Veterinarians and zoonotic pathogens, infections and diseases - questionnaire study and case series, Finland

BACKGROUND

Veterinarians are at risk for numerous zoonotic infections. In this paper, we summarise descriptions of zoonotic infections from a questionnaire study and a series of work-related zoonotic cases, aiming to add to the knowledge on occupational zoonotic risks of veterinarians.

METHODS

We collected data on zoonotic infections contracted by veterinarians in Finland in two studies:1) using a questionnaire in 2009, and 2) inviting veterinarians who had encountered an occupational zoonosis to report it in structured interviews in 2019.

RESULTS AND CONCLUSIONS

In the questionnaire study in 2009, of 306 veterinarians several reported zoonotic bacterial skin infections (12%), dermatophytosis (ringworm; 4.2%), virus infections (3.9%), bacterial gastroenteritis (3.3%), other bacterial zoonoses (2.3%), and parasitic infections/infestations (2.3%). In the 2019 interviews, 16 occupational zoonosis cases were reported. Of them, seven were selected to the case series. The selected cases included Capnocytophaga canimorsus sepsis following a dog bite, cryptosporidiosis after a contact with calves, cutaneous listeriosis following calving assistance, Salmonella gastroenteritis contracted at laboratory, Trichophyton dermatophytosis after equine contact, Bacillus anthracis exposure at necropsy, and exposure to rabies through a horse bite. In four of the seven cases, the veterinarian disagreed or strongly disagreed with having had good knowledge of the zoonosis before the incident. The results from the questionnaire study and the case series illustrate the variety of zoonotic pathogens that veterinarians may encounter. There is a need to improve the occupational health of veterinarians and to increase awareness in the occupational health sector. We encourage addressing this need using a One Health approach.

Zoonotic Majocchi's Granuloma of the Vulva

A healthy 32-year-old woman presented to clinic with tender pruritic lesions of 2-month duration at the vulva and lesions for weeks on the shins. She was treated with topical corticosteroids and intravenous vancomycin without significant improvement. On examination, dozens of follicular hemorrhagic papulopustules were detected at the suprapubic area and vulva (Figure 1). Similar but less prominent lesions were observed on the shins as well. Biopsies of the vulva and shin revealed a follicular inflammatory infiltrate of neutrophils, histiocytes, and lymphocytes as well as fungal hyphae within the follicular infundibulum and hair shafts, consistent with Majocchi's granuloma (MG). Gram and Fite-Faraco staining, direct immunofluorescence, and bacterial culture were negative. Tissue culture grew Trichophyton mentagrophytes, which was identified using sequence analysis of the D1/D2 region of the 28s rDNA. Minimum inhibitory concentrations for terbinafine, ketoconazole, and itraconazole were determined, with terbinafine having the lowest concentration. Additional history revealed that shortly prior to commencement of her clinical manifestations, the patient had acquired a pet guinea pig with eruptions and hair loss (Figure 2). The patient was prescribed ketoconazole cream and terbinafine, 250 mg daily, with almost immediate improvement. Based on clinical response, the patient remained on terbinafine and ketoconazole cream for 6 months. Her skin remained clear 4 months after discontinuing all antifungals. Based on the results of patient's culture, a veterinarian treated her guinea pig successfully with systemic terbinafine and miconazole lotion.

Molecular Verification of Trichophyton in the Brazilian URM Culture Collection

Trichophyton species cause dermatophytosis in humans, with a high, worldwide frequency of reports and important public health relevance. We evaluated 61 Trichophyton strains from different sources deposited in the University Recife Mycology (URM) culture collection of the Universidade Federal de Pernambuco, Brazil. Strains were phenotypically identified and confirmed by sequencing Internal Transcribed Spacers rDNA and partial beta-tubulin 2-exon. Additionally, we evaluated their susceptibility to terbinafine and itraconazole. Physiological analyses included urease activity and growth in casein medium. Phenotypic methods allowed the reliable identification of T. rubrum only, whereas, for other species, molecular methods were mandatory. All Trichophyton species exhibited susceptibility profiles to itraconazole (0.04-5.33 μg/mL) and terbinafine (0.17-3.33 μg/mL). Our analyses revealed a heterogeneous distribution of T. mentagrophytes, which does not support the current distribution within the species complex of T. mentagrophytes and its genotypes.

Prior selection of itraconazole in the treatment of recalcitrant Trichophyton indotineae infection: Real-world results from retrospective analysis

BACKGROUND

The number of terbinafine-resistant Trichophyton indotineae is increasing in recent years while the treatment is still a matter to discuss.

OBJECTIVES

To explore the best therapeutic approach, we present real-world treatment of T. indotineae infection by analysing publicly available data.

METHODS

We have reviewed all published articles, mainly including case reports and case series, on the drug-resistant T. mentagrophytes complex by using the key search terms to search the databases.

RESULTS

We enrolled 25 articles from 14 countries, including 203 times of treatment information for 113 patients. The cure rate of itraconazole 200 mg per day at the fourth, eighth and the twelfth week were 27.27%, 48.48% and 54.55%, respectively, which was significantly higher than terbinafine 250 mg per day (8.77%, 24.56% and 28.07%) and even 500 mg/d terbinafine. Griseofulvin 500-1000 mg for 2-6 months may be effective while fluconazole had no record of successful treatment. Voriconazole and ravuconazole had potential therapeutic efficacy. Topical therapy alone showed limited therapeutic efficacy, but the combination with oral antifungals can be alternative.

CONCLUSION

Oral itraconazole 200 mg per day for 4-8 weeks was the most effective treatment out of these commonly used antifungal drugs, and can be prior selection.

Association of Kallikrein Related Peptidase 3 (KLK3) gene with dermatophytosis in the UK biobank cohort

BACKGROUND

In a previous genome wide association study (GWAS) of UK Biobank (UKB) data, we identified one susceptibility locus, tubulointerstitial nephritis antigen (TINAG), with genome wide significance for dermatophytosis. We used genotype calls from file UKB22418. These data are derived directly from Affymetrix DNA microarrays but are missing many genotype calls. Using computationally efficient approaches, UKB has entered imputed genotypes into a second dataset, UKB22828, increasing the number of testable variants by over 100-fold to 96 million variants.

METHODS

In the current study, we used UKB imputed genotypes in UKB22828 to identify dermatophytosis susceptibility loci. To identify cases of dermatophytosis, we used ICD10 code B35, which covers tinea barbae, tinea capitis, tinea unguium, tinea manuum, tinea pedis, tinea corporis, tinea imbricata, tinea cruris, other dermatophytoses and dermatophytosis, unspecified. We used PLINK, a whole-genome association analysis toolset, to analyse the UKB22828 chromosome files.

RESULTS

GWAS summary (Manhattan) plot of the meta-analysis association statistics highlighted two susceptibility loci, TINAG and Kallikrein Related Peptidase 3 (KLK3), with genome wide significance for dermatophytosis. KLK3, also known as prostate specific antigen (PSA), belongs to a subclass of serine proteases with a variety of physiological functions.

CONCLUSION

KLK3 may be a dermatophytosis susceptibility gene. KLK3 could affect risk of dermatophytosis, since kallikreins are necessary for normal homeostasis of the skin.

Pediatric tinea capitis in Jilin Province: analyzing previous results from a new perspective

OBJECTIVES

To investigate the current etiological, diagnostic, and therapeutic characteristics of tinea capitis in children in Jilin Province.

METHODS

Sixty pediatric patients with tinea capitis were enrolled between August 2020 and December 2021. Data on calcofluor white (CFW) fluorescence microscopy, fungal culture, Wood's lamp examination, dermoscopy, treatment, and follow-up were collected and analyzed.

RESULTS

1. Of all the enrolled patients, 48 had a history of animal contact, mostly with cats and dogs. Fifty-one strains were isolated, of which 46 were Microsporum canis (M. canis). 2. All enrolled patients were examined using fluorescence microscopy, and 59 were positive. Forty-one cases of tinea alba were examined using Wood's lamp, and 38 were positive. Forty-two cases of tinea alba were examined using dermoscopy, and 39 demonstrated specific signs. Effective treatment manifested as a fading bright green fluorescence, decreased mycelial/spore load, reduced specific dermoscopic signs, and hair regrowth. 3. Treatment was terminated in 23 and 37 cases based on mycological and clinical cures, respectively. No recurrence occurred during follow-up.

CONCLUSION

1. M. canis is the predominant pathogen causing tinea capitis in children in Jilin Province. Animal contact is considered the main risk factor. 2. CFW fluorescence microscopy, Wood's lamp, and dermoscopy can be used to diagnose ringworms and follow-up patients. 3. Both mycological and clinical cures can be the endpoint of adequate treatment for tinea capitis.

Revisiting the pathogenesis of dermatophytosis: A cross-sectional analytic study of serum levels of interleukins-2, 8, 10 and 17

BACKGROUND

Given the current epidemic-like scenario of dermatophyte infections, it is prudent to revisit the immunopathogenesis of dermatophytosis. Comprehending the intricate interactions among interleukins can aid in understanding the recent trends in infection. There is a paucity of literature on the various cytokine levels observed in the serum of patients suffering from various dermatophytoses.

AIM

To study serum cytokine levels of interleukins 2, 8, 10 and 17 in patients with dermatophytosis.

METHODS

A cross-sectional analytic study was conducted on 64 cases of clinical dermatophyte infections (KOH confirmed) and 64 controls. The clinico-epidemiological profile of the cases was studied. By using a solid phase sandwich ELISA (enzyme-linked immunosorbent assay), the serum levels of interleukins 2, 8, 10 and 17 were measured and compared between cases and controls. Serum interleukin-2, 8, 10 and 17 levels were studied among cases based on mode of onset, duration of illness, treatment history, site of infection and multiple other morphological characteristics of the infection.

RESULTS

The cases had statistically higher levels of interleukins-8, 10 and 17 in comparison with controls. The levels of interleukin-8 were significantly lower (p < .05) among those who had received oral antifungals. In cases where the lesion had scaling, the serum levels of interleukin-10 were significantly higher (p < .05). The lesional hyperpigmentation was significantly (p < .05) associated with low levels of interleukin-17. Also, interleukin-17 was significantly (p < .05) elevated in patients with lesions in the abdomen.

CONCLUSION

It is the first time that serum interleukin levels are studied in dermatophytosis. There is an immunological dysfunction specific to dermatophytoses initiated by their infection. Key factor in this dysfunction is the elevation of IL-10, contributing to persistent infection. In turn, causing an increase in IL-17, promoting inflammation and tissue damage. This cycle of elevated IL-10 and IL-17 can further exacerbate the infection and lead to chronicity. The activity of IL-2 and the Th1 immune pathway is reduced by two opposing immune pathways: the Th17 and Th2 axes.

Dual RNA-Sequencing and Liquid Chromatography-Mass Spectrometry Unveil Specific Insights on the Pathogenicity of Trichophyton mentagrophytes Complex

Trichophyton mentagrophytes is increasingly considered to be a public health hazard because it causes the most severe manifestations of dermatophytosis. In this study, we performed a series of studies to determine the pathogenicity of the T. mentagrophytes complex. We show that the T. mentagrophytes complex interacts with keratinocytes through pattern-recognition receptors‒MAPK/noncanonical NF-κB pathways and that the hyphal form of T. mentagrophytes is responsible for the increased inflammatory responses in keratinocytes. Moreover, SN-38 is likely a toxin of T. mentagrophytes that induces apoptosis in keratinocytes both in vivo and in vitro. Our results explain the severe pathogenicity and destructiveness of T. mentagrophytes observed in the clinic and pave the way for designing novel toxin-directed therapies to improve patient outcomes.

Potential Treatment of Dermatophyte Trichophyton rubrum in Rat Model Using Topical Green Biosynthesized Silver Nanoparticles with Achillea santolina Extract

Trichophyton rubrum is the most common dermatophyte, and can cause cutaneous infections in humans and animals (dermatophytosis). In this study, we investigated the anti-dermatophytic potential of green synthesized silver nanoparticles using Achillea santolina extract (AS-AgNPs) in an in vitro and in vivo rat model of dermal T. rubrum dermatophytosis (TRD). The green synthesis of AS-AgNPs was performed using A. santolina extract and characterized by UV-VIS spectroscopy, zeta potential, imaging (transmission electron microscopy (TEM), X-ray diffraction (XRD), Fourier transform infrared spectroscopy (FTIR) and Energy dispersive X-ray analysis (EDX). The antifungal activity of AS-AgNPs was determined by the broth microdilution method, conidial germination, and hyphal growth inhibition. TEM and SEM were used to study the mode of the antifungal action of AS-AgNPs. AS-AgNPs inhibited the growth of T. rubrum with an MIC of 128 μg/mL, and suppressed the conidial germination and hyphal growth by 55.3% 84.6%, respectively. AS-AgNPs caused modified mycelial structures, increased cell membrane permeability, and cell wall damage. AS-AgNPs significantly increase the permeability of the fungal membrane, as revealed by reducing ergosterol biosynthesis. An increase in the intracellular ROS and the induction of apoptosis were also observed during AS-AgNP treatment. In addition, AS-AgNPs reduced the cell wall integrity, as shown by the reduction in the β-(1,3)-d-glucan synthase and chitin synthase activities. AS-AgNPs showed very low toxicity on primary human dermal fibroblasts (HDF) at the MIC. The topical treatment of the infected skin in the TRD rat model with AS-AgNPs showed a significant reduction in the fugal burden after 7 days and a complete clearance of fungal conidia, with a high recovery of epidermal and dermal structures after 14 days, compared to control rats. Interestingly, AS-AgNPs significantly attenuated the infiltrated inflammatory cells, in association with reducing the tissue proinflammatory cytokines including TNF-α, IL-1, IL-6, MOP and IL-17. In conclusion, our data prove AS-AgNPs to be a novel green topical therapy for dermatophytosis caused by T. rubrum.

Phylogeny, Antifungal Susceptibility, and Point Mutations of SQLE Gene in Major Pathogenic Dermatophytes Isolated From Clinical Dermatophytosis

Drug resistance is one of the major challenges to skin fungal infections, especially in tropical and subtropical infections caused by dermatophytes. This study aimed to determine the antifungal susceptibility of clinically dermatophytes and evaluate point mutations in terbinafine-resistant isolates. A total number of 123 clinical dermatophyte isolates in eight species were evaluated in terms of sensitivity to seven major antifungals. Furthermore, the point mutation in squalene epoxidase (SQLE) gene responsible for terbinafine resistance was studied. The dermatophytes species were identified by morphological characteristics and confirmed by the ITS sequencing. Also, the phylogenetic tree was drawn using the RAxML analyses for 123 dermatophytes isolates. A new XXIX genotype was also found in 4 Trichophyton mentagrophytes isolates. Based on the results obtained, terbinafine was the most effective antifungal drug followed by itraconazole and voriconazole. Trichophyton rubrum and Trichophyton tonsurans were the most susceptible species (MIC₅₀ = 0.01, 0.09 μg/ml), and T. mentagrophytes was the most resistant species (MIC₅₀ = 0.125 μg/ml) to terbinafine. Of the 123 dermatophytes isolates, six isolates showed reduced susceptibility to terbinafine, and only Trichophyton indotineae had a mutation in SQLE gene as a Phe397Leu substitution. Overall, the antifungal susceptibility test is necessary for managing dermatophytosis. These results help physicians to control the course of the disease and provide further insights to select effective drugs for patients with dermatophytosis, especially in tropical and subtropical regions of the world, where dermatophytosis is still a public health problem.

Mycobacterium marinum hand infection masquerading as tinea manuum: a case report and literature review

Fish tank granuloma is a rare skin infection caused by Mycobacterium marinum. It occurs after exposure of skin abrasions to contaminated water or infected fish. The majority of M. marinum infections today are fish tank-related. The most common presentation is a solitary nodule, often with sporotrichoid spread. Other presentations do not occur often. The diagnosis is often delayed because of lack of suspicion, nonspecific histopathological findings, and frequently unsuccessful cultivation. Here we present the case of a 37-year-old male with M. marinum skin infection, presenting as erythematous scaling plaques. Because the initial results of laboratory and histopathological examinations were negative for a fungal infection or nontuberculous mycobacteria, the patient was treated empirically with several systemic antibiotics and antifungals without any success. Finally, the diagnosis of fish tank granuloma was confirmed 3 months after the initial presentation of the patient. After the introduction of treatment with rifampicin and clarithromycin, complete clinical remission was observed after 6 months of therapy.

A global view on fungal infections in humans and animals: infections caused by dimorphic fungi and dermatophytoses

Fungal infections are still underappreciated and their prevalence is underestimated, which renders them a serious public health problem. Realistic discussions about their distribution, symptoms, and control can improve management and diagnosis and contribute to refinement of preventive actions using currently available tools. This article represents an overview of dermatophytes and endemic fungi that cause infections in humans and animals. In addition, the impact of climate change on the fungal spread is discussed. The endemic fungal infections characterized in this article include coccidioidomycosis, histoplasmosis, blastomycosis, lobomycosis, emergomycosis and sporotrichosis. Moreover the geographic distribution of these fungi, which are known to be climate sensitive and/or limited to endemic tropical and subtropical areas, is highlighted. In turn, dermatophytes cause superficial fungal infections of skin, hairs and nails, which are the most prevalent mycoses worldwide with a high economic burden. Therefore, the possibility of causing zoonoses and reverse zoonoses by dermatophytes is highly important. In conclusion, the article illustrates the current issues of the epidemiology and distribution of fungal diseases, emphasizing the lack of public programmes for prevention and control of these types of infection.

Magnitude, characteristics and consequences of topical steroid misuse in rural North India: an observational study among dermatology outpatients

INTRODUCTION

Current evidence indicates an alarming increase in topical steroid (TS) misuse in India. Data regarding the magnitude and characteristics of this problem in rural India, where 68% of the population resides, are insufficient. This study analyses the magnitude, causes, characteristics and consequences of TS misuse in rural India. It also examines the association between TS misuse and patients' perception of skin disease.

METHODS

A mixed-method observational study was conducted among the attendees of the dermatology outpatient department in a rural North Indian hospital. Those with a history of TS misuse were analysed for behaviour patterns and outcome.

RESULTS

Out of 723 patients, 213 (29.2%) misused TS. Clobetasol propionate (58.2%) was most commonly misused. Seventy brands of inappropriate fixed drug combination steroid creams were recovered from the patients. Pharmacists and local healers together contributed to 78% of the sources for steroid misuse. Almost 58% of participants perceived their skin conditions to be allergic reactions to food, when in fact 70.1% were tinea, 10% scabies and 9% acne. Eighty per cent of the respondents having tinea had tinea incognito and 97% had extensive lesions. Eighty-five per cent of the participants with scabies had atypical lesions and 80% with acne had steroid rosacea or aggravation of acne. The median expenditure incurred in purchasing these potentially harmful steroid creams was Rs 1000 (US$14.1, equivalent to 3 days' wages of a labourer).

CONCLUSION

Steroid misuse is a problem of epidemic proportion in rural India. This practice is changing the profile of many common and infective skin conditions, which portends diagnostic dilemmas and therapeutic challenges for clinicians. Misconceptions about skin disease drive the public to seek 'quick fixes' from non-allopathic providers who have unrestricted access to potent steroids. There is an urgent need to tighten regulatory controls over the manufacturing, sale and prescription of irrational TS combinations.

Skin Infections and Outpatient Burn Management: Fungal and Viral Skin Infections

Fungal and viral skin infections are common and typically are managed by family physicians. The fungal skin infections commonly seen in family practice include the various forms of tinea: tinea corporis, tinea gladiatorum, tinea cruris, tinea pedis, tinea capitis, and tinea unguium (eg, onychomycosis). Common viral skin infections include herpes simplex virus infection, herpes zoster, cutaneous and genital warts, and molluscum contagiosum. Many fungal and viral skin infections have a classic appearance but variations and atypical manifestations can make patients with these conditions difficult to diagnose definitively. Confirmatory testing often is not required. In complex cases with atypical features, microscopy, culture, or blood tests can help in making a diagnosis. For some infections, treatment may be initiated before confirmatory test results are received. Most fungal skin infections can be managed effectively with topical antifungals. Tinea capitis and onychomycosis should be managed with oral drugs. Oral antiviral drugs are used to manage most viral skin infections but dosages vary based on the condition and phase of the infectious process. Cutaneous warts typically are managed with salicylic acid and/or cryotherapy.

Dermatophyte Immune Memory Is Only Skin-Deep

A new report in this issue of Journal of Investigative Dermatology reveals a role for IL-17 and IFN-gamma, signature cytokines of T-helper 17 and T-helper 1 cells, in immunity to Trichophyton benhamiae (Heinen et al., 2018). While there have been many recent advances in understanding host defenses against common fungi, this work illuminates not only adaptive immunity, but also innate immune responses to dermatophytosis.

[Suppression of experimental inflammation by anti-fungal agent liranaftate in mice]

To evaluate the anti-inflammatory activity of the thiocarbamate antifungal agent liranaftate, the edema and the neutrophil accumulation detected by the activity of neutrophil marker enzyme, myeloperoxidase (MPO), were examined following application of liranaftate to mouse ears with inflammation induced by phorbol 12-myristate 13-acetate (PMA). Topical 20 microl administration of liranaftate in a dose-range between 1-4% suppressed the increase in ear thickness 6 hr after PMA application dose-dependently. Similarly, it decreased the weight increase of an ear section after 24 hr dose-dependently. More than 1% of liranaftate also suppressed augmentation of MPO activity of the ear section. This and histological observation indicate that liranaftate treatment suppressed neutrophil accumulation in PMA-applied ear lesion. From these results, we discussed that liranaftate might suppress inflammatory symptoms caused by trychophytosis in a clinical condition.

Delusional tinea: a novel subtype of delusional parasitosis

Delusions of parasitosis is one of the more complex management problems encountered in the dermatology clinic. The difficulty mainly arises from the fact that a psychiatric disease is responsible for the cutaneous pathology. Typically, patients complain of "parasites" or other crawling bugs on their skin. The delusion and its presentation are surprisingly consistent from patient to patient and effective management requires incorporation of psychiatric principles. In this report, we present a rare case of delusion in which the perpetrator was believed to be a "fungus."

Astrocyte-neurone communication following oxygen-glucose deprivation

We looked at the possible interactions between astrocytes and neurones during reperfusion using an in vitro model of ischaemia-reperfusion injury, as a controlled environment that lends itself easily to manipulation of the numerous variables involved in such an insult. We constructed a chamber in which O2 can be lowered to a concentration of 1 microm and developed a primary cortical neuronal culture that is 99% pure and can survive to at least 10 days in vitro. We also established a novel system for the co-culture of astrocytes and neurones in order to study the communication between these cells in a manner that allows the complete separation of one cell type from another. Neurone cultures showed profound cell death following an ischaemic period of only 15 min. We co-cultured neurones that had been subjected to a 15-min ischaemic insult with either non-insulted astrocytes or astrocyte-conditioned medium during the reperfusion stage. Both astrocytes and astrocyte-conditioned medium enhanced neuronal survival. Our data also suggest that astrocyte-sourced neuronal glutathione synthesis may play a role in preventing neuronal death.

Superficial fungal infections in adolescence

Cutaneous fungal infections occur frequently in the adolescent population, and are second only to acne in generating skin-related adolescent anguish. Though superficial fungal infections of the skin are rarely life-threatening, they can cause significant worrisome cutaneous findings (e.g., white spots from pityriasis versicolor, distorted nails from onychomycosis). Such changes are particularly threatening to an adolescent who wants to be just like everybody else. This article focuses on several of the more common cutaneous fungal infections in adolescence, including pityrosporum (tinea) versicolor and dermatophyte infections of the feet, groin, skin, and nails. The prevalence of each disease is discussed, along with its clinical presentation, differential diagnosis, and methods of treatment.

A SEVENTEEN-YEAR SURVEY OF THE RINGWORM FLORA OF BIRMINGHAM

The nature of the ringworm flora of Birmingham over 17 years was investigated and tabulated by species, geographical distribution and concentration.

The rise and fall of such outbreaks as occurred has been charted.

The persistent preponderance of zoophilic species, in spite of the recent decline in over-all incidence, has been demonstrated.