Avaliação clínica e micológica de onicomicose em pacientes brasileiros com HIV/AIDS

Retrospective Analysis of Onychomycosis Risk Factors Using the 2003-2014 National Inpatient Sample

INTRODUCTION

Onychomycosis, a fungal nail infection, is associated with significant morbidity and negative impact on quality of life. Therefore, understanding associated risk factors may inform onychomycosis screening guidelines.

OBJECTIVES

This retrospective study investigated common demographic and comorbidity risk factors among hospitalized patients using the National Inpatient Sample.

METHODS

The 2003-2014 National Inpatient Sample (NIS) database was used to identify onychomycosis cases and age and sex matched controls in a 1:2 ratio. Chi-square tests and T-tests for independent samples were utilized to compare categorical and continuous patient factors. Demographic and comorbidity variables significant (P < 0.05) on univariate analysis were analyzed via a multivariate regression model with Bonferroni correction (P < 0.0029).

RESULTS

119,662 onychomycosis cases and 239,324 controls were identified. Compared to controls, onychomycosis patients frequently were White (69.0% versus 68.0%; P < 0.001), Black (17.9% versus 5.8%; P < 0.0001), and insured by Medicare or Medicaid (80.1% versus 71.1%; P < 0.0001). Patients had greater hospital stays (9.69 versus 5.39 days; P < 0.0001) and costs ($39,925 versus $36,720; P < 0.001) compared to controls. On multivariate analysis, onychomycosis was commonly associated with tinea pedis (odds ratio [OR]: 111.993; P < 0.0001), human immunodeficiency virus (OR: 4.372; P < 0.001), venous insufficiency (OR: 6.916; P < 0.0001), and psoriasis (OR: 3.668; P < 0.001).

CONCLUSIONS

Onychomycosis patients had longer hospital stays and greater costs compared to controls. Black patients were disproportionately represented among cases compared to controls. Onychomycosis was associated with tinea pedis, venous insufficiency, human immunodeficiency virus, psoriasis, obesity (body mass index [BMI] ≥ 30 kg/m2), peripheral vascular disease, and diabetes with chronic complications, suggesting that inpatients with onychomycosis should be screened for these conditions.

Hallazgos en piel en pacientes con infección por VIH en Bogotá

Objetivo Describir los hallazgos en piel y las características sociodemográficas de pacientes VIH positivos atendidos en un centro de remisión en Bogotá. Métodos Se realizó un estudio observacional descriptivo, incluyendo adultos con infección por VIH atendidos en el Hospital Universitario San Ignacio de Bogotá, entre abril de 2019 y febrero de 2020. A partir de un interrogatorio, un examen físico y la revisión de historias clínicas, se registraron hallazgos en piel, datos de terapia antirre- troviral recibida, conteo de linfocitos CD4+ y carga viral para VIH, así como pruebasmicológicas e histopatológicas (cuando fueron necesarias). Resultados Se evaluó un total de 168 pacientes que, en su mayoría, eran hombres (88,7%), en la cuarta década de la vida, de orientación HSH (77,4%), con fototipos del II al IV (97%) y manejados con terapia antirretroviral (94,6%). Se encontraron hallazgos en piel en el 97,6% de los pacientes, siendo más frecuentes las infecciones (43,8%), específicamente los condilomas anogenitales, principalmente en pacientes con <200 linfocitos CD4+/mm3, seguidas por las condiciones inflamatorias (35,4%), principalmente dermatitis seborreica y acné. Este último, más frecuente en pacientes con >200 linfocitos CD4+/mm3. Conclusiones Los hallazgos más frecuentes en piel fueron: dermatitis seborreica, condilomas anogenitales, verrugas virales, moluscos contagiosos y micosis superficiales, que se asemeja a lo reportado en poblaciones con buen control inmunovirológico de la enfermedad. La alta prevalencia de condilomas anogenitales nos invita a imple- mentar estrategias de tamización para VPH, así como de educación en infecciones de transmisión sexual.

Nail dermatophytoma in HIV-infected patients in Cali, Colombia

INTRODUCTION

A dermatophytoma is a mass of hyphae that is observed at direct examination, it responds poorly to treatment with antifungal drugs, some authors have proposed that it is actually a biofilm. This pathology is underdiagnosed, and its true incidence is unknown.

OBJECTIVES

This study presents the clinical findings of dermatophytoma in HIV/AIDS patients from Colombia presenting onychomycosis.

MATERIAL AND METHODS

A transversal observational descriptive study was carried out in a third level university hospital. One hundred thirty HIV positive patients diagnosed using ELISA and Western Blot that presented nail lesions on their hands and/or feet compatible with onychomycosis were included. Samples taken from affected nails were observed in direct examination with KOH and seeded onto Sabouraud agar, mycosel agar and dextrose-potato agar. Molds were identified based on macroscopic and microscopic characteristics.

RESULTS

Six (4.6%) individuals presented dermatophytoma. Average age was 43 years (range 33-50); nails more commonly affected (5/6) were on the toes, principally the hallux. Clinical manifestations included a yellow or white, rounded or linear dense area on the nail. Superficial white onychomycosis was present in 83.3% of the patients. Fungal cultures were obtained in only 5 patients; Trichophyton mentagrophytes complex was found in 2 individuals while T. rubrum, T. tonsurans and Epidermophyton floccosum were in the other 3. Average cell count for CD4⁺T lymphocytes was 86.8 cells/mm³ (range 9-282).

CONCLUSIONS

This is the first report in Colombia of dermatophytoma in HIV/AIDS patients, most of them had a CD4+ T lymphocytes count less than 200 cells/mm3. Several clinical forms of onychomycosis were observed, the most frequent was the white superficial onychomycosis.

Virulence properties and sensitivity profile of Candida parapsilosis complex species and Kodamaea ohmeri isolates from onychomycosis of HIV/AIDS patients

Cutaneous fungal infections include onychomycosis, an infection of the nail that affects both healthy and immunocompromised patients. This study investigated the in vitro hydrolytic enzymes production, adhesion and biofilm formation capacity of Candida parapsilosis complex species and Kodamaea ohmeri isolates from onychomycoses of HIV/AIDS patients and also established the antifungal sensitivity profiles of these isolates. Onychomycosis in HIV/AIDS patients showed a high prevalence of emerging yeasts, among which C. parapsilosis complex species and K. ohmeri were the most frequent. Three C. parapsilosis sensu stricto and two C. orthopsilosis isolates were resistant to amphotericin B and 83% of isolates were resistant to terbinafine. All three different species evaluated were proteinase and hemolysin producers. All isolates adhered to stainless steel and siliconized latex surfaces, and carbohydrates intensified adhesion of all isolates. Isolates adhered to keratinous nail and 50% formed biofilms with strong intensity. In multispecies or polymicrobial biofilms, C. albicans and Staphylococcus aureus regulated the biofilm formation of the analyzed species, decreasing the number of their cells in biofilms. The isolation of emerging yeast species from onychomycosis which are great producers of hydrolytic enzymes and with high adhesion and biofilm formation capacity is a result that should be considered relevant in clinical practice. In addition, half of the isolates was resistant to at least one of the tested antifungals. Taken together these data corroborate the infectious capacity and viability of these isolates under favorable conditions.

Study of prevalence of dermatophytes among human immunodeficiency virus/AIDS patients in Shadan Institute of Medical Sciences and Teaching Hospital and Research Centre, Hyderabad, Telangana, India

Introduction:

The objective of the study was to evaluate the prevalence of dermatophytoses in human immunodeficiency virus (HIV) patients as well as to analyze the influence of CD4+ T-cell level in the Dermatology and STD Outpatient Department of Shadan Institute of Medical Sciences Teaching Hospital and Research Centre, Himayat sagar road, Hyderabad (Telangana state). The patients were tested for dermatophytic infections, as well as for the CD4+ T-cell counts. A total of 120 HIV-seropositive patients were included in this study, among which 38 were diagnosed of dermatophytosis. A majority of patients were in the 21–30 years’ age group. Tinea cruris was seen in majority of the cases, with Trichophyton rubrum being the most common culprit.

Background:

Cutaneous fungal infections have been reported worldwide as being one of the most common human infectious diseases in clinical practice. Dermatophytoses in individuals with HIV infection seem to manifest with atypical, multiple, or extensive lesions more frequently.

Aims:

The aim of this study was to determine the prevalence of dermatophytic infections among HIV-seropositive patients and their relation with CD4 count.

Materials and Methods:

This single-center prospective study was conducted in all HIV-seropositive patients (by double ELISA methods) who attended the Dermatology and STD Outpatient Department of Shadan Institute of Medical Sciences Teaching Hospital and Research Centre, Himayat sagar road, Hyderabad (Telangana state), from March 2015 to September 2016. They were screened for cutaneous fungal infections and those who tested positive were recruited for this study.

Results:

A total of 120 HIV-seropositive patients were included in this study, among which 38 were diagnosed of dermatophytosis. Most patients were in the 21–30 years’ age group. Tinea cruris was the most common variant, and T. rubrum was the most common offending pathogen. It was also found that the CD4+ T-cell count does not influence the occurrence of dermatophytoses.

Conclusion:

Superficial fungal infections are a common yet significant problem in HIV infection. They are characterized by the diversity of clinical aspects; the lesions are mostly caused by T. rubrum. It is essential that optimum treatment should be administered.

Dermatologic manifestations among human immunodeficiency virus patients in Morocco and association with immune status

OBJECTIVE

The objective was to determine if the type and number of skin diseases can be clinical indicators of underlying immune status in HIV1 disease by estimating and correlating with the CD4 count and CDC stage.

MATERIALS AND METHODS

This was a retrospective cross-sectional descriptive study. All consecutive patients infected with HIV1 followed at the Dermatology Department of Rabat Military Hospital between January 2008 and January 2017 were studied for dermatological manifestations, CD4 count and CDC clinical stage.

RESULTS

A total of 170 patients with 304 dermatological manifestations were included. The most common dermatoses were fold dermatophytic infections (67%), genital warts (43%), herpes zoster (21%), xerosis (21%), and oral candidiasis (12%). The number of dermatologic manifestations was significantly greater in patients with CD4 count less than 200/mm³ or in stage C of the CDC classification. Five types of skin diseases (dermatophyte infections of the folds, genital warts, shingles, oral candidiasis, and seborrheic dermatitis) were significantly associated (P < 0.05) with CD4 count <200/mm³ . Seborrheic dermatitis was the only one skin disease significantly associated with AIDS stage. In multivariate analysis, genital warts (OR = 0.3, 95% CI 0.10-0.92) are independently associated with CD4 count less than 200 CD4/mm³ .

CONCLUSIONS

Skin manifestations not only act as markers but also reflect the underlying immune status. Seborrheic dermatitis and genital warts appear to be a marker of immune status, and seborrheic dermatitis appears to be associated with CDC stage C, especially in their chronic and severe forms.

An Update on Candida tropicalis Based on Basic and Clinical Approaches

Candida tropicalis has emerged as one of the most important Candida species. It has been widely considered the second most virulent Candida species, only preceded by C. albicans. Besides, this species has been recognized as a very strong biofilm producer, surpassing C. albicans in most of the studies. In addition, it produces a wide range of other virulence factors, including: adhesion to buccal epithelial and endothelial cells; the secretion of lytic enzymes, such as proteinases, phospholipases, and hemolysins, bud-to-hyphae transition (also called morphogenesis) and the phenomenon called phenotypic switching. This is a species very closely related to C. albicans and has been easily identified with both phenotypic and molecular methods. In addition, no cryptic sibling species were yet described in the literature, what is contradictory to some other medically important Candida species. C. tropicalis is a clinically relevant species and may be the second or third etiological agent of candidemia, specifically in Latin American countries and Asia. Antifungal resistance to the azoles, polyenes, and echinocandins has already been described. Apart from all these characteristics, C. tropicalis has been considered an osmotolerant microorganism and this ability to survive to high salt concentration may be important for fungal persistence in saline environments. This physiological characteristic makes this species suitable for use in biotechnology processes. Here we describe an update of C. tropicalis, focusing on all these previously mentioned subjects.

Tinea pedis due to Cylindrocarpon lichenicola beginning onycholysis

A 33 year old woman presented with both feet, humid and white Tinea pedis at the second, third and fourth inter-toes areas associated with a beginning onycholysis of the nails lasting for 18 months. KOH mount of the samples was positive for fungal hyphae. The fungus was isolated on Sabouraud-chlorampphenicol agar and identified as Cylindrocarpon lichenicola. The patient was treated with an association of terbinafine tablet and terbinafine cream and presented clinical cure after three months.

[Epidemiological aspects of cutaneous mycosis of HIV-infected patients in the National Referral Center of Burkina Faso, West Africa]

AIM

Our study aimed to analyze the epidemiological aspects of cutaneous mycosis in people living with human immunodeficiency virus (PLHIV).

MATERIALS AND METHODS

This is a descriptive study of 382 patients living with HIV. Following an investigation into the risk factors, mycological samples have been performed. Each sample underwent direct examination and cultivation for the identification of fungal species. The Blastese test is used for the identification of Candida albicans.

RESULTS

One hundred and six (106) of the 382 people living with human immunodeficiency virus undergo a mycological collection of which 76 gave a positive result. The overall prevalence of cutaneous mycosis was 19.9 %. It was significantly higher in women and in patients who had a CD4 count ≤500/mm3. C. albicans and Trichophyton rubrum were the most isolated species with 22.4 and 19.8 % of all fungal species isolated, respectively.

CONCLUSION

Cutaneous mycoses are common among people living with human immunodeficiency virus and whose CD4 count ≤ 500/mm(3).

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.

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.

[Onychomycosis: multicentre epidemiological, clinical and mycological study]

BACKGROUND

Onychomycosis accounts for up to 50% of all nail disorders. They can be caused by: yeasts, dermatophytes and non-dermatophyte moulds.

OBJECTIVES AND METHODS

A multicentre study designed to determine the prevalence, mycological test results, aetiological agents, and clinical presentation of onychomycosis was carried out. All fingernail and toenail samples taken during a one year period at 9 diagnostic centres were included.

RESULTS

A total of 5,961 samples were analysed, of which 82.3% were from toenails and 17.7% from fingernails. The mean age of the patients was 49.7 years, and 66% were females. Direct microscopic examination was positive in 61% of the samples. In adults, 61.2% of toenails were positive using potassium hydroxide (KOH), and 43.7% were positive in cultures. The prevailing aetiological agents belong to the dermatophyte group (82.8%), and distal subungual was the most common clinical form. In fingernails, direct examination showed 59.8% positive samples, and cultures were positive in 52.9%. The prevailing agents were yeasts belonging to Candida species, and onycholysis was the most common lesion.

CONCLUSIONS

Direct mycological examinations were positive in 61%, a higher value than that found in other series. Dermatophytes were prevalent in toenails of both sexes, and in finger nails yeast were prevalent in females, and dermatophytes in males. Non-dermatophyte moulds corresponded to 4.8% of toenail and 2.05% of fingernails isolates.