mannose and galactose. The binding was inhibited by the addition of methyl alpha-D-mannopyranoside and methyl alpha-D-galactopyranoside, and showed higher fluorescence intensity at 37 than at 28 degrees C. Trypsin treatment and heating of the cells reduced the binding, suggesting a (glyco) protein nature for the microconidia adhesins. The presence of lectin-like molecules in fungus cell could be observed by scanning electron microscopy of the fungus incubated with colloidal-gold labeled neoglycoproteins. Our results suggest that T. rubrum has the ability to invade mammalian cells and expresses carbohydrate-specific adhesins on microconidia surface that recognize mannose and galactose. These adhesins may play an important role on the adhesion and invasion of the fungus during the infectious process of dermatophytosis.

Tinea corporis in human immunodeficiency virus-positive patients: case report and assessment of oral therapy

Dermatophytosis in immunocompromised hosts is more varied and often more severe than in immunocompetent hosts. Early recognition and treatment with systemic therapy are important in human immunodeficiency virus (HIV)-positive patients in order to prevent severe infection. Potential drug resistance can occur due to chronic usage of systemic azole therapy in such patients, or the existence of atypical fungi. Although warnings have been made of possible drug interactions between certain antifungals and antiretroviral medications, only one combination has shown a clinically significant interaction. A case treated aggressively with oral terbinafine at the onset is presented.

BACKGROUND

Dermatophytosis in immunocompromised hosts is more varied and often more severe than in immunocompetent hosts. Early recognition and treatment with systemic therapy are important in human immunodeficiency virus (HIV)-positive patients in order to prevent severe infection.

OBJECTIVE

To analyze potential therapies for dermatophyte infections in immunocompromised patients and risk of drug resistance and interactions with antiretroviral medications.

METHODS

Literature search based on MEDLINE (1966-March 2003) and additional references obtained from cross-referencing retrieved articles. All information deemed relevant by the reviewers was included. A case study was employed to exemplify the usage of this information in patient care.

RESULTS

Although warnings have been made of possible drug interactions between certain antifungals and antiretroviral medications, only one combination has shown a clinically significant interaction.

CONCLUSIONS

When considering drug interactions and side-effects, there are no clinically significant reasons to avoid any oral antifungal for dermatophytosis in the HIV-positive patient.

Clinical Trichophyton rubrum Strain Exhibiting Primary Resistance to Terbinafine

The in vitro antifungal susceptibilities of six clinical Trichophyton rubrum isolates obtained sequentially from a single onychomycosis patient who failed oral terbinafine therapy (250 mg/day for 24 weeks) were determined by broth microdilution and macrodilution methodologies. Strain relatedness was examined by random amplified polymorphic DNA (RAPD) analyses. Data obtained from both broth micro- and macrodilution assays were in agreement and revealed that the six clinical isolates had greatly reduced susceptibilities to terbinafine. The MICs of terbinafine for these strains were >4 μg/ml, whereas they were <0.0002 μg/ml for the susceptible reference strains. Consistent with these findings, the minimum fungicidal concentrations (MFCs) of terbinafine for all six strains were >128 μg/ml, whereas they were 0.0002 μg/ml for the reference strain. The MIC of terbinafine for the baseline strain (cultured at the initial screening visit and before therapy was started) was already 4,000-fold higher than normal, suggesting that this is a case of primary resistance to terbinafine. The results obtained by the broth macrodilution procedure revealed that the terbinafine MICs and MFCs for sequential isolates apparently increased during the course of therapy. RAPD analyses did not reveal any differences between the isolates. The terbinafine-resistant isolates exhibited normal susceptibilities to clinically available antimycotics including itraconazole, fluconazole, and griseofulvin. However, these isolates were fully cross resistant to several other known squalene epoxidase inhibitors, including naftifine, butenafine, tolnaftate, and tolciclate, suggesting a target-specific mechanism of resistance. This is the first confirmed report of terbinafine resistance in dermatophytes.

Clinical Trichophyton rubrum strain exhibiting primary resistance to terbinafine

The in vitro antifungal susceptibilities of six clinical Trichophyton rubrum isolates obtained sequentially from a single onychomycosis patient who failed oral terbinafine therapy (250 mg/day for 24 weeks) were determined by broth microdilution and macrodilution methodologies. Strain relatedness was examined by random amplified polymorphic DNA (RAPD) analyses. Data obtained from both broth micro- and macrodilution assays were in agreement and revealed that the six clinical isolates had greatly reduced susceptibilities to terbinafine. The MICs of terbinafine for these strains were >4 microg/ml, whereas they were <0.0002 microg/ml for the susceptible reference strains. Consistent with these findings, the minimum fungicidal concentrations (MFCs) of terbinafine for all six strains were >128 microg/ml, whereas they were 0.0002 microg/ml for the reference strain. The MIC of terbinafine for the baseline strain (cultured at the initial screening visit and before therapy was started) was already 4,000-fold higher than normal, suggesting that this is a case of primary resistance to terbinafine. The results obtained by the broth macrodilution procedure revealed that the terbinafine MICs and MFCs for sequential isolates apparently increased during the course of therapy. RAPD analyses did not reveal any differences between the isolates. The terbinafine-resistant isolates exhibited normal susceptibilities to clinically available antimycotics including itraconazole, fluconazole, and griseofulvin. However, these isolates were fully cross resistant to several other known squalene epoxidase inhibitors, including naftifine, butenafine, tolnaftate, and tolciclate, suggesting a target-specific mechanism of resistance. This is the first confirmed report of terbinafine resistance in dermatophytes.

The cutaneous manifestations of HIV infection

Dermatologic disease is extremely common and varied in HIV-infected patients. While some cutaneous findings are nearly exclusive to HIV-seropositive individuals, many are found in the general population. However, HIV-infected individuals often have an increased prevalence or severity, atypical presentations, or difficulty with treatment of the disease. Immune reconstitution with HAART significantly reduces the prevalence of many dermatologic diseases, but also has associated cutaneous side effects. Correct and early diagnosis of skin disease in HIV-infected individuals allows for early management and improved quality of life. Because dermatologic manifestations may be the first clue of HIV infection, offering HIV testing to affected individuals can lead to early diagnosis and treatment of HIV infection and, ideally, a decrease in disease progression and transmission.