Hair dermatophytosis diagnosed by reflectance confocal microscopy: six cases

Comprehensive Review of Tinea Capitis in Adults: Epidemiology, Risk Factors, Clinical Presentations, and Management

Tinea capitis is a fungal infection of the scalp and hair caused by dermatophyte molds, that most often affects children and may also affect adults. Previous estimates suggest that between 3% and 11% of all tinea capitis cases worldwide occur in adults, although updated epidemiological studies are needed to reassess the prevalence of tinea capitis in adult populations specifically. Postmenopausal adult women are most often affected by tinea capitis, with African American or Black women particularly at risk. Adults who experience crowded living conditions, who live in close proximity to animals, who are immunosuppressed, and/or who live in households with affected children are at greatest risk of infection. Tinea capitis can be non-inflammatory or inflammatory in nature, and the subtype affects the extent and severity of clinical symptoms. Fungal culture and potassium hydroxide preparations are the most commonly used diagnostic tools. Trichoscopy, defined as dermoscopic imaging of the scalp and hair, is a useful adjunct to the physical examination. The mainstay of therapy is oral antifungal therapy, and topical therapy alone is not recommended. Since tinea capitis infection is uncommon in adults, there are no widely accepted treatment guidelines. Rather, the same medications used for tinea capitis infection among children are recommended for adults at varying doses, including griseofulvin, and terbinafine, and, less commonly, itraconazole and fluconazole. The prognosis for tinea capitis in adults is typically excellent when prompt and adequate treatment is administered; however, delayed diagnosis or inadequate treatment can result in scarring alopecia. Over the past decade, dermatophyte infections resistant to treatment with topical and oral antifungal agents have emerged. While tinea capitis infections resistant to antifungal therapy have been rarely reported to date, antifungal resistance is rising among superficial fungal infections in general, and antifungal stewardship is necessary to ensure that resistance to treatment does not develop among dermatophytes that cause tinea capitis.

Mini-Review: The Diagnostic Methods of Tinea Capitis

Tinea capitis is a widespread superficial fungal infection that affects children predominately. Microscopic examination and fungal culture are the conventional gold standards for diagnosis, but they are insensitive and time-consuming. In recent years, new diagnostic methods have been developed to facilitate the diagnosis and identification of causative pathogens. Trichoscopy examination showed high sensitivity and specificity for diagnosing tinea capitis with the characteristic signs of comma hairs, corkscrew hairs, bar code-like hairs and zigzag hairs. Reflectance confocal microscopy has also been used in the rapid diagnosis of tinea capitis in several studies. Molecular assays such as polymerase chain reaction and matrix-assisted desorption/ionization time to flight mass spectrometry are extensively utilized for rapid and accurate identification of the pathogens. Early diagnosis and treatment can aid in disease control and scarring reduction.

Role of VivaScope 2500 ex vivo confocal microscopy in skin pathology: Advantages, limitations, and future prospects

BACKGROUND

Vivascope 2500 ex vivo confocal microscopy (EVCM) is an emerging optical imaging device that allows nuclear level resolution of freshly excised tissues. EVCM provides, rapid real-time pathological examination in many subspecialties of pathology including skin, prostate, breast, liver, etc. In contrast to traditional time-consuming frozen sectioning and histological analysis.

AIMS

To evaluate the current state of EVCM utilization.

MATERIALS AND METHODS

This study highlights the advantages, limitations, and prospects of EVCM in skin pathology.

RESULTS

Our findings demonstrate that EVCM is a promising adjunctive tool to assess margins in Mohs surgery and to provide rapid, accurate diagnosis of cutaneous tumors, infectious and inflammatory diseases.

CONCLUSION

EVCM is a revolutionary device that can be used as an adjunct to paraffin-fixed, hematoxylin and eosin-stained slides and frozen sectioning. Additional refinements are required before EVCM can be used as an alternative to frozen sectioning or traditional tissue processing.

Applications of Reflectance Confocal Microscopy in the Diagnosis of Fungal Infections: A Systematic Review

Cutaneous and adnexal fungal infections are typically diagnosed with potassium hydroxide (KOH) skin scrapings, fungal cultures, and Periodic acid-Schiff (PAS) biopsy staining. All three current methods of fungal diagnosis require sample processing and turnover time which leads to a delay in diagnosis. Reflectance confocal microscopy (RCM) is a non-invasive, in vivo skin imaging technology that provides real-time dermatologic diagnoses. We present an updated systematic review of the applications of RCM in diagnosing fungal infections in an effort to explore the utility of RCM as an adjunct clinical tool in detecting cutaneous and adnexal fungi We systematically searched the MEDLINE (via PubMed) for studies published from January 2000 to October 2022 that described the utility of RCM in the setting of fungal infections. Of the 25 studies that met the inclusion criteria, 202 patients were included. The following information on the application of RCM in the setting of fungal infections was extracted from each study, if reported: study type, year published, number of patients included, diagnosis/diagnostic methods, and RCM description. Concordant within all included studies, fungal infections presented on RCM as bright, linear, branching, filamentous structures at the level of stratum corneum. A limitation of this review is that 11 of 25 studies were case reports (n = 1). Larger scale studies should be conducted to explore the utility of RCM in diagnosing fungal infections and to enrich the RCM descriptions of specific fungal conditions.

Immunofluorescence and histopathological assessment using ex vivo confocal laser scanning microscopy in lichen planus

Ex vivo confocal laser scanning microscopy (CLSM) provides rapid, high-resolution imaging, fluorescence detection and digital haematoxylin-eosin (H&E)-like staining. We aimed to assess the performance of ex vivo CLSM in identifying histomorphology and immunoreactivity in lichen planus (LP) and comparing its accuracy with conventional histopathology and direct immunofluorescence (DIF). Thirty-three sections of 17 LP patients stained with acridine orange (AO) and FITC-labelled anti-fibrinogen antibody and 21 control samples stained with AO were examined using ex vivo CLSM. Ex vivo CLSM was in perfect agreement with conventional histopathology in identifying interface dermatitis, vacuolar degeneration and band-like infiltration. ROC analysis showed that the presence of vacuolar degeneration, interface dermatitis and band-like infiltration was useful to distinguish LP sections from controls (p < .0001). The detection rates of fibrinogen deposition using DIF and in conclusion ex vivo CLSM were 93.8% and 62.5%, respectively. ex vivo CLSM enables histopathological and immunofluorescence examination in LP with the advantage of digital H&E-like staining.

Ex vivo Confocal Laser Scanning Microscopy: A Potential New Diagnostic Imaging Tool in Onychomycosis Comparable With Gold Standard Techniques

Ex vivo confocal laser scanning microscopy (CLSM) is an innovative imaging tool that enables real-time examination of specimens and may be used in evaluating fungal infections. We aimed to assess the applicability of ex vivo CLSM in the diagnosis of onychomycosis by comparing results to those obtained by histopathology, potassium hydroxide (KOH) examination, and fungal culture. In this prospective study, 57 patients with the clinical diagnosis of distal nail fungal infection were examined and compared using all four of the above-mentioned diagnostic tools in terms of sensitivity, positive and negative predictive value. Ex vivo CLSM showed the highest sensitivity, followed by KOH examination, histopathology and fungal culture. Regarding positive and negative predictive values, ex vivo CLSM was superior and showed even higher sensitivity than the combined gold standard comprised of KOH examination, fungal culture or histopathology.

Ex vivo confocal microscopy: revolution in fast pathology in dermatology

Confocal microscopy with in vivo and ex vivo modalities has been used in the evaluation of skin cancer and other dermatological disorders. Recent developments in ex vivo confocal microscopy allow for faster pathology assessment with greater accuracy by the visualization of cellular and architectural details, similarly to standard pathology, in either paraffin-embedded or frozen samples. They include the possibility of multimodal confocal microscopy using different lasers and fusion images. New staining protocols including immunostaining, with no damage to conventional histopathology preparation, have been recently described in melanocytic tumours and inflammatory skin diseases. Digital staining with haematoxylin and eosin is also incorporated in the new devices. In this review the applications of ex vivo confocal microscopy will be presented with the description of the technique and the technology, clinical evidence in dermatology and other fields, and further applications.

Ex vivo confocal laser scanning microscopy: An innovative method for direct immunofluorescence of cutaneous vasculitis

Ex vivo confocal laser scanning microscopy (ex vivo CLSM) offers an innovative diagnostic approach through vertical scanning of skin samples with a resolution close to conventional histology. In addition, it enables fluorescence detection in tissues. We aimed to assess the applicability of ex vivo CLSM in the detection of vascular immune complexes in cutaneous vasculitis and to compare its diagnostic accuracy with direct immunofluorescence (DIF) microscopy. Eighty-two sections of 49 vasculitis patients with relevant DIF microscopy findings were examined using ex vivo CLSM following staining with fluorescent-labeled IgG, IgM, IgA, C3 and fibrinogen antibodies. DIF microscopy showed immunoreactivity of vessels with IgG, IgM, IgA, C3 and Fibrinogen in 2.0%, 49.9%, 12.2%, 59.2% and 44.9% of the patients, respectively. Ex vivo CLSM detected positive vessels with the same antibodies in 2.0%, 38.8%, 8.2%, 42.9% and 36.7% of the patients, respectively. The detection rate of positive superficial dermal vessels was significantly higher in DIF microscopy as compared to ex vivo CLSM (P < .05). Whereas, ex vivo CLSM identified positive deep dermal vessels more frequently compared to DIF microscopy. In conclusion, ex vivo CLSM could identify specific binding of the antibodies in vessels and showed a comparable performance to conventional DIF microscopy in diagnosing vasculitis.

Ex vivo confocal microscopy: an emerging technique in dermatology

This review aims to give an overview of the current available applications of ex vivo confocal microscopy (EVCM) in dermatology. EVCM is a relatively new imaging technique that allows microscopic examination of freshly excised unfixed tissue. It enables a rapid examination of the skin sample directly in the surgery room and thus represents an alternative to the intraoperative micrographic control of the surgical margins of cutaneous tumors by standard microscopic examination on cryopreserved sections during Mohs surgery. Although this technique has mainly been developed for the margin’s control of basal cell carcinoma, many other skin tumors have been studied, including melanoma. Use of EVCM is continuing to evolve, and many possible applications are under investigation, such as the study of nails and hair diseases and the diagnosis of skin infections.

[The role of reflectance confocal microscopy in the diagnosis of secondary syphilis of the vulva and anus: A first case report]

PATIENTS AND METHODS

Herein we report the case of an 18-year-old pregnant patient presenting with plantar and ano-genital lesions of syphilis, pharyngitis, erythematosus and scalynasolabial intertrigo and angular cheilitis.

REFLECTANCE CONFOCAL MICROSCOPY

In vivo reflectance confocal microscopy examination (Vivascope 3000^®; Caliber Inc, Rochester, NY, USA, distributed in France by Mavig, Munich) of ano-genital lesions enabled us to identify hyper-reflective elongated rods in the papillary dermis suggesting spirochetes. The diagnosis was confirmed by TPHA and VDRL as well as immunohistological examination.

COMMENTS

We identified for the first time rod shaped structures in ano-genital lesions of secondary syphilis, regularly alternating hyper-reflective and non-reflective areas corresponding to helix-shaped treponemes visualized by darkfield microscopy, which may not be confused with other cell structures.