Onychomycosis due to Scopulariopsis brevicaulis: clinical features and response to systemic antifungals

Molecular identification of keratinophilic fungi associated with hair scalp and antifungal activity of green-synthesis zinc oxide nanoparticles

A diverse population of fungi colonizes human hair and skin due to millions of years of functional integration and mutual adaptation. The human body, with its fungal communities, forms a complex entity. Microbial imbalance is promoted by instabilities in the host-mycobiota interaction system, which can be related to the development of various diseases. By morphological and molecular identification, 15 genera comprising 24 species were isolated from 18 scalp samples collected from girls. Yeast-like structures were the most common species in this study; they were recovered from six samples (33.3%). They were represented by five species: Arachniotus ruber; Cosmospora aurantiicola; Cutaneotrichosporon oleaginosum; Geotrichum candidum and Suhomyces tanzawaensis. For the synthesis of zinc oxide nanoparticles (ZnO NPs), an aqueous extract of Zingiber officinale was utilized as a reducing and capping agent. The prepared NPs tested by X-ray diffraction, they had a hexagonal wurtzite structure. Most of the ZnO NPs were spherical, and their diameter was about 38.9 nm using a transmission electron microscope. ZnO NPs of the Fourier-transform infrared spectroscopy spectra were recorded in the range of 400-4000 cm-1. UV-visible diffuse reflectance spectroscopy showed the 200-800 nm wavelength range. ZnO NPs showed the highest activity against Ambrosiella hartigii Ambh2; Cladosporium cladosporioides Cladcl12; C. cf. cucumerinum Cladcu13; S. tanzawaensis Suht34, with minimal inhibitory concentrations 1.25 × 103 µg/mL on the four isolates.

Nondermatophyte mould onychomycosis

Nondermatophyte moulds (NDMs) onychomycosis is often difficult to diagnose as NDMs have been considered contaminants of nails. There are several diagnostic methods used to identify NDMs, however, repeated laboratory isolation is recommended to validate pathogenicity. With NDM and mixed infection (dermatophytes plus NDM) onychomycosis on the rise, accurate clinical diagnosis along with mycological tests is recommended. Systemic antifungal agents such as itraconazole and terbinafine (e.g. pulse regimen: 1 pulse = every day for one week, followed by no treatment for three weeks) have shown efficacy in treating onychomycosis caused by various NDMs such as Aspergillus spp., Fusarium spp., Scopulariopsis brevicaulis, and Onychocola canadensis. Studies investigating topical therapy and devices for NDM onychomycosis are limited. The emergence of antifungal resistance necessitates the incorporation of antifungal susceptibility testing into diagnosis when possible, for the management of recalcitrant infections. Case studies documented in the literature show newer azoles such as posaconazole and voriconazole as sometimes effective in treating resistant NDM onychomycosis. Treatment with broad-spectrum antifungal agents (e.g. itraconazole and efinaconazole) and other combination therapy (oral + oral and/or oral + topical) may be considerations in the management of NDM onychomycosis.

First reported case of disseminated Microascus gracilis infection in a lung transplant patient

Microascus gracilis is a specie of the genus Microascus in the family of Microascaceae and has been isolated from lung. It has never been reported as the cause of disseminated infection in humans. Herein, we report a fatal case of disseminated Microascus gracilis infection in a 65-year-old man with a history of primary idiopathic pulmonary fibrosis, status-post bilateral lung transplant. His course was complicated by donor lung cultures positive for multiple organisms and persistent pleural effusions. Multiple lung biopsy and bronchial lavage specimens were negative for mold. Later, pleural fluid cultures grew M. gracilis confirmed by DNA sequencing. Despite aggressive antifungal treatment, the patient continued to deteriorate with altered mental status. Imaging showed scattered hemorrhagic and hypodense lesions in the brain. The patient eventually succumbed to his infections and a restricted autopsy was performed. Autopsy findings included multiple hemorrhagic foci and abscesses involving the whole brain. Numerous punctuate, tan-white circular lesions were on the endocardium and diffuse tan exudates covered the pericardium and lungs. Histologically, similar fungal organisms with septate branching hyphae and short chains of conidia were identified, along with hemorrhage, neutrophilic inflammation, and necrosis in the brain, pleura, peripheral parenchyma of lungs and heart. This is the first reported case of disseminated M. gracilis infection in an immunosuppressed human, indicating it can cause localized infections and disseminated infections. This case increases our awareness of such fatal opportunistic infections, particularly in lung transplant patients, and urges earlier aggressive prophylaxis, diagnosis, and treatment.

First Record of the Complete Mitochondrial Genome of a Saprotrophic and Opportunistic Human Pathogenic Fungus, Scopulariopsis brevicaulis

Scopulariopsis brevicaulis is a widely distributed soil fungus known as a common saprotroph of biodegradation. It is also an opportunistic human pathogen that can produce various secondary metabolites. Here, we report the first complete mitochondrial genome sequence of S. brevicaulis isolated from air in South Korea. Total length of the mitochondrial genome is 28,829 bp and encoded 42 genes (15 protein-coding genes, 2 rRNAs, and 25 tRNAs). Nucleotide sequence of coding region takes over 26.2%, and overall GC content is 27.6%. Phylogenetic trees present that S. brevicaulis is clustered with Lomentospora prolificans with presenting various mitochondrial genome length.

Current knowledge on the etiology and epidemiology of Scopulariopsis infections

Scopulariopsis is a common fungus in the environment, characterized by its intrinsic resistance to the available antifungal drugs. Around 70 cases of infection by this fungus have been described in the literature. Pulmonary and disseminated infections are the most common and their treatment is difficult; therefore, very diverse approaches have been taken, with varied results. A successful outcome has been reported in only a few cases, generally attributed to a multitreatment strategy combining medical and surgical procedures that ultimately led to the resection of the infected tissue if possible, identification of the mould, and an aggressive long-term antifungal therapy. Although most of the infections are caused by Scopulariopsis brevicaulis, a few other species have also been linked to these cases, although molecular evidence has not been proven for all of them. On this basis, more knowledge on the epidemiology, presentation, diagnosis, treatment, and prognosis of these unusual infections would improve their management. This review aims to compile the current data on Scopulariopsis infections.

Mechanistic Insights of Formulation Approaches for the Treatment of Nail Infection: Conventional and Novel Drug Delivery Approaches

Onychomycosis is a chronic disorder that is difficult to manage and hard to eradicate with perilous trends to relapse. Due to increased prevalence of HIV, use of immunosuppressant drugs and lifestyle-related factors, population affected with fungal infection of nail (Onychomycosis) happens to increase extensively in last two decades. Modalities available for the treatment of onychomycosis include systemically administered antifungals, mechanical procedures, and topical drug therapy. But the efficacy of the most of approaches to deliver drug at targeted site, i.e., deep-seated infected nail bed is limited due to compact and highly keratinized nail structure. A series of advanced formulation approaches, such as transfersomes, liposomes, nano/micro emulsion, nail lacquers etc., have been attempted to improve the drug penetration into nail plate more efficiently. The manuscript reviews these formulation approaches with their possible mechanisms by which they improve the drug penetration.Comparative analysis of available treatment modalities for onychomycosis has been provided with pros and cons of each alternatives. Additionally, ongoing research about the application of biological materials such as modified cationic antimicrobial peptides (AMPs), plant-derived proteins, and synthetic antimicrobial peptidomimetics have also been explored.

PCR-RFLP assays for species-specific identification of fungi belonging to Scopulariopsis and related genera

Fungi of the Scopulariopsis genus, commonly found in the environment, are opportunistic pathogens that can cause various types of human infections. So far, no efficient molecular method has been developed for species differentiation among Scopulariopsis and related genera. In order to advance this field, we have evaluated performance of polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) assays, based on cytochrome c oxidase subunit 1 and β-tubulin genes. The assays resulted in 2-10 restriction patterns, depending on the gene amplified and restriction enzyme applied. Pooled analysis of the patterns allowed to propose an algorithm, that can be successfully used for an accurate species-specific identification of 21 species of the Scopulariopsis-like fungi.

Dermatophytosis: Prevalence of Dermatophytes and Non-Dermatophyte Fungi from Patients Attending Arsho Advanced Medical Laboratory, Addis Ababa, Ethiopia

BACKGROUND

Dermatophytosis is a disease of major public health problem around the globe causing a considerable morbidity.

OBJECTIVE

To study the prevalence of dermatophytosis and the spectrum of fungi implicated in causing the infection.

METHODS

Nail, skin, and scalp scrapings were collected from 318 patients and were used for microscopy and culture study. Fungal pathogens were identified by studying the macroscopic and microscopic characteristics of their colonies.

RESULT

Tinea capitis was the predominant clinical manifestation consisting of 48.1% of the cases. Among 153 patients with tinea capitis, 73.2% were in the age group of 1-14 years. Of 318 study participants, 213 (67.98%) were found to be positive for dermatophytosis microbiologically. Out of 164 fungal isolates, 86 were dermatophytes and 78 were non-dermatophyte fungi. Among 86 dermatophytes, T. violaceum represented 38.4% of dermatophyte isolates and 89.7% of the isolates were recovered from tinea capitis. Of 76 non-dermatophyte molds, Aspergillus spp., Scytalidium dimidiatum, and Cladosporium spp. were the most common isolates, respectively.

CONCLUSIONS

Failure to detect or isolate fungal pathogens in a large number of clinical samples revealed the limitation of clinical diagnosis in differentiating dermatophytosis from other skin infections demonstrating that clinical diagnosis should be coupled with laboratory methods. Recovery of large number of non-dermatophyte fungi along with dermatophytes in our study showed that non-dermatophyte fungi are emerging as important causes of dermatophytosis, warranting the implementation of intensive epidemiological studies of dermatophytosis across the country.

Invasive Scopulariopsis alboflavescens infection in patient with acute myeloid leukemia

Scopulariopsis alboflavescens is a soil saprophyte that is widely distributed in nature. Recently, there have been increasing number of reports of invasive infections with Scopulariopsis species in immunocompromised patients. In this report, we described an adult woman with acute myeloid leukemia and who developed S. alboflavescens pneumonia. Liposomal amphotericin B and voriconazole combination therapy was unsuccessful and the patient died because of pneumonia. Scopulariopsis is highly resistant to available antifungal agents and almost invariably fatal. This case report should alert clinicians to the importance of listing Scopulariopsis as a pathogenic fungus in immunocompromised patients.

Chitin Deacetylases: Structures, Specificities, and Biotech Applications

Depolymerization and de-N-acetylation of chitin by chitinases and deacetylases generates a series of derivatives including chitosans and chitooligosaccharides (COS), which are involved in molecular recognition events such as modulation of cell signaling and morphogenesis, immune responses, and host-pathogen interactions. Chitosans and COS are also attractive scaffolds for the development of bionanomaterials for drug/gene delivery and tissue engineering applications. Most of the biological activities associated with COS seem to be largely dependent not only on the degree of polymerization but also on the acetylation pattern, which defines the charge density and distribution of GlcNAc and GlcNH₂ moieties in chitosans and COS. Chitin de-N-acetylases (CDAs) catalyze the hydrolysis of the acetamido group in GlcNAc residues of chitin, chitosan, and COS. The deacetylation patterns are diverse, some CDAs being specific for single positions, others showing multiple attack, processivity or random actions. This review summarizes the current knowledge on substrate specificity of bacterial and fungal CDAs, focusing on the structural and molecular aspects of their modes of action. Understanding the structural determinants of specificity will not only contribute to unravelling structure-function relationships, but also to use and engineer CDAs as biocatalysts for the production of tailor-made chitosans and COS for a growing number of applications.

Nests of Marsh harrier (Circus aeruginosus L.) as refuges of potentially phytopathogenic and zoopathogenic fungi

Birds' nests may be refuges for various species of fungi including that which are potentially phytopathogenic and zoopathogenic. Among the 2449 isolates of fungi obtained from nests of Marsh harriers 96.8% belonged to filamentous fungi. In total, 37 genera were identified from 63 fungi species. Within the mycobiotas of the examined nests populations of fungi which are potentially pathogenic for humans, homoiothermous animals and plants dominated. Among 63 species, 46 (72%) were potentially pathogenic fungi of which 18 species were potentially phytopathogenic and 32 species were pathogenic for homoiothermous animals. Inter alia species of fungi were found in the Marsh harriers nests: Aspergillus fumigatus, Aspergillus flavus, Scopulariopsis brevicaulis, Chrysosporium keratinophilum and Fusarium poae, Fusarium sporotrichioides. In terms of numbers, dominant in Marsh harrier nests were fungi pathogenic to birds, other homoiothermous animals and humans. On that basis it was concluded that Marsh harrier nests are both a source of fungal infections for that species and one of the links in the epidemiological cycle of opportunistic fungi for humans.

Scopulariopsis and scopulariopsis-like species from indoor environments

Scopulariopsis-like species are often reported from the indoor environment, as well as from clinical samples. The lack of type isolates and thorough phylogenetic studies in the Microascaceae hampered the correct identification of these isolates. Based on recent phylogenetic studies, which resulted in multiple name changes, the aim is to molecularly identify the Scopulariopsis and scopulariopsis-like species which occur in the indoor environment and give an overview of the current species in these genera and their habitats. Strains from the CBS culture collection were supplemented with almost 80 indoor strains of which the internal transcribed spacer 1 and 2 and intervening 5.8S nrDNA (ITS), beta-tubulin (tub2) and translation elongation factor 1-alpha (tef1) gene regions were sequenced for phylogenetic inference. The multi-gene phylogenies recognise 33 Microascus species and 12 Scopulariopsis species and showed that the recently established genus Fuscoannellis, typified by Scopulariopsis carbonaria, should be synonymized with the genus Yunnania. Seven new Microascus species, four new Scopulariopsis species, and one new Yunnania species, are described, and a new name in Microascus and two new name combinations (one in Microascus, and one in Yunnania) are proposed. In the indoor environment 14 Microascus species and three Scopulariopsis species were found. Scopulariopsis brevicaulis (22 indoor isolates) and Microascus melanosporus (19 indoor isolates) are the most common indoor species, in number of isolates, followed by M. paisii (8 indoor isolates) and S. candida (7 indoor isolates). A genus phylogeny based on the ITS, tef1 and the large subunit 28S nrDNA (LSU) of the type or representative isolates of all here recognised species is provided depicting all species habitats. No correlation between phylogenetic relationship and habitat preference could be observed. Ten species which are found indoor are also found in relation with human-derived samples. A table showing recent name changes and a key to common species of Scopulariopsis and scopulariopsis-like genera found indoors is included.

Itraconazole and Terbinafine Treatment of Some Nondermatophyte Molds Causing Onychomycosis of the Toes and a Review of the Literature

Background:

Onychomycosis may be caused by dermatophytes (which form the majority of organisms), Candida species, and nondermatophyte molds.

Objective:

To evaluate the efficacy and safety of itraconazole and terbinafine in the treatment of some nondermatophyte molds that cause toe onychomycosis and to review the literature on the treatment of nondermatophyte mold toe onychomycosis using the oral antifungal agents.

Patients and Methods:

Patients with nondermatophyte mold toe onychomycosis were treated in an open, prospective manner with either itraconazole (pulse) or terbinafine therapy. In each instance, light microscopic examination was consistent with the diagnosis of a nondermatophyte mold. For each patient, mycological evaluation of the target nail resulted in 3 or more successive cultures yielding growth of the mold alone.

Results:

All 15 patients had onychomycosis of the toes which was of the distal and lateral type. The patients were treated with itraconazole given as the standard 3 pulses with additional pulses administered depending upon the response exhibited by the toe onychomycosis in the patient. Similarly, terbinafine was given for 12 weeks with additional therapy administered as dictated by the response. Efficacy parameters were mycological cure (MC) and clinical cure (CC). Mycological cure was negative light microscopic examination (KOH) and culture. Clinical cure was the appearance of a completely normal-looking nail. At month 12 from the start of treatment, the response was as follows: Scopulariopsis brevicaulis: itraconazole (MC 4/4, CC 2/4) and terbinafine (MC 0/1, CC 0/1), Fusarium species: itraconazole (MC 1/1, CC 1/1) and terbinafine (MC 0/1, CC 0/1), Aspergillus species: itraconazole (MC 5/6, CC 3/6), Alternaría alternata: itraconazole (MC 0/1, CC 0/1), and Onychocola canadensis: itraconazole (MC 1/1, CC 0/1). There were no significant clinical or laboratory adverse effects.

Conclusions:

In the present series itraconazole demonstrated efficacy against onychomycosis of the toenails caused by 5. brevicaulis and Aspergillus species. A review of the literature confirms our experience with itraconazole and further suggests that terbinafine may also demonstrate efficacy against cases of S. brevicaulis and Aspergillus toe onychomycosis. Additionally, reports in the literature suggest that pedal onychomycosis caused by Fusarium species may also show response to itraconazole and terbinafine. For the other species, there are fewer data, making it difficult to draw conclusions.

Rapid Assays for Specific Detection of Fungi of Scopulariopsis and Microascus Genera and Scopulariopsis brevicaulis Species

Purpose

Fungi of Scopulariopsis and Microascus genera cause a wide range of infections, with S. brevicaulis being the most prevalent aetiological agent of mould onychomycosis. Proper identification of these pathogens requires sporulating culture, which considerably delays the diagnosis. So far, sequencing of rDNA regions of clinical isolates has produced ambiguous results due to the lack of reference sequences in publicly available databases. Thus, there is a clear need for the development of new molecular methods that would provide simple, rapid and highly specific identification of Scopulariopsis and Microascus species. The objective of this study was to develop simple and fast assays based on PCR and real-time PCR for specific detection of fungi from Scopulariopsis and Microascus genera, and separately, S. brevicaulis species.

Methods

On the basis of alignment of β-tubulin gene sequences, Microascus/Scopulariopsis-specific primers were designed and S. brevicaulis-specific primers were reevaluated. DNA from cultured fungal isolates, extracted in a two-step procedure, was used in Microascus/Scopulariopsis-specific and S. brevicaulis-specific PCR and real-time PCR followed by electrophoresis or melting temperature analysis, respectively.

Results

The specificity of the assays was confirmed, as positive results were obtained only for Scopulariopsis spp. and Microascus spp. isolates tested in Microascus/Scopulariopsis-specific assay, and only for S. brevicaulis and S. koningii (syn. S. brevicaulis) isolates in a S. brevicaulis-specific assay, respectively, and no positive results were obtained neither for other moulds, dermatophytes, yeast-like fungi, nor for human DNA.

Conclusions

The developed assays enable fast and unambiguous identification of Microascus spp. and Scopulariopsis spp. pathogens.

In Vitro Triple Combination of Antifungal Drugs against Clinical Scopulariopsis and Microascus Species

Broth microdilution checkerboard techniques based on the methodology of the Clinical and Laboratory Standards Institute (CLSI) were employed to study the triple antifungal combination of caspofungin, posaconazole, and terbinafine against 27 clinical isolates of Scopulariopsis and Microascus species. Synergy was observed for 26 isolates, whereas antagonism was observed for Scopulariopsis candida in this study.

Management of Onychomycosis in Canada in 2014

Background

Onychomycosis has several clinical presentations and is caused by various infectious organisms.

Objective

To provide guidance for selection of appropriate treatment.

Methods

The literature on onychomycosis management was reviewed to generate an evidence-based decision tree.

Results and Conclusion

Several options are available: terbinafine, itraconazole, fluconazole, ciclopirox 8% nail lacquer, efinaconazole 10% nail solution, and laser therapy. Further studies on lasers are needed before use can be recommended. Nondermatophyte molds or mixed infection can be managed with terbinafine or itraconazole with or without topicals. Itraconazole, fluconazole, and efinaconazole can be used for Candida infection. For dermatophytes, topicals can be considered for mild to moderate onychomycosis. For moderate to severe cases, any oral monotherapy can be used; however, we suggest terbinafine if there is a possibility of a drug interaction. These recommendations can be applied for all ages, immune function, or metabolic status, but proper monitoring and contraindications should be taken into consideration.

Isolation of dermatophytes (and other fungi) from human nail and skin dust produced by podiatric medical treatments in Australia

BACKGROUND

Podiatric physicians routinely use electric drills for the treatment of nail and skin conditions. The grinding process produces human nail and skin dust that is generally vacuumed into bags in the grinding unit. Many of the nails are thought to be mycotic, particularly because they are obtained from patients with symptoms of dermatophyte infections. Currently, there is limited information available on the detection of fungi from nail dust samples. Herein, we attempt to address this situation and outline some of the difficulties that pathology laboratories face in isolating and identifying dermatophytes from nail samples.

METHODS

Fifty nail dust bags from podiatric medical clinics across all of the states and territories of Australia were collected and analyzed. Samples from the bags were inoculated onto primary isolation media. Fungal colonies that grew were then inoculated onto potato dextrose agar for identification using standard morphological (macroscopic and microscopic) features.

RESULTS

One hundred fifty-one colonies of dermatophytes were identified from 43 of the 50 samples. In addition 471 nondermatophyte molds were isolated, along with some yeasts and bacteria.

CONCLUSIONS

The most common dermatophytes isolated were from the Trichophyton mentagrophytes/interdigitale complexes. Trichophyton rubrum, Trichophyton tonsurans, Trichophyton soudanense, and Epidermophyton floccosum were also isolated. An unidentified group of dermatophytes was also present. The three most common genera of nondermatophyte molds were Aspergillus, Penicillium, and Scopulariopsis, all of which have been implicated in onychomycosis and more general disease. The presence of viable fungal pathogens in the dust could potentially pose a health problem to podiatric physicians.

[Onychomycoses due to molds]

Onychomycoses represent about 30% of superficial mycosis that are encountered in Dermatology consults. Fungi such as dermatophytes, which are mainly found on the feet nails, cause nearly 50% of these onychopathies. Yeasts are predominantly present on hands, whereas non-dermatophytic moulds are very seldom involved in both foot and hand nails infections. According to literature, these moulds are responsible for 2 to 17% of onychomycoses. Nevertheless, we have to differentiate between onychomycoses due to pseudodermatophytes such as Neoscytalidium (ex-Scytalidium) and Onychocola canadensis, which present a high affinity for keratin, and onychomycoses due to filamentous fungi such as Aspergillus, Fusarium, Scopulariopsis, Acremonium... These saprophytic moulds are indeed most of the time considered as colonizers rather than real pathogens agents. Mycology and histopathology laboratories play an important role. They allow to identify the species that is involved in nail infection, but also to confirm parasitism by the fungus in the infected nails. Indeed, before attributing any pathogenic role to non-dermatophytic moulds, it is essential to precisely evaluate their pathogenicity through samples and accurate mycological and/or histological analysis. The treatment of onychomycoses due to non-dermatophytic moulds is difficult, as there is today no consensus. The choice of an antifungal agent will first depend on the species that is involved in the infection, but also on the severity of nail lesions and on the patient himself. In most cases, the onychomycosis will be cured with chemical or mechanical removing of the infected tissues, followed by a local antifungal treatment. In some cases, a systemic therapy will be discussed.

Detoxification of Jatropha curcas kernel cake by a novel Streptomyces fimicarius strain

A huge amount of kernel cake, which contains a variety of toxins including phorbol esters (tumor promoters), is projected to be generated yearly in the near future by the Jatropha biodiesel industry. We showed that the kernel cake strongly inhibited plant seed germination and root growth and was highly toxic to carp fingerlings, even though phorbol esters were undetectable by HPLC. Therefore it must be detoxified before disposal to the environment. A mathematic model was established to estimate the general toxicity of the kernel cake by determining the survival time of carp fingerling. A new strain (Streptomyces fimicarius YUCM 310038) capable of degrading the total toxicity by more than 97% in a 9-day solid state fermentation was screened out from 578 strains including 198 known strains and 380 strains isolated from air and soil. The kernel cake fermented by YUCM 310038 was nontoxic to plants and carp fingerlings and significantly promoted tobacco plant growth, indicating its potential to transform the toxic kernel cake to bio-safe animal feed or organic fertilizer to remove the environmental concern and to reduce the cost of the Jatropha biodiesel industry. Microbial strain profile essential for the kernel cake detoxification was discussed.

Scopulariopsis, a poorly known opportunistic fungus: spectrum of species in clinical samples and in vitro responses to antifungal drugs

Ninety-nine isolates of clinical origin, tentatively identified as Scopulariopsis or Microascus, were morphologically and molecularly characterized by a combined analysis of the D1/D2 domains of the 28S rRNA gene and a fragment of the elongation factor 1-α gene (EF1-α) sequences. The most prevalent species was Scopulariopsis brevicaulis (49.4%), followed by Scopulariopsis gracilis (14.4%), Scopulariopsis brumptii (7.2%), Microascus cinereus (5.2%), the Scopulariopsis candida species complex (3.1%), and Microascus cirrosus (2.1%). The most common anatomic sites of isolation were the respiratory tract (61.6%), superficial tissue (19.2%), and deep tissue or fluid samples (19.2%). The antifungal susceptibilities of the isolates to eight drugs were tested in vitro, with all the drugs generally showing poor activity.

Fungal contamination in swine: a potential occupational health threat

Poor air quality in a pig-confinement building may potentially place farmers at higher health risk than other workers for exposure to airborne pollutants that may reach infectious levels. The aim of this study was to assess worker exposure to fungi in indoor environments in Portuguese swine buildings. Air samples from 7 swine farms were collected at a flow rate of 140 L/min, at 1 m height, onto malt extract agar supplemented with chloramphenicol (MEA). Surfaces samples of the same indoor sites were obtained by swabbing the surfaces. Samples from the floor covering were also collected from four of seven swine farms. All collected samples were incubated at 27°C for 5-7 days. After lab processing and incubation of obtained samples, quantitative colony-forming units (CFU)/m(3), CFU/cm(2), and CFU/g and qualitative results were determined with identification of isolated fungal species. Aspergillus versicolor was the most frequent species found in air (21%), followed by Scopulariopsis brevicaulis (17%) and Penicillium sp. (14%). Aspergillus versicolor was also the most frequent species noted on surfaces (26.6%), followed by Cladosporium sp. (22.4%) and Scopulariopsis brevicaulis (17.5%). Chrysosporium was the most frequently found genera in the new floor covering (38.5%), while Mucor was the most prevalent genera (25.1%) in used floor covering. Our findings corroborate a potential occupational health threat due to fungi exposure and suggest the need for a preventive strategy.

Onychomycosis caused by Scopulariopsis brevicaulis: report of two cases

Onychomycosis is usually caused by dermatophytes, but some nondermatophytic molds and yeasts are also associated with invasion of nails. Scopulariopsis brevicaulis is a nondermatophytic mold found in soil as a saprophyte. We report two cases of onychomycosis caused by S. brevicaulis in a 48-year-old male and a 79-year-old female. The two patients presented with a typical distal and lateral subungual onychomycosis. Direct microscopic examination of the potassium hydroxide preparation revealed fungal elements. From toenail lesions of the patients, brown colonies with powdery surface, which are a characteristic of S. brevicaulis, were cultured on two Sabouraud's dextrose agar plates. Three cultures taken from nail plates within a 2-week interval yielded similar findings. Numerous branched conidiophores with chains of rough walled, lemon-shaped conidia were observed in slide culture by light microscopy and scanning electron microscopy. The nucleotide sequences of the internal transcribed spacer for the two clinical isolates were identical to that of S. brevicaulis strain WM 04.498. To date, a total of 13 cases of S. brevicaulis onychomycosis including the two present cases have been reported in Korea. Mean age of the patients was 46.1 years, with a higher prevalence in males (69.2%). Toenail involvement was observed in all cases including a case involving both fingernail and toenail. The most frequent clinical presentation was distal and lateral subungual onychomycosis in 12 cases, while one case was proximal subungual onychomycosis.

Fungal contamination of poultry litter: a public health problem

Although numerous studies have been conducted on microbial contaminants associated with various stages related to poultry and meat products processing, only a few reported on fungal contamination of poultry litter. The goals of this study were to (1) characterize litter fungal contamination and (2) report the incidence of keratinophilic and toxigenic fungi presence. Seven fresh and 14 aged litter samples were collected from 7 poultry farms. In addition, 27 air samples of 25 litters were also collected through impaction method, and after laboratory processing and incubation of collected samples, quantitative colony-forming units (CFU/m³) and qualitative results were obtained. Twelve different fungal species were detected in fresh litter and Penicillium was the most frequent genus found (59.9%), followed by Alternaria (17.8%), Cladosporium (7.1%), and Aspergillus (5.7%). With respect to aged litter, 19 different fungal species were detected, with Penicillium sp. the most frequently isolated (42.3%), followed by Scopulariopsis sp. (38.3%), Trichosporon sp. (8.8%), and Aspergillus sp. (5.5%). A significant positive correlation was found between litter fungal contamination (CFU/g) and air fungal contamination (CFU/m³). Litter fungal quantification and species identification have important implications in the evaluation of potential adverse health risks to exposed workers and animals. Spreading of poultry litter in agricultural fields is a potential public health concern, since keratinophilic (Scopulariopsis and Fusarium genus) as well as toxigenic fungi (Aspergillus, Fusarium, and Penicillium genus) were isolated.

[Fusarium in dermatology]

The relevance of infections with moulds in humans is increasing. Relevant genera are Alternaria, Cladosporium, Scopulariopsis, and Fusarium. Fusarium thereby is characterized by typical makroconidia and special makroscopical features. Known as pathogen in plants the fungi can also cause intoxications and - more seldom - infections, mainly in immunosuppressed patients. Problematic are infections of the eye, which were described in users of contact lenses, they are difficult to treat. Manifestations of skin fusariosis are necroses, ulcerations, papulo-pustular skin lesions as well as abscesses and paronychia. In immuno-compromised patients, these circumscribed lesions can merge into generalized infections. Thus, systemical fusariosis is one differential diagnosis in neutropenic fever. Thereby, systemic fusariosis is often associated with generalized papular and nodular skin lesions, which tend to ulcerate. In some cases, these lesions may be surrounded by a targetoid erythema. Altogether, the prognosis of systemic fusariosis is not favourable. Thus, early diagnosis of the disease is crucial and requires especially the dermatologist as medical consultant.

Scanning electron microscopy and fungal culture of hoof horn from horses suffering from onychomycosis

Horn samples were taken from the hooves of eight horses with clinical signs of equine onychomycosis in at least one hoof capsule. None of the horses had a documented mycological history. The predominant alterations of the horn capsules were sand cracks, white line disease, brittleness (especially around the nail holes), parakeratosis and bruising. The horn samples were stored in sterile tubes for transportation and transferred onto Sabouraud Dextrose Agar and dermatophyte test agar for mycological examination within 6 h. Fungal cultures were incubated for 30 days at room temperature. Fungal identification was based on colonial morphology and microscopic examination of conidia. Horn samples were also stored at -80°C until used for scanning electron microscopy (SEM). The fungal culture revealed that the hoof horn from all eight horses was infected with keratinophilic fungi. The keratinopathogenic fungi Trichophyton spp and Scopulariopsis brevicaulis were also detected in six horses. SEM revealed severe alterations of the horn structure in horn samples infected with keratinopathogenic fungi compared to horn samples from a sound hoof. The most evident changes were deterioration of the tubular structure of the horn wall, disruption of the horny layers, superficial lysis of cornified cells and the presence of fungal elements. Samples without dermatophyte or Scopulariopsis infection, in contrast, were similar to healthy hoof horn.

Pathogenicity of Metarhizium anisopliae (Hypocreales: Clavicipitaceae) to tick eggs and the effect of egg cuticular lipids on conidia development

The ovicidal efficacy of two entomopathogenic hyphomycetes fungi--Metarhizium anisopliae variety acridum (M. an. ac.) Driver and Milner (Hypocreales: Clavicipitaceae) and Metarhizium anisopliae variety anisopliae (M. an. an.) (Metschn.) Sorokin (Hypocreales: Clavicipitaceae)--was evaluated against eggs of three tick species (Acari: Ixodidae)--Hyalomma excavatum (Koch), Rhipicephalus (Boophilus) annulatus (Say), and Rhipicephalus sanguineus (Latereille)--by placing eggs, laid by surface-sterilized females, on conidia-impregnated filter paper. Although M. an. an. strains differed in their virulence to the tested ticks, they reduced the hatching percentages of eggs of all three tick species to 0-32% compared with 80-90% in the control eggs. The M. an. ac. strains were found highly virulent to H. excavatum and R. sanguineus eggs, reducing the hatching percentages to 2-6% but had no influence on hatching of R. annulatus eggs. Older tick eggs were more susceptible to fungal infection than newly laid ones. The effects of polar and nonpolar lipid fractions, extracted from the surface of tick eggs, on the development of conidia were tested. Both germination of M. an. an. conidia and formation of appressoria were stimulated by extracts from egg cuticles of all three tested tick species. However, the stimulating effect was lower when the conidia were exposed to lipids from relatively less susceptible R. annulatus eggs than when exposed to lipids from H. excavatum or R. sanguineus eggs. Unlike those of M. an. an., conidia of M. an. ac. exposed to such lipid extracts did not germinate and did not form appressoria.

Scopulariopsis brevicaulis

Scopulariopsis hominis, Scopulariopsis rufulus, Penicillium brevicaulis

Histopathologic evidence of the nondermatophytic mould Scopulariopsis brevicaulis masking the presence of dermatophytes in a toenail infection

Nondermatophytic toenail infection with Scopulariopsis brevicaulis is rare, but may occur often in association with dermatophytes. We report a case of an 84-year-old man who presented with onychomycosis of the big toenail. Histopathologic examination of the avulsed nail showed evidence of S. brevicaulis coinfection with a dermatophyte, despite negative mycology results for the latter. Our case underscores the importance of histopathologic examination of nail specimens as an additional invaluable tool in the diagnosis of onychomycosis, as it may unmask false-negative mycology findings.

Generalized hyperkeratosis caused by Scopulariopsis brevicaulis in a Japanese Black calf

A 6-month-old Japanese Black female calf became gradually emaciated over a 40-day period and was humanely killed. At necropsy, hyperkeratotic nodules were seen to have spread over almost the entire body surface. Scopulariopsis brevicaulis was isolated from the skin and identified morphologically and by gene sequence analysis of the D1/D2 domain of large subunit ribosomal RNA. Numerous periodic acid-Schiff-positive, lemon-shaped conidia were detected histologically in the keratinized layer and the hair follicles. The distribution of the fungal elements in the skin corresponded to that of the hyperkeratotic lesions. This is the first report of a disease caused by S. brevicaulis in animals. Previously reported human infections have not included generalized hyperkeratosis.

In vitro activities of 10 combinations of antifungal agents against the multiresistant pathogen Scopulariopsis brevicaulis

The activities of 10 combinations of antifungal agents against 25 clinical isolates of Scopulariopsis brevicaulis were tested by the checkerboard technique. An average indifferent effect was detected for all combinations. Synergy was observed for some isolates and combinations, particularly with posaconazole-terbinafine (68% of strains), amphotericin B-caspofungin (60%), and posaconazole-caspofungin (48%).

Non-dermatophytic molds as agents of onychomycosis in Izmir, Turkey - a prospective study

The purpose of this study was to determine the prevalence of causative non-dermatophytic filamentous fungi in onychomycosis. Totally 1,222 (1,222 x 3 = 3,666) samples of nail scrapings from 1,146 patients (from 76 patients two specimens: both from finger- and toe-nails) with prediagnosis of onychomycosis sent to the Mycology Laboratory from the Clinic of Dermatology, Ege University Hospital, Izmir, Turkey, July 2001-December 2003, were prospectively studied with conventional mycological procedures. The set criteria for the diagnosis of onychomycosis due to non-dermatophytic molds were: (1) Observation of fungal elements in 15% KOH-preparations made from nail scrapings, (2) growth of the same mold in all three consecutive cultures of the specimens taken three times from the same patient with one-week intervals, (3) no growth of a dermatophyte or yeast in three consecutive cultures. As agents of onychomycosis molds were detected in 33 (9%), dermatophytes in 175 (48%), yeasts in 150 (41%), and mixed (two different fungi) in 8 (2%) patients. In cases of mold onychomycosis, 11 (33%) had finger-nail and 22 (67%) toe-nail infection; 25 (76%) were female and 8 (24%) male; and 27 (82%) were above 40 years of age. The agents of mold onychomycosis, in order of frequency, were Aspergillus niger (7), Acremonium spp. (6), Fusarium spp. (6), Ulocladium spp. (4), sterile mycelia (2), Alternaria sp. (1), Aspergillus flavus (1), Aspergillus fumigatus (1), Aspergillus terreus (1), Cladosporium sp. (1), Paecilomyces spp. (1), Scopulariopsis sp. (1) and Trichoderma sp. (1). In conclusion, this study showed that non-dermatophytic molds were responsible for nearly 10% of onychomycoses cases attending the dermatology outpatient clinic of a university hospital in Izmir, Turkey. Since molds are common contaminants in the laboratory, cultures from consecutively taken nail scrapings should be made and carefully evaluated in order to diagnose a "mold onychomycosis".

How to improve cure rates for the management of onychomycosis

To improve the treatment of onychomycosis clinicians need to identify correctly the causative organism, choose a therapy that is effective against the pathogen, and take into consideration the pharmacokinetics (eg, bioavailability, drug interactions) of the oral agent. In addition, variations of the standard regimens may need to be considered (ie, booster or supplemental therapy). To reduce the recurrence of onychomycosis, once mycologic cure has been achieved, clinicians should educate their patients about proper foot care. Familiarity with the symptoms and signs of tinea pedis and onychomycosis may enable patients to seek appropriate care when the disease is at an early stage.

Scopulariopsis brevicaulis, a fungal pathogen resistant to broad-spectrum antifungal agents

The antifungal susceptibility results for 32 clinical isolates of Scopulariopsis brevicaulis are presented. Flucytosine and itraconazole were inactive in vitro, and MICs of amphotericin B, voriconazole, and terbinafine for all isolates were high, with geometric means of 13, 25.8, and 14.4 microg/ml, respectively.

Non-dermatophyte onychomycosis

Non-dermatophyte organisms are becoming increasingly prevalent in onychomycosis. This apparent emergence might be an artifact of improved diagnostic techniques and increased awareness that these fungi are potential etiologic agents. It is important to bear in mind that all isolated organisms should be evaluated as potential pathogens when diagnosing fungal infections, especially given the increasing use of immunosuppressive drugs and the increasing numbers of chronically immunocompromised individuals. While many patients with non-dermatophyte mold onychomycosis will respond to oral or topical antifungal therapy, poor or incomplete response might still be expected in some patients.

Itraconazole versus terbinafine in the management of onychomycosis: an overview

Ever since the introduction of itraconazole and terbinafine in the management of onychomycosis, there has been a revival of interest in the latter. In order to comprehend the intricate emerging scenario, an endeavor has been made to form a distinct outline in the shape of an overview on several of their facets. The review, therefore, envisages forming and facilitating instant decision-making.

Pharmacoeconomic analysis of ciclopirox nail lacquer solution 8% and the new oral antifungal agents used to treat dermatophyte toe onychomycosis in the United States

BACKGROUND

Recently a novel topical nail lacquer, ciclopirox solution 8%, has been approved for the treatment of onychomycosis.

OBJECTIVE

This was undertaken to determine the most cost-effective treatment for the treatment of dermatophyte onychomycosis of the toes in the United States in 2000.

METHODS

The nature of the problem was defined. The drug comparators were ciclopirox nail lacquer, terbinafine, itraconazole (pulse), itraconazole (continuous), fluconazole, and griseofulvin. A decision analytic model that reflected the manner in which pedal tinea unguium is managed was produced. Studies that have evaluated the efficacy of the nail lacquer and the oral antifungal agents for this indication were identified. Appropriate studies were used in a meta-analysis to determine the mycologic and clinical response rates when the drug comparators are used for the treatment for toe dermatophyte onychomycosis. For each drug comparator a cost of regimen analysis was carried out. This is the sum of the drug acquisition cost, the cost of medical management, and the cost of managing adverse effects. Next, the expected cost of management was calculated, disease free days were determined, and a sensitivity analysis was conducted.

RESULTS

For each comparator the meta-analytic average mycologic cure (MC) rate and clinical response (CR) rates were: ciclopirox nail lacquer (MC: 52.6 +/- 4.2%, CR: 52.4 +/- 9.0%), griseofulvin (MC: 41.1 +/- 20.4%, CR: 33.7 +/- 14.1%), itraconazole (continuous) (MC: 66.3 +/- 4.2%, CR: 70.3 +/- 4.2%), itraconazole (pulse) (MC: 70.8 +/- 5.7%, CR: 73.6 +/- 4.6%), terbinafine (MC: 77.2 +/- 4.0%, CR: 75.3 +/- 2.9%), and fluconazole (MC: 65.6 +/- 7.1%, CR: 66.5 +/- 11.7%). The cost of regimen for the drug comparators was: ciclopirox nail lacquer $325.2, griseofulvin $1413.1, itraconazole (continuous) $1410.2, itraconazole (pulse) $811.7, terbinafine $890.1, and fluconazole $966.8. The cost/mycologic cure rate and expected cost/expected symptom free day were, ciclopirox nail lacquer ($618.2, 1.69), griseofulvin $3438.2, 5.3), itraconazole (continuous) ($2126.9, 3.52), itraconazole (pulse) ($1146.4, 2.01), terbinafine ($1153.0, 2.14), and fluconazole ($1473.7, 2.10). The relative cost-effectiveness was ciclopirox nail lacquer 1.00, itraconazole (pulse) 1.19, fluconazole 1.24, terbinafine 1.27, itraconazole (continuous) 2.08, and griseofulvin 3.13. Sensitivity analysis indicated that ciclopirox nail lacquer was a cost effective alternative compared with the oral regimens of terbinafine, itraconazole (continuous), and griseofulvin when clinical response rate was used as the primary efficacy parameter.

CONCLUSION

Ciclopirox nail lacquer solution 8% is a recent addition to the armamentarium of therapies available to the physician and patient for the treatment of onychomycosis. The nail lacquer is a cost effective agent compared with the oral antifungal therapies, terbinafine, itraconazole, fluconazole, and griseofulvin.