Molecular typing and antifungal susceptibility of Trichophyton rubrum isolates from patients with onychomycosis pre- and post-treatment

Genotyping of Russian isolates of fungal pathogen Trichophyton rubrum, based on simple sequence repeat and single nucleotide polymorphism

BACKGROUND

The Trichophyton rubrum species group consists of prevalent causative agents of human skin, nail and hair infections, including T rubrum sensu stricto and T violaceum, as well as other less well-established or debatable taxa like T soudanense, T kuryangei and T megninii. Our previous study provided limited evidence in favour of the existence of two genetic lineages in the Russian T rubrum sensu stricto population.

OBJECTIVES

We aimed to study the genetic structure of the Russian population of T rubrum and to identify factors shaping this structure.

METHODS

We analysed the polymorphism of 12 simple sequence repeat (SSR or microsatellite) markers and single nucleotide polymorphism in the TERG_02941 protein-coding gene in 70 T rubrum isolates and performed a phylogenomic reconstruction.

RESULTS

All three types of data provided conclusive evidence that the population consists of two genetic lineages. Clustering, performed by means of microsatellite length polymorphism analysis, was strongly dependent on the number of nucleotide repeats in the 5'-area of the fructose-1,6-bisphosphate aldolase gene. Analysis of molecular variance (AMOVA) on the basis of SSR typing data indicated that 22%-48% of the variability was among groups within T rubrum. There was no clear connection of population structure with types of infection, places of geographic origin, aldolase gene expression or urease activity.

CONCLUSION

Our results suggest that the Russian population of T rubrum consists of two cosmopolitan genetic lineages.

The survey of tinea capitis and scalp dermatophyte carriage in nursing home residents

Tinea capitis is a contagious dermatophyte infection of scalp and associated hairs. On the other hand, asymptomatic carriage is a status of positive dermatophyte scalp culture, but without signs or symptoms of tinea capitis, and no evidence of hair shaft invasion confirmed by direct microscopy. Tinea capitis and asymptomatic carriage mostly occur in children, but adult females are becoming another population in recent decades. In this study, we focused on the prevalence and related fungi of tinea capitis and asymptomatic carriage in elderly by the shampoo brush method, as well as the source of transmission, in 10 nursing home residents. Two hundred and thirteen residents were screened, and 186 isolates were identified, of which only three were dermatophytes (1.4%). The scalp dermatophyte isolates were identified as Trichophyton rubrum by morphological characters and sequences comparisons in all three cases. After revisiting, these cases were proved to be asymptomatic carriers by negative microscopic and culture examination; however, two cases were found to have concurrent tinea pedis and onychomycosis, which were identified as T. rubrum and Trichophyton interdigitale. The source of the T. rubrum scalp carriage may come from tinea elsewhere on the body of the same subject or from other people in the same institute. Finding and treating the source of carriage, as well as treating scalp carriage patients according to the colony counts, may help prevent disease spreading.

Molecular Strain Typing of Clinical Isolates, Trichophyton rubrum using Non Transcribed Spacer (NTS) Region as a Molecular Marker

INTRODUCTION

Dermatophytes are a group of fungi which infect keratinized tissues and causes superficial mycoses in humans and animals. The group comprises of three major genera, Trichophyton, Microsporum and Epidermophyton. Among them Trichophyton rubrum is a predominant anthropophilic fungi which causes chronic infections. Although, the infection is superficial and treatable, reinfection/coinfection causes inflation in the treatment cost. Identifying the source and mode of transmission is essential to prevent its transmission. Accurate discrimination is required to understand the clinical (relapse or reinfection) and epidemiological implications of the genetic heterogeneity of this species. Polymorphism in the Non Transcribed Spacer (NTS) region of ribosomal DNA (rDNA) clusters renders an effective way to discriminate strains among T. rubrum.

AIM

To carry out the strain typing of the clinical isolates, Trichophyton rubrum using NTS as a molecular marker.

MATERIALS AND METHODS

Seventy T.rubrum clinical isolates obtained from April-2011-March 2013, from Sri Ramachandra Medical Centre, Chennai, Tamil Nadu, India, were identified by conventional phenotypic methods and included in this prospective study. The isolates were then subjected to Polymerase Chain Reaction (PCR) targeting two subrepeat elements (SREs), TRS-1 and TRS-2 of the NTS region.

RESULTS

Strain-specific polymorphism was observed in both subrepeat loci. Total, nine different strains were obtained on combining both TRS-1 and TRS-2, SREs.

CONCLUSION

The outcome has given a strong representation for using NTS region amplification in discriminating the T. rubrum clinical isolates. The method can be adapted as a tool for conducting epidemiology and population based study in T. rubrum infections. This will help in future exploration of the epidemiology of T. rubrum.

Molecular epidemiology, phylogeny and evolution of dermatophytes

Dermatophytes are fungi that invade and propagate in the keratinized skin of mammals, including humans, often causing contagious infections. The species of medical concern belong to the genera Microsporum, Trichophyton, Epidermophyton (in their anamorphic state) and Arthroderma (in their telomorphic state), which were traditionally identified based on their morphology and biochemical characters. Nonetheless, limitations linked to the differentiation of closely related agents at species and strains level have been recently overcome by molecular studies. Indeed, an accurate identification of dermatophytes is pivotal for the establishment of effective control and prevention programs as well as for determining the most appropriate and effective antifungal therapies to be applied. This article reviews the DNA techniques and the molecular markers used to identify and to characterize dermatophyte species, as well as aspects of their phylogeny and evolution. The applications of typing molecular strain to both basic and applied research (e.g., taxonomy, ecology, typing of infection, antifungal susceptibility) have also been discussed.

Increase in resistance to fluconazole and itraconazole in Trichophyton rubrum clinical isolates by sequential passages in vitro under drug pressure

Trichophyton rubrum, an anthropophilic dermatophyte fungus, is the predominant causative agent of superficial skin infections in human population. There are only scanty reports on drug susceptibility profiling of T. rubrum. Neither mechanisms for drug resistance development nor correlation between in vitro drug susceptibility and in vivo response to treatment is known for that species. In this study, changes in the in vitro susceptibilities to fluconazole (FLZ) and itraconazole (ITZ) among thirty T. rubrum clinical strains subjected to sequential passages in the presence or absence of the azoles were investigated. Each strain was passaged 12 times at 4-week intervals as three parallel cultures, maintained on a drug-free medium (1), and a medium containing FLZ (2) or ITZ (3) at subinhibitory concentrations. Susceptibility to FLZ and ITZ of the original strain and its 3 subcultures was determined by microdilution method. The MIC values of the two azoles remained unaltered for all T. rubrum strains tested, after 12 passages on a drug-free medium. Among the strains grown with FLZ, an increase in the MICs of FLZ and ITZ was noted in 17 (56.7 %) and 19 (63.3 %) strains, respectively. Increased MICs of ITZ and FLZ were demonstrated for 24 (80 %) and 20 (66.7 %) strains that were propagated with ITZ. The results indicate the capacity of T. rubrum to develop resistance toward the azoles after prolonged exposure to these drugs. Resistance of T. rubrum to azoles plays an important role in therapy failures and consequently contributes to persistence and chronicity of the infections.

Griseofulvin Only Modestly Diminishes Persistence of Trichophyton tonsurans on the Scalp of Carriers

OBJECTIVES

Using genetic strain typing, we previously identified a high rate of T. tonsurans carriage among preschool-aged children attending an urban daycare center. No treatment was provided as part of the observational study; however, children when symptomatic were treated in accordance with daycare policies. This retrospective investigation examines antifungal drug therapy received during the previous investigation and characterizes the impact of treatment on persistence of the fungus on the scalp.

METHODS

Children in whom serial typeable isolates of T. tonsurans were recovered were eligible for evaluation. Clinic charts were reviewed and dispensing records obtained from the primary pharmacies serving the daycare. Infection patterns were examined before and after treatment.

RESULTS

We identified 72 dispensing records for 53 children, all of whom received griseofulvin. Nine children could not be evaluated because treatment was coincident with their last study visit. Thus, 63 treatment events in 44 children with 331 discrete infection events remained. After a single course of griseofulvin, 22.7% of children became culture negative, 6.8% acquired another strain of T. tonsurans and, 70.5% remained persistently positive with the same strain carried prior to treatment. Among those receiving a second course of therapy, 54% remained positive and the cumulative percent of children that became culture negative increased to 36.4%. If children subsequently acquiring a different strain are considered together with those that became culture negative, cumulative strain clearance was observed in 43% of children. Neither the griseofulvin dose nor the duration of time over which children were infected prior to treatment differed between those that remained positive and those that became negative.

CONCLUSIONS

Griseofulvin eradicates dermatophyte scalp carriage in less than one-half of preschool-aged children receiving between one and four 4-week courses of the drug.

An update on treatment of onychomycosis

Onychomycosis (OM) is a fungal infection of the nail plate or nail bed which is highly prevalent in the general population and also responsible for significant morbidity. The condition needs to be treated in view of the physical and emotional handicap it produces. The peculiarities of the nail apparatus in health and disease lead to difficulties in being able to successfully treat this condition. Hence, the very same antifungals which produce high cure rates in skin infections are rendered less efficacious in nail disease. Low cure rates and high relapse rates even with highly efficacious antifungals have lead to an increasing interest in exploring newer treatment options which can ensure drug penetration, drug persistence, mycological cure and effective prevention of relapse. The current review aims to summarize our current status of knowledge about the treatment options for OM. It also summarizes the newer areas of research especially with respect to devices related therapies; physical measures to enhance penetration through nail; and development and evaluation of synergistic combinations.

Identification and differentiation of Trichophyton rubrum clinical isolates using PCR-RFLP and RAPD methods

Trichophyton rubrum represents the most frequently isolated causative agent of superficial dermatophyte infections. Several genotyping methods have recently been introduced to improve the delineation between pathogenic fungi at both the species and the strain levels. The purpose of this study was to apply selected DNA fingerprinting methods to the identification and strain discrimination of T. rubrum clinical isolates. Fifty-seven isolates from as many tinea patients were subjected to species identification by polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) analysis and strain differentiation using a randomly amplified polymorphic DNA (RAPD) method, with two primers designated 1 and 6. Using PCR-RFLP, 55 of the isolates studied were confirmed to be T. rubrum. Among those, a total of 40 and five distinct profiles were obtained by RAPD with primers 1 and 6, respectively. The combination of profiles from both RAPD assays resulted in 47 genotypes and an overall genotypic diversity rate of 85.4%. A dendrogram analysis performed on the profiles generated by RAPD with primer 1 showed most of the isolates (87.3%) to be genetically related. PCR-RFLP serves as a rapid and reliable method for the identification of T. rubrum species, while the RAPD analysis is rather a disadvantageous tool for T. rubrum strain typing.

Trichophyton rubrum and Trichophyton interdigitale: genetic diversity among species and strains by random amplified polymorphic DNA method

Onychomycosis is a common condition that represents up to 50% of all nail problems and 30% of all cases of dermatophytoses. Trichophyton rubrum and Trichophyton interdigitale are the most common agents involved in this condition. In cases of recurrent post-treatment onychomycosis, strain fingerprinting could reveal whether the original isolate is responsible, a new strain has been acquired or if multiple strains are involved. The aim of this study was to evaluate the efficacy of the RAPD method for species and strain differentiation of T. rubrum and T. interdigitale obtained from patients with subungeal distal-lateral onychomycosis. A set of 86 strains of onychomycosis causative dermatophytes were submitted to species differentiation and strain typing by RAPD method with two previously described primers. Both primers proved capable of strain differentiation when tested for each species. Nineteen molecular profiles were configured for T. rubrum isolates with primers 1 and 6. For T. mentagrophytes, ten molecular profiles were configured with primer 1 and twenty-one with primer 6. We found that T. interdigitale and T. rubrum species were grouped in different clusters when both primers were analyzed together. This study shows that these primers are valuable tools for strain differentiation with T. rubrum and T. intedigitale.

Evaluation of a PCR melting profile method for intraspecies differentiation of Trichophyton rubrum and Trichophyton interdigitale

In order to identify the source of infections caused by dermatophytes, as well as the pathogen transmission pathway, there is a need to determine methods that allow detailed genetic differentiation of the strains within the dermatophyte genera. In this work, a PCR melting profile (PCR-MP) technique based on the ligation of adaptors and the difference in melting temperatures of DNA restriction fragments was used for the first time for intraspecies genotyping of dermatophytes. Clinical isolates and reference strains of dermatophytes isolated from skin, scalp, toenails and fingernails were used for this study. PCR-MP and random amplification of polymorphic DNA (RAPD) were used to type 11 isolates of Trichophyton rubrum, 40 isolates of Trichophyton interdigitale and 14 isolates of Microsporum canis. The results distinguished five types (containing one subtype) characteristic for T. rubrum and seven types characteristic for T. interdigitale using the PCR-MP technique. Analysis conducted using RAPD revealed five types for T. rubrum and four types for T. interdigitale isolates. No differentiation was observed for the M. canis isolates with either method. These results demonstrate that PCR-MP is a reliable method for the differentiation of T. rubrum and T. interdigitale strains and yields a discriminatory power that is at least equal to that of RAPD.

Preventing long term relapsing tinea unguium with topical anti-fungal cream: a case report

Background

The patient was aged 34 when he consulted a dermatologist in Vancouver BC with onychomycosis affecting the right great toenail.

Case presentation

Trichophyton rubrum was cultured from nail clippings. Griseofulvin was taken for 6 months, resulting in clinical and mycological cure. Over the next 27 years there were multiple relapses. Each course of treatment with oral terbinafine (for up to 18 months) or itraconazole resulted in clinical and mycological cure. A dermatological colleague suggested the reason for relapse was likely to be self re-infection.

Conclusion

No clinical relapse has occurred with once-weekly miconazole cream applied to the toenail and webspaces of the right foot over the last four years.