Fusarium spp. as agents of onychomycosis in immunocompetent hosts

Onychomycosis due to Fusarium species in different continents, literature review on diagnosis and treatment

Fusarium species are an emerging cause of onychomycosis, and the number of cases has dramatically increased in recent decades worldwide. This review presents an overview of the onychomycosis cases caused by Fusarium species and diagnosis and treatment that have been reported in the literature. The most common causative agent of onychomycosis is F. solani species complex, which accounts for 11.68% of the cases of Fusarium onychomycosis, followed by the F. oxysporum species complex (164 out of 1669), which is accounted for 9.83% of the total. F. fujikuroi species complex (42 out of 1669) and F. dimerum species complex (7 out of 1669) are responsible for 2.52% and 0.42 cases, respectively. Fusarium nail infections were reported in patients aged range 1-98, accounting for 5.55% (1669 out of 30082) of all cases. Asia has the highest species diversity of Fusarium onychomycosis (31.51%). South America accounts for 21.09%, and the most common causative agent is F. solani (19.32%), followed by F. oxysporum species complex (15.63%). Europe accounts for 4.90% of cases caused by F. oxysporum, followed by F. solani. Africa accounts for 23.87% of the cases due to the F. solani species complex, followed by F. oxysporum and F. fujikuroi. Distal and lateral subungual onychomycosis was the most common clinical symptom accounting for 58.7% (135 out of 230) of the cases. Data analysis relieved that terbinafine and itraconazole are active treatments for Fusarium onychomycosis. For a definitive diagnosis, combining of direct examination, culture and sequencing of the elongation factor of translation 1α are recommended. Accurate identification of the causative agents of onychomycosis due to Fusarium species and antifungal susceptibility testing is essential in patient management.

Possibly the first case of onychomycosis by Fusarium lactis: Case presentation and literature review of onychomycosis by Fusarium species

Fusarium species (spp.) is frequently found in soil and plant residues and on plant bodies in all climatic zones worldwide. Although there have been few reports of onychomycosis caused by Fusarium spp., it is characterized by drug sensitivity and other characteristics. Here, we report what may be the first case of onychomycosis caused by Fusarium lactis. We analyzed the mycology and characterized previously reported cases of onychomycosis caused by Fusarium spp. A 73-year-old otherwise healthy woman presented with discoloration and thickening of her right thumbnail with paronychia. Direct microscopy revealed unevenly swollen hyphae, and a Grocott-stained nail specimen showed septate hyphae. Based on the morphological features and gene analysis of fungus isolated from the nail, we diagnosed onychomycosis caused by F. lactis belonging to Fusarium fujikuroi species complex. Partial nail removal and topical application of 1% luliconazole solution resolved the condition in 6 months. Minimum inhibitory concentrations for isolated F. lactis showed high sensitivity to luliconazole but not itraconazole or terbinafine. The isolated F. lactis was temperature-sensitive. A search of the literature revealed 57 cases of onychomycosis caused by Fusarium spp. with delineated clinical characteristics. Since those cases were investigated using morphological and/or molecular methods, we analyzed them by species complex as well as species. Onychomycosis caused by Fusarium spp. is predominantly found on the big toe, with Fusarium solani species complex and Fusarium oxysporum species complex accounting for over 70% of cases. Infection of only one digit with paronychia is a characteristic clinical manifestation of onychomycosis caused by Fusarium spp. Since there has been an increase in instances of molecular determination of Fusarium spp., it is deemed necessary to clarify its clinical and fungal nature. Due to its characteristic drug sensitivity and temperature-sensitive nature, new treatments are expected to be developed.

Detection of 2-ethyl-1-hexanol and its modulating effect in biofilm of Fusarium oxysporum

In immunocompetent individuals, Fusarium spp. stands out as the causative agent of onychomycosis, among the non-dermatophyte molds. Despite evidence indicating that Fusarium oxysporum organizes itself in the form of a biofilm causing onychomycosis, there is little literature on the etiopathogenesis of the biofilm on the nail, specifically the signaling molecules present, known as quorum sensing (QS). Thus, this study detected the presence of a molecule related to QS from the ex vivo biofilm of F. oxysporum on human nail and investigated its effect on preformed biofilm in vitro. The detection and physicochemical characterization of a QS molecule, from the extracellular matrix (ECM), was carried out by Fourier transform infrared (FTIR) spectroscopy with an attenuated total reflectance (ATR) accessory and by headspace gas chromatography coupled to mass spectrometry (GC-MS) analyses. Determination of viable cells, cell activity, total biomass, ECM components and scanning electron microscopy (SEM) were performed to evaluate the influence of the QS molecule on the in vitro biofilm of F. oxysporum. The beginning, in the ex vivo biofilm of F. oxysporum on human nails, the volatile organic compound 2-ethyl-1-hexanol (2EH) was detected as a component of QS. Thereafter in vitro analyses, synthetic 2EH was able to modulate the biofilm by stimulating its filament, increasing total biomass and ECM production in terms of total carbohydrates, but with a reduction in total proteins and nucleic acids. We thus evidence, for the first time, the presence of 2EH in the biofilm of F. oxysporum, developed on the human nail, and the in vitro action of this compound as a QS molecule.

Light-Driven Tetra- and Octa-β-substituted Cationic Zinc(II) Phthalocyanines for Eradicating Fusarium oxysporum Conidia

Photodynamic inactivation (PDI) is an emerging therapeutic approach that can effectively inactivate diverse microbial forms, including vegetative forms and spores, while preserving host tissues and avoiding the development of resistance to the photosensitization procedure. This study evaluates the antifungal and sporicidal photodynamic activity of two water-soluble amphiphilic tetra- and octa-β-substituted zinc(II) phthalocyanine (ZnPc) dyes with dimethylaminopyridinium groups at the periphery (ZnPcs 1, 2) and their quaternized derivatives (ZnPcs 1a, 2a). Tetra(1, 1a)- and octa(2, 2a)-β-substituted zinc(II) phthalocyanines were prepared and assessed as photosensitizers (PSs) for their effects on Fusarium oxysporum conidia. Antimicrobial photoinactivation experiments were performed with each PS at 0.1, 1, 10, and 20 µM under white light irradiation at an irradiance of 135 mW·cm-2, for 60 min (light dose of 486 J·cm-2). High PDI efficiency was observed for PSs 1a, 2, and 2a (10 µM), corresponding to inactivation until the method's detection limit. PS 1 (20 µM) also achieved a considerable reduction of >5 log10 in the concentration of viable conidia. The quaternized PSs (1a, 2a) showed better PDI performance than the non-quaternized ones (1, 2), even at the low concentration of 1 µM, and a light dose of 486 J·cm-2. These cationic phthalocyanines are potent photodynamic drugs for antifungal applications due to their ability to effectively inactivate resistant forms, like conidia, with low concentrations and reasonable energy doses.

Cutaneous Fungal Infections Caused by Dermatophytes and Non-Dermatophytes: An Updated Comprehensive Review of Epidemiology, Clinical Presentations, and Diagnostic Testing

Cutaneous fungal infection of the skin and nails poses a significant global public health challenge. Dermatophyte infection, mainly caused by Trichophyton spp., is the primary pathogenic agent responsible for skin, hair, and nail infections worldwide. The epidemiology of these infections varies depending on the geographic location and specific population. However, epidemiological pattern changes have occurred over the past decade. The widespread availability of antimicrobials has led to an increased risk of promoting resistant strains through inappropriate treatment. The escalating prevalence of resistant Trichophyton spp. infections in the past decade has raised serious healthcare concerns on a global scale. Non-dermatophyte infections, on the other hand, present even greater challenges in terms of treatment due to the high failure rate of antifungal therapy. These organisms primarily target the nails, feet, and hands. The diagnosis of cutaneous fungal infections relies on clinical presentation, laboratory investigations, and other ancillary tools available in an outpatient care setting. This review aims to present an updated and comprehensive analysis of the epidemiology, clinical manifestations, and diagnostic testing methods for cutaneous fungal infections caused by dermatophytes and non-dermatophytes. An accurate diagnosis is crucial for effective management and minimizing the risk of antifungal resistance.

High Diversity of Fusarium Species in Onychomycosis: Clinical Presentations, Molecular Identification, and Antifungal Susceptibility

Fusarium are uncommon but important pathogenic organisms; they cause non-dermatophyte mould (NDM) onychomycosis. Patients typically respond poorly to treatment owing to Fusarium's native resistance to multiple antifungal drugs. However, epidemiological data for Fusarium onychomycosis are lacking in Taiwan. We retrospectively reviewed the data of 84 patients with positive Fusarium nail sample cultures at Chang Gung Memorial Hospital, Linkou Branch between 2014 and 2020. We aimed to investigate the clinical presentations, microscopic and pathological characteristics, antifungal susceptibility, and species diversity of Fusarium in patients with Fusarium onychomycosis. We enrolled 29 patients using the six-parameter criteria for NDM onychomycosis to determine the clinical significance of Fusarium in these patients. All isolates were subjected to species identification by sequences and molecular phylogeny. A total of 47 Fusarium strains belonging to 13 species in four different Fusarium species complexes (with Fusarium keratoplasticum predominating) were isolated from 29 patients. Six types of histopathology findings were specific to Fusarium onychomycosis, which may be useful for differentiating dermatophytes from NDMs. The results of drug susceptibility testing showed high variation among species complexes, and efinaconazole, lanoconazole, and luliconazole showed excellent in vitro activity for the most part. This study's primary limitation was its single-centre retrospective design. Our study showed a high diversity of Fusarium species in diseased nails. Fusarium onychomycosis has clinical and pathological features distinct from those of dermatophyte onychomycosis. Thus, careful diagnosis and proper pathogen identification are essential in the management of NDM onychomycosis caused by Fusarium sp.

In Vitro Photoinactivation of Fusarium oxysporum Conidia with Light-Activated Ammonium Phthalocyanines

Antimicrobial photodynamic therapy (aPDT) has been explored as an innovative therapeutic approach because it can be used to inactivate a variety of microbial forms (vegetative forms and spores) without causing significant damage to host tissues, and without the development of resistance to the photosensitization process. This study assesses the photodynamic antifungal/sporicidal activity of tetra- and octasubstituted phthalocyanine (Pc) dyes with ammonium groups. Tetra- and octasubstituted zinc(II) phthalocyanines (1 and 2) were prepared and tested as photosensitizers (PSs) on Fusarium oxysporum conidia. Photoinactivation (PDI) tests were conducted with photosensitizer (PS) concentrations of 20, 40, and 60 µM under white-light exposure at an irradiance of 135 mW·cm^-2, applied during 30 and 60 min (light doses of 243 and 486 J·cm^-2). High PDI efficiency corresponding to the inactivation process until the detection limit was observed for both PSs. The tetrasubstituted PS was the most effective, requiring the lowest concentration and the shortest irradiation time for the complete inactivation of conidia (40 µM, 30 min, 243 J·cm^-2). Complete inactivation was also achieved with PS 2, but a longer irradiation time and a higher concentration (60 µM, 60 min, 486 J·cm^-2) were necessary. Because of the low concentrations and moderate energy doses required to inactivate resistant biological forms such as fungal conidia, these phthalocyanines can be considered potent antifungal photodynamic drugs.

Appraisal of selected ethnomedicinal plants as alternative therapies against onychomycosis: Evaluation of synergy and time-kill kinetics

Introduction: This study aims at the biological profiling of Allium sativum, Zingiber officinale, Nigella sativa, Curcuma longa, Mentha piperita, Withania somnifera, Azadirachta indica, and Lawsonia inermis as alternatives against onychomycosis to combat the treatment challenges. Methods: An extract library of aqueous (DW), ethyl acetate (EA), and methanol (M) extracts was subjected to phytochemical and antioxidant colorimetric assays to gauge the ameliorating role of extracts against oxidative stress. RP-HPLC quantified therapeutically significant polyphenols. Antifungal potential (disc diffusion and broth dilution) against filamentous (dermatophytes and non-dermatophytes) and non-filamentous fungi (yeasts; Candida albicans), synergistic interactions (checkerboard method) with terbinafine and amphotericin-B against resistant clinical isolates of dermatophytes (Trichophyton rubrum and Trichophyton tonsurans) and non-dermatophytes (Aspergillus spp., Fusarium dimerum, and Rhizopus arrhizus), time-kill kinetics, and protein estimation (Bradford method) were performed to evaluate the potential of extracts against onychomycosis. Results: The highest total phenolic and flavonoid content along with noteworthy antioxidant capacity, reducing power, and a substantial radical scavenging activity was recorded for the extracts of Z. officinale. Significant polyphenolics quantified by RP-HPLC included rutin (35.71 ± 0.23 µg/mgE), gallic acid (50.17 ± 0.22 µg/mgE), catechin (93.04 ± 0.43 µg/mgE), syringic acid (55.63 ± 0.35 µg/mgE), emodin (246.32 ± 0.44 µg/mgE), luteolin (78.43 ± 0.18 µg/mgE), myricetin (29.44 ± 0.13 µg/mgE), and quercetin (97.45 ± 0.22 µg/mgE). Extracts presented prominent antifungal activity against dermatophytes and non-dermatophytes (MIC-31.25 μg/ml). The checkerboard method showed synergism with 4- and 8-fold reductions in the MICs of A. sativum, Z. officinale, M. piperita, L. inermis, and C. longa extracts and doses of amphotericin-B (Amp-B) and terbinafine (against non-dermatophytes and dermatophytes, respectively). Furthermore, the synergistic therapy showed a time-dependent decrease in fungal growth even after 9 and 12 h of treatment. The inhibition of fungal proteins was also observed to be higher with the treatment of synergistic combinations than with the extracts alone, along with the cell membrane damage caused by terbinafine and amp-B, thus making the resistant fungi incapable of subsisting. Conclusion: The extracts of A. sativum, Z. officinale, M. piperita, L. inermis, and C. longa have proven to be promising alternatives to combat oxidative stress, resistance, and other treatment challenges of onychomycosis.

Efficacy of Propolis Gel on Mature Biofilm Formed by Neocosmospora keratoplastica Isolated from Onychomycosis

This article describes Neocosmospora keratoplastica as an etiological onychomycosis agent. Ex vivo studies were initially performed to demonstrate the ability of this species to grow and form a well-organized characteristic biofilm on sterilized healthy nails. Based on the history of excellent results, both for antifungal and antibiofilm, of propolis resin gum, we evaluated its activity using artificially formed biofilm. In vitro, the minimal biofilm eradication concentration of the propolis extract (PE) was 375 µg of total polyphenol content (TPC) per mL, while for the propolis gel (PG) it was 450 µg of TPC per mL. In biofilm exposed to the propolis products, a decrease in hyphae and conidia was evident, accompanied by a disorganization of the extracellular matrix. Additionally, this low concentration of PE was able to significantly reduce the number of colony-forming units and the metabolic activity. Furthermore, the treatment of a 15-year nail infection due to N. keratoplastica was carried out exclusively using a topical treatment with a gel containing propolis (30%) with a daily dosage. This treatment achieved complete remission of the onychomycosis in 12 months. It is important to point out that some inconveniences previously reported by other patients treated with propolis extract were eliminated, increasing adherence to treatment.

Insights on the etiopathogenesis of onychomycosis by dermatophyte, yeast and non dermatophyte mold in ex vivo model

Fungal biofilms have been involved in the pathogenesis of onychomycosis, but the aspects contributing to this association need to be enlightened. This study aimed to investigate the ability of three different fungi to form biofilm on the nail. All evaluated fungi were able to grow on the nails, using them as the only nutritional source and formed a structure strongly suggestive of biofilms. However, their architecture and morphology were highly contrasting: Candida albicans showed dense growth, exhibited a well-structured community and a large amount of extracellular matrix (ECM), and FTIR-ATR spectroscopy reinforced these findings revealing components suggestive of the biofilm. For Fusarium oxysporum these events were also observed, but in lower intensity. Furthermore, while Trichophyton rubrum presented a well-organized architecture, the ECM was not visualized. We hypothesize that these findings are related to the symptomatology of onychomycosis. When it is caused by a non-dermatophyte, it usually is accompanied with paronychia, pain, edema, inflammation and few signals of keratolysis, while dermatophytes are more associated with intense onycholysis and absence of the inflammatory signals. Biofilm seems to be crucial for non-dermatophytes to cause onychomycosis, but not for T. rubrum.

Prevalence, genetic diversity and antifungal susceptibility profiles of F. fujikuroi, F. solani, and Fusarium incarnatum-equiseti species complexes from onychomycosis in North of Iran

Onychomycosis, a nail fungal infection, is normally caused by dermatophytes. However, yeasts and non-dermatophyte molds (NDM) are among pathogens that cause nail disease. Regarding, this study aimed to describe the molecular epidemiology of Fusarium onychomycosis in the North of Iran. 257 nail samples collected from the patients clinically suspected of onychomycosis were subjected to direct microscopy, calcofluor white staining, and culture. Fusarium isolates were identified at a species level through determination of multi-locus sequences for internal transcribed spacer and translation elongation factor 1 alpha. Based on the findings, Fusarium species were isolated from onychomycosis patients (n=27). According to a previous partial genes analysis, the species in the resent study belonged to the members of F. fujikuroi species complex (n=14), Fusarium incarnatum-equiseti species complex (n=1) and F. solani species complex (n=12). In rhis study, F. proliferatum was the dominant Fusarium species collected from the samples. The correct identification of Fusarium species is essential regarding the increased prevalence of Fusarium onychomycosis and the inherent resistance of these agents to a wide spectrum of antifungals. The obtained results indicated variation in the epidemiology of Fusarium species isolated from onychomycosis. Moreover, the minimum inhibitory concentration (MIC) of luliconazole and lanoconazole was in the range of 0.001-1 μg/mL, with the geometric mean of MICs obtained at 0.0103 and 0.0343 μg/mL against Fusarium species, respectively. These findings can increase researchers' knowledge regarding diversity of species, distribution of onychomycosis, and the choice of a proper treatment.

Relevant insights into onychomycosis' pathogenesis related to the effectiveness topical treatment

Onychomycosis (OM) is a fungal infection, responsible for about 50% of nail diseases. OM has been attributed to the ability of fungi to naturally organize themselves into biofilms on nail surfaces. However, little is known about the exact role of the biofilm in the etiopathogenesis of OM, as well as its influence in the permeation of a topical treatment. The objectives of this study were to review the literature for topical OM treatments in clinical trials, assess the efficiency of these treatments, and discuss factors that could affect the success of these treatments. First, a systematic search of articles published in the MEDLINE database (PubMed) between January 2010 and December 2019 was conducted, focusing on drugs under clinical trials for the topical treatment of OM. Of the publications selected, it was clear that none of them had considered the fungi organized in biofilm. Therefore, we reflected on some important variables involved in OM, such as the nail structure and the mechanism of fungal invasion. Some methods, such as histopathologic analysis and spectroscopy techniques, were found to be effective in the detection of nail biofilm, and could be used in future drug permeation studies. This review allowed us to conclude that novel antifungals for the topical treatment of OM must consider the drug to permeate through biofilm. Natural products, such as propolis, seem strong candidates in this respect.

Characterization of a biofilm formed by Fusarium oxysporum on the human nails

BACKGROUND

Fusarium spp. has been considered as an onychomycosis agent, but little is known about the etiopathogenesis of fusarial onychomycosis; thus, the objective of this study was to characterize the fungal-nail interaction and the consequences of the nail infection process by Fusarium oxysporum using the human nail, in an ex␣vivo model.

METHODS

The kinetic of biofilm production and infection by F. oxysporum using the nail as the only nutritional source were evaluated by scanning electron microscopy, number of culturable cells, metabolic activity, characterization of extracellular matrix, spectroscopy and histopathology analyses.

RESULTS

After evaluating the biofilm kinetic over 7 days using different parameters and techniques, it was possible to characterize the Fusarium-nail interaction.

CONCLUSIONS

This study is a part of a big project aiming to clarify the fusarial pathogenesis and contributes to proving F. oxysporum is able to adapt, grow, develop, and form a biofilm on healthy human nails, which are crucial steps for the invasion process.

Hypericin-P123-photodynamic therapy in an ex vivo model as an alternative treatment approach for onychomycosis caused by Fusarium spp

BackgroundFusarium has been considered an opportunistic pathogen, causing several infections in humans, including onychomycosis. In addition, a high resistance to conventional antifungals has been linked to this genus. Photodynamic Therapy (PDT), known as a non-invasive therapy, can be an alternative treatment for fungal infections, based on the excitation of a photosensitizing compound (PS) by a specific length of light, causing damage to the target. The aim of this study was to evaluate the effects of a formulation of Hypericin (Hyp) encapsulated in Pluronic™ (P123), via photodynamic therapy (PDT), on planktonic cells and biofilms in Fusarium spp. using in vitro and ex vivo assays. Materials & Methods epidemiology studies about Fusarium spp. in onychomycosis was perfomed, carried out molecular identification, compared the antifungal activity of the conventional antifungals with PDT with encapsulated Hypericin (Hyp-P123), carried out detection of reactive oxygen species, and measured the antibiofilm effect of the Hyp-P123-PDT in vitro and in an ex vivo model of onychomycosis. Results Hyp-P123-PDT exhibited a fungicidal effect in vitro with reductions ≥ 3 log₁₀. ROS generation increased post-Hyp-P123-PDT in Fusarium spp. Hyp-P123-PDT showed a potent inhibitory effect on adhesion-phase and mature biofilms in vitro tests and an ex vivo model of onychomycosis (p<0.0001). Conclusion Hyp-P123-PDT had a potent effect against Fusarium spp., suggesting that photodynamic therapy with Hyp-P123 is a safe and promising treatment for onychomycosis in clinical practice.

Predisposing factors, clinical features and treatment outcomes of Fusarium onychomycosis and comparison of its characteristics with Neoscytalidium onychomycosis

BACKGROUND

Fusarium spp. are common organisms causing onychomycosis. Research on the clinical presentations and treatment of this condition is limited.

OBJECTIVE

This study evaluated the demographic data, clinical characteristics, and treatment outcomes of Fusarium onychomycosis.

METHODS

A retrospective study was conducted at Siriraj Hospital, Thailand. Patients with onychomycosis, at least 2 repeated positive mycological cultures for Fusarium spp., and a photo at diagnosis (January 2014-December 2019) were included. Demographic data and clinical characteristics of Fusarium onychomycosis were analyzed and compared with those of Neoscytalidium onychomycosis, the other common nondermatophytes onychomycosis in tropical countries.

RESULTS

Seventeen patients with twenty-four nails were analyzed. Fusarium onychomycosis was significantly related to a history of pedicure (p = 0.04). Predominant lateral involvements of subungual hyperkeratosis onychomycosis, but without concurrent foot infections, were significantly found in Fusarium onychomycosis (p < 0.001 for each). Among the treatments, urea was 80% effective. Topical amphotericin B was 75% effective. Both amorolfine 5% nail lacquer and long-pulsed 1064-nm neodymium:yttrium-aluminum-garnet laser were 66.7% effective. Lastly a combination of long-pulsed 1064-nm neodymium:yttrium-aluminum-garnet laser and amorolfine 5% nail lacquer was 50% effective.

CONCLUSIONS

Important predisposing factors and clinical manifestations of Fusarium onychomycosis were a history of pedicure and predominant lateral-nail involvement, but no concomitant fungal foot infections. Topical treatment (urea cream, amphotericin B, or amorolfine nail lacquer) showed excellent outcomes.

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.

Immune response and Raman scattering assessment in rats skin after contact with Fusarium oxysporum metabolites

The secondary metabolites produced by Fusarium can cause disease and death when consumed and produce biological responses even in the absence of the microorganism. The IL-6, TNF-α and TGF-β1 cytokines immune reactivity was associated with histopathological and physico-chemical changes in skin of immune competent rats after administration of Fusarium oxysporum crude extract. Rats were intradermally injected with 50 μl of 0.5 mg/ml crude extract and were euthanized at 3, 6, 12 and 24 h after injection. The inflammatory response was quantified by enzyme myeloperoxidase activity and by immunohistochemical method to detect the IL-6, TNF-α and TGF-β1. Physico-chemical analysis was performed using FT-Raman Spectroscopy. The inflammatory response was most intense at 6 and 12 h after crude extract administration and the most significant histopathological changes were observed in the dermis. Myeloperoxidase activity was intense from 3 to 24 h after injection. The immunostaining of pro-inflammatory cytokines IL-6 and TNF-α peaked at 6 h. Immunostaining for TGF-β1 was highest at 12 and 24 h. FT-Raman spectral analysis showed both, the most intense Fusarium interaction with the skin at 6 h, as revealed by the changes in the stretching of -CH bands (3100-2800 cm^-1) in the dermis, and skin recovery trending after 12 h after crude extract injection. The results showed that secondary metabolites stimulated histopathologic changes and inflammatory responses even in the absence of the fungus, increasing myeloperoxidase activity and pro-inflammatory cytokine expression besides promoting physico-chemical changes.

Phylogenetic Analysis of Clinically Relevant Fusarium Species in Iran

Fungi of the genus Fusarium are well known as major plant pathogens but also cause a broad spectrum of human infections. Sixty-three clinical isolates, collected during 2014-2017, were identified using a part of the TEF1 gene as barcoding marker. Fusarium fujikuroi species complex (FFSC, n = 41, 65%) showed to be the dominant etiological agent, followed by F. solani species complex (FSSC, n = 14, 22%) and F. oxysporum species complex (FOSC, n = 7, 11%). There was one strain belonging to F. lateritium species complex (FLSC, n = 1, 1.5%). For final identification, a phylogenetic tree was constructed including the type strains of each species complex. Most cases of fusariosis were due to nail infection (n = 38, 60.3%), followed by keratitis (n = 22, 34%). Fusarium infections are difficult to be treated due to their intrinsic resistance to different azoles; however, accurate and fast identification of etiological agents may enhance management of the infection. We present the first phylogenetic study on clinical Fusarium spp. from Iran.

Fusarium onychomycoses in Switzerland-A mycological and histopathological study

Onychomycoses in temperate climates are most commonly due to dermatophytes, particularly Trichophyton rubrum. Non-dermatophyte nail infections are much less frequent, and their diagnosis requires a careful and repeated search for a potential dermatophyte that may have been overgrown in culture. A series of histological slides of suspected onychomycoses with uncommon fungal morphology prompted us to search for non-dermatophytic moulds causing dermatophytosis-like nail infections. Thirty cases were identified by culture as F solani, F oxysporum, F dimerum or F spp, and two more were only diagnosed histopathologically. None of these patients was immunocompromised. Treatment was mostly unsuccessful with terbinafine whereas itraconazole showed a moderately better treatment result; in all cases, a topical ciclopirox nail varnish in a hydroxychitosan base was added.

Antimicrobial photodynamic therapy with phenothiazinium photosensitizers in non-vertebrate model Galleria mellonella infected with Fusarium keratoplasticum and Fusarium moniliforme

Fusarium keratoplasticum and Fusarium moniliforme are filamentous fungi common in the environment and cause mycosis in both animals and plants. Human infections include mycetoma, keratitis and onychomycosis, while deeper mycosis occurs in immunocompromised patients. Most of the Fusarium spp. are frequently resistant to treatment with currently used antifungals. The frequent occurrence of antifungal resistance has motivated the study of antimicrobial photodynamic therapy as an alternative treatment for fungal infections. Many studies have investigated the in vitro use of antimicrobial photodynamic therapy to kill fungi, but rarely in animal models of infection. Thus, here we employed the invertebrate wax moth Galleria mellonella to study the in vivo effects of antimicrobial photodynamic therapy with three different phenothiazinium photosensitizers, methylene blue, new methylene blue N and the pentacyclic S137 against infection with microconidia of Fusarium keratoplasticum and Fusarium moniliforme. The effect of antimicrobial photodynamic therapy using these photosensitizers and light-emitting diodes with an emission peak at 635 nm and an integrated irradiance from 570 to 670 nm of 9.8 mW cm^-2 was investigated regarding the toxicity, fungal burden, larval survival and cellular immune response. The results from this model indicate that antimicrobial photodynamic therapy with methylene blue, new methylene blue N and S137 is efficient for the treatment of infection with F. keratoplasticum and F. moniliforme. The efficiency can be attributed to the fungal cell damage caused by antimicrobial photodynamic therapy which facilitates the action of the host immune response.

Fusarium oxysporum is an onychomycosis etiopathogenic agent

AIM

To evaluate and characterize the etiopathogenesis of the fusarial onychomycosis in an ex vivo study through fragments of sterile human nail, without the addition of any nutritional source.

MATERIALS & METHODS

The infection and invasion of Fusarium oxysporum in the nail were evaluated by scanning electron microscopy (SEM), CFU, matrix, histopathology and Fourier Transform Infrared Spectrometer coupled to an equipment with diamond accessory (FTIR-ATR).

RESULTS

F. oxysporum infected and invaded across the nail, regardless of application face. However, the dorsal nail surface was the strongest barrier, while the ventral was more vulnerable to infection and invasion process. The fungal-nail interaction resulted in the formation of a dense biofilm.

CONCLUSION

F. oxysporum infect and invade the healthy human nail, resulting in biofilm formation. Therefore, F. oxysporum is likely a primary onychomycosis agent.

Disseminated cutaneous fusariosis in human immunodeficiency virus-infected patient and dramatic response with oral itraconazole

Fusarium species are known to cause disseminated cutaneous lesions in immunocompromised patients. Some cases of fusariosis are reported in patients infected with the human immunodeficiency virus. There are two reports in such patients with systemic comorbidities like lymphoma, neutropenia and infective port-a-catheter. Another reported patient had systemic fusariosis, without skin involvement. Diagnosis and treatment of cutaneous fusariosis is difficult and resistance to antifungals is a problem. Our patient was at an advanced human immunodeficiency virus infection stage with disseminated cutaneous fusariosis, without any systemic involvement, who responded completely to oral itraconazole.

In vitro susceptibility and multilocus sequence typing of Fusarium isolates causing keratitis

Fungal keratitis is recognized as a significant cause of ocular morbidity and blindness especially in developing countries. In this study, we aimed to present the molecular identification and susceptibility of Fusarium isolates causing fungal keratitis in a university hospital in southern Brazil. The samples were identified using the second largest subunit of the RNA polymerase gene (RPB2) and the translation elongation factor 1-alpha (TEF1), while the antifungal susceptibility was tested by the broth microdilution method according to the Clinical and Laboratory Standards Institute (CLSI) methodology. The majority of the isolates belonged to the Fusarium solani species complex (F. solani, F. keratoplasticum and F. falciforme) and Fusarium oxysporum species complex. Antifungal susceptibility has shown that amphotericin B and natamycin were the most effective antifungals across all isolates, followed by voriconazole. Variation among Fusarium complexes in their antifungal sensitivities was observed in our study. The identification of Fusarium species from human samples is important not only from an epidemiological viewpoint, but also for choosing the appropriate antifungal agent for difficult-to-treat Fusarium infections such as keratitis.

Onychomycosis Caused by Fusarium spp. in Dakar, Senegal: Epidemiological, Clinical, and Mycological Study

Fusarium spp. represent 9 to 44% of onychomycoses caused by fungi other than dermatophytes. This retrospective study describes 17 cases of Fusarium onychomycosis diagnosed at the Laboratory of Parasitology and Mycology of Le Dantec University Hospital in Dakar, Senegal, from 2014 to 2016. It included all patients received in the laboratory for suspicion of onychomycosis between January 1, 2014, and December 31, 2016. Diagnosis was based on mycological examination including direct examination and culture. Mycological analysis was considered positive when direct examination and culture were positive after at least one repeat. Seventeen Fusarium onychomycosis cases representing 12.9% of all onychomycoses reported were diagnosed. There were 5 cases on the fingernails and 12 on the toenails in 6 males and 11 females, and the mean age was 44 years (range: 26-64). Onychomycoses were diagnosed in immunocompetent patients except in a diabetic patient. The mean duration of lesions was 4.9 years (range: 1-15), and distal subungual onychomycosis was predominant. Almost all patients were from suburban areas of Dakar region. The most frequent species isolated belong to Fusarium solani complex. Because of the risk of disseminated infection in immunocompromised patients, realization of susceptibility tests is necessary to ensure better therapeutic management.

[Interdigital tinea pedis resulting from Fusarium spp. in Dakar, Senegal]

INTRODUCTION

Fungal interdigital tinea pedis (ITP) is a common pathology mainly due to dermatophytes and yeasts. Fusarium sp. is rarely incriminated in the genesis of intertrigo. In Dakar, a recent study conducted in 2016 on fungal ITP showed that Fusarium were more involved in the etiology of ITP than dermatophytes, coming just after yeasts dominated by Candida. Following this, we wanted to draw attention to the increasing incidence of ITP resulting from Fusarium spp., in Dakar, Senegal, and to analyze the epidemiological and mycological particularities of these ITP due to Fusarium spp.

PATIENTS AND METHODS

A retrospective study including all patients received at the laboratory for suspicion of ITP between January 1st, 2014 and June 30th, 2017 was conducted. Diagnosis was based on mycological examination, including direct examination and culture. Mycological analysis was considered positive when direct examination and culture were positive after at least one repeat.

RESULTS

Twenty-nine cases of Fusarium ITP accounting for 44.6% of all ITP in the study period were diagnosed in 15 men and 14 women. The mean age of the patients was 48.4 years. Fusarium ITP were diagnosed in immunocompetent patients except in two diabetics. The mean duration of the lesions was 6.83 years. The most frequent species isolated belonged to the Fusarium solani complex with 19 cases.

CONCLUSION

Fusarium ITP in a healthy subject requires regular monitoring because any subsequent decrease in immune defenses could lead to fatal hematogenous spread.

Antibiofilm activity of propolis extract on Fusarium species from onychomycosis

AIM

The present study evaluated the capacity of three species of Fusarium isolated from onychomycosis to form biofilms and the antibiofilm effect of propolis extract on these biofilms.

MATERIALS & METHODS

The biofilms and antibiofilm effects were evaluated by quantifying the colony-forming units, mitochondrial metabolic activity assays, total biomass by crystal violet staining and scanning electron microscopy.

RESULTS

Propolis extract demonstrated significant antibiofilm efficiency on Fusarium spp. isolates and reduced F. solani, F. oxysporum and F. subglutinans mature biofilms.

CONCLUSION

Propolis extract can be an alternative topical treatment of onychomycosis caused by Fusarium spp.

Epidemiological Study of Fusarium Species Causing Invasive and Superficial Fusariosis in Japan

In Japan, Fusarium species are known etiological agents of human fungal infection; however, there has been no report of a large-scale epidemiological study on the etiological agents of fusariosis. A total of 73 Fusarium isolates from patients with invasive fusariosis (IF, n= 36) or superficial fusariosis (SF, n= 37), which were obtained at hospitals located in 28 prefectures in Japan between 1998 and 2015, were used for this study. Fusarium isolates were identified using Fusarium- and Fusarium solani species complex (FSSC) -specific real-time PCR and partial DNA sequences of the elongation factor-1 alpha (EF-1α) gene and the nuclear ribosomal internal transcribed spacer (ITS) region. FSSC was predominately isolated from both patients with IF and SF (IF, 77.8% and SF, 67.6%). Distribution of the phylogenetic species of FSSC isolates from patients with IF and SF exhibited different spectra; specifically, F. keratoplasticum (FSSC 2) (25.0%) was the most frequent isolate from patients with IF, whereas F. falciforme (FSSC 3+4) (32.4%) was the most frequent isolate from patients with SF. Fusarium sp. (FSSC 5) was the second most frequent isolate from both patients with IF and SF (IF, 22.2% and SF, 24.3%). Notably, F. petroliphilum (FSSC 1) was isolated only from patients with IF. Each species was isolated from a broad geographic area, and an epidemic was not observed. This is the first epidemiological study of Fusarium species causing IF and SF in Japan.

Genetic diversity and antifungal susceptibility of Fusarium isolates in onychomycosis

Fusarium species have emerged as an important human pathogen in skin disease, onychomycosis, keratitis and invasive disease. Onychomycosis caused by Fusarium spp. The infection has been increasingly described in the immunocompetent and immunosuppressed hosts. Considering onychomycosis is a difficult to treat infection, and little is known about the genetic variability and susceptibility pattern of Fusarium spp., further studies are necessary to understand the pathogenesis and better to define the appropriate antifungal treatment for this infection. Accordingly, the objective of this study was to describe the in vitro susceptibility to different antifungal agents and the genetic diversity of 35 Fusarium isolated from patients with onychomycosis. Fusarium spp. were isolated predominantly from female Caucasians, and the most frequent anatomical location was the nail of the hallux. Results revealed that 25 (71.4%) of isolates belonged to the Fusarium solani species complex, followed by 10 (28.5%) isolates from the Fusarium oxysporum species complex. Noteworthy, the authors report the first case of Neocosmospora rubicola isolated from a patient with onychomycosis. Amphotericin B was the most effective antifungal agent against the majority of isolates (60%, MIC ≤4 μg/mL), followed by voriconazole (34.2%, MIC ≤4 μg/mL). In general, Fusarium species presented MIC values >64 μg/mL for fluconazole, itraconazole and terbinafine. Accurate pathogen identification, characterisation and susceptibility testing provide a better understanding of pathogenesis of Fusarium in onychomycosis.

Antimold Prophylaxis May Reduce the Risk of Invasive Fusariosis in Hematologic Patients with Superficial Skin Lesions with Positive Culture for Fusarium

Hematologic patients with superficial skin lesions on admission growing Fusarium spp. are at a high risk for developing invasive fusariosis during neutropenia. We evaluated the impact of primary prophylaxis with a mold-active azole in preventing invasive fusariosis in these patients. Between August 2008 and December 2014, patients with acute leukemia or aplastic anemia and recipients of hematopoietic cell transplants were screened on admission with dermatologic and direct exams and fungal cultures of superficial skin lesions. Until November 2009, no interventions were made. Beginning in December 2009, patients with baseline skin lesions and a direct exam and/or culture suggestive of the presence of Fusarium spp. received prophylaxis with voriconazole or posaconazole. Skin lesions in the extremities (mostly onychomycosis and interdigital intertrigo) were present on admission in 88 of 239 episodes (36.8%); 44 lesions had hyaline septate hyphae identified by direct exam, and cultures from 11 lesions grew Fusarium spp. Antimold prophylaxis was given for 20 episodes (voriconazole for 17 and posaconazole for 3). Invasive fusariosis was diagnosed in 14 episodes (5.8%). Among patients with baseline skin lesions with positive cultures for Fusarium spp., 4 of 5 without antimold prophylaxis developed invasive fusariosis versus 0 of 6 with antimold prophylaxis (P = 0.01; 95% confidence interval for the difference between proportions, 22% to 96%). Primary antifungal prophylaxis with an antimold azole may prevent the occurrence of invasive fusariosis in high-risk hematologic patients with superficial skin lesions on admission growing Fusarium spp.

Genotyping of Fusarium Isolates from Onychomycoses in Colombia: Detection of Two New Species Within the Fusarium solani Species Complex and In Vitro Antifungal Susceptibility Testing

Fusariosis have been increasing in Colombia in recent years, but its epidemiology is poorly known. We have morphologically and molecularly characterized 89 isolates of Fusarium obtained between 2010 and 2012 in the cities of Bogotá and Medellín. Using a multi-locus sequence analysis of rDNA internal transcribed spacer, a fragment of the translation elongation factor 1-alpha (Tef-1α) and of the RNA-dependent polymerase subunit II (Rpb2) genes, we identified the phylogenetic species and circulating haplotypes. Since most of the isolates studied were from onychomycoses (nearly 90 %), we carried out an epidemiological study to determine the risk factors associated with such infections. Five phylogenetic species of the Fusarium solani species complex (FSSC), i.e., F. falciforme, F. keratoplasticum, F. lichenicola, F. petroliphilum, and FSSC 6 as well as two of the Fusarium oxysporum species complex (FOSC), i.e., FOSC 3 and FOSC 4, were identified. The most prevalent species were FOSC 3 (38.2%) followed by F. keratoplasticum (33.7%). In addition, our isolates were distributed into 23 haplotypes (14 into FOSC and nine into FSSC). Two of the FSSC phylogenetic species and two haplotypes of FSSC were not described before. Our results demonstrate that recipients of pedicure treatments have a lower probability of acquiring onychomycosis than those not receiving such treatments. The antifungal susceptibility of all the isolates to five clinically available agents showed that amphotericin B was the most active drug, while the azoles exhibited lower in vitro activity.

Efinaconazole 10% nail solution: a new topical treatment with broad antifungal activity for onychomycosis monotherapy

BACKGROUND

Topical therapies for onychomycosis are associated with less adverse events than systemic therapies, but poor nail penetration limits their efficacy. Consequently, an efinaconazole 10% nail solution was developed.

OBJECTIVE

To review the evidence supporting the usefulness of efinaconazole monotherapy in onychomycosis management.

METHODS

PubMed and clinicaltrials.gov databases and abstracts from the 2013 annual meeting of the American Academy of Dermatology were searched in April 2013 using the terms "efinaconazole," "IDP-108," and "KP-103."

RESULTS

In vitro, efinaconazole possesses a broad antifungal activity similar or superior to that of other antifungals. Its low affinity for keratin results in good nail penetration. Efinaconazole 10% nail solution administered daily for 36 or 48 weeks to treat mild to moderate toenail onychomycosis caused by dermatophytes results in complete and mycologic cure rates of 15 to 25% and 53 to 87%, respectively. No serious skin reaction is associated with its use.

CONCLUSION

Efinaconazole 10% nail solution is a promising new treatment for onychomycosis.

Spectrum of Fusarium infections in tropical dermatology evidenced by multilocus sequencing typing diagnostics

Fusarium species are emerging causative agents of superficial, cutaneous and systemic human infections. In a study of the prevalence and genetic diversity of 464 fungal isolates from a dermatological ward in Thailand, 44 strains (9.5%) proved to belong to the genus Fusarium. Species identification was based on sequencing a portion of translation elongation factor 1-alpha (tef1-α), rDNA internal transcribed spacer and RNA-dependent polymerase subunit II (rpb2). Our results revealed that 37 isolates (84%) belonged to the Fusarium solani species complex (FSSC), one strain matched with Fusarium oxysporum (FOSC) complex 33, while six others belonged to the Fusarium incarnatum-equiseti species complex. Within the FSSC two predominant clusters represented Fusarium falciforme and recently described F. keratoplasticum. No gender differences in susceptibility to Fusarium were noted, but infections on the right side of the body prevailed. Eighty-nine per cent of the Fusarium isolates were involved in onychomycosis, while the remaining ones caused paronychia or severe tinea pedis. Comparing literature data, superficial infections by FSSC appear to be prevalent in Asia and Latin America, whereas FOSC is more common in Europe. The available data suggest that Fusarium is a common opportunistic human pathogens in tropical areas and has significant genetic variation worldwide.

Fusarium onychomycosis: prevalence, clinical presentations, response to itraconazole and terbinafine pulse therapy, and 1-year follow-up in nine cases

BACKGROUND

Invasive fusariosis is an infection with Fusarium spp. that primarily affects patients with hematologic malignancies and hematopoietic cell transplant recipients. Wounds, digital ulcers, onychomycosis, and paronychia are the typical cutaneous portals of entry. Early management of mycotic nails in immunocompromised and diabetic hosts is crucial to prevent life-threatening disease.

OBJECTIVES

We report nine cases of Fusarium onychomycosis (F. dimerum, n = 5; F. oxysporum, n = 3; Fusarium spp., n = 1) in immunocompetent hosts and their response to itraconazole and terbinafine pulse therapy.

METHODS

The patients received either itraconazole 400 mg daily or terbinafine 500 mg daily for 7 d/month; two pulses for fingernails and three pulses for toenails.

RESULTS

Of the 68 confirmed cases of onychomycosis, eight (11.7%) were Fusarium spp.; the ninth patient was culture positive but microscopy negative and responded well to itraconazole. Distal subungual onychomycosis was the commonest clinical manifestation (seven of nine), one had proximal subungual onychomycosis, and total onychodystrophy was noted on four patients. Associated paronychia was marked on 66.7% (six of eight) patients. Itraconazole was given to six patients/25 nails and terbinafine to three patients/20 nails. All nine patients completed treatments, but one defaulted at 12 months follow-up. The efficacy parameters were clinical cure (CC) and mycological cure (MC). At month 12 after the start of treatment, the response was itraconazole CC 13 of 25 (52%)/MC four of six (66.6%) and terbinafine CC four of eight (50%)/MC one of two (50%). Recurrence was noted in four of 13 (30.7%) and eight of 13 (61.5%) cured nails in the itraconazole group within 3 and 12 months, respectively.

CONCLUSIONS

Fusarium onychomycosis was clinically indistinguishable from other onychomycosis. Both itraconazole and terbinafine pulse therapy were only partially effective on Fusarium onychomycosis. Antifungals that are more effective should be sought.

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.

Onychomycosis by Fusarium oxysporum probably acquired in utero

Fusarium oxysporum has been described as a pathogen causing onychomycosis, its incidence has been increasing in immunocompetent and disseminated infection can occur in immunosuppressed individuals. We describe the first case of congenital onychomycosis in a child caused by Fusarium oxysporum. The infection being acquired in utero was proven by molecular methods with the identification of the fungus both in the nail and placenta, most probably as an ascending contamination/infection in a HIV-positive, immunosuppressed mother.

Increased incidence of invasive fusariosis with cutaneous portal of entry, Brazil

Most cases of infection with Fusarium spp. fungi involved primary skin lesions.

Invasive fusariosis (IF) is an infection with Fusarium spp. fungi that primarily affects patients with hematologic malignancies and hematopoietic cell transplant recipients. A cutaneous portal of entry is occasionally reported. We reviewed all cases of IF in Brazil during 2000–2010, divided into 2 periods: 2000–2005 (period 1) and 2006–2010 (period 2). We calculated incidence rates of IF and of superficial infections with Fusarium spp. fungi identified in patients at a dermatology outpatient unit. IF incidence for periods 1 and 2 was 0.86 cases versus 10.23 cases per 1,000 admissions (p<0.001), respectively; superficial fusarial infection incidence was 7.23 versus 16.26 positive cultures per 1,000 superficial cultures (p<0.001), respectively. Of 21 cases of IF, 14 showed a primary cutaneous portal of entry. Further studies are needed to identify reservoirs of these fungi in the community and to implement preventive measures for patients at risk.

Non-dermatophyte mould onychomycosis: a clinical and epidemiological study at a dermatology referral centre in Bogota, Colombia

Worldwide prevalence of non-dermatophyte mould onychomycosis has increased in recent years; however, available information on the topic is confusing and oftentimes contradictory, probably due to the small number of reported cases. The aim of this study was to determine and describe the aetiological agents, as well as the epidemiological and clinical characteristics of non-dermatophyte mould onychomycosis in a dermatology referral centre in Bogota, Colombia. A cross-sectional descriptive study was conducted between January 2001 and December 2011 among patients who attend the National Institute of Dermatology with a confirmed diagnosis of onychomycosis by non-dermatophytes moulds. There were 317 confirmed cases of non-dermatophyte mould onychomycosis in 196 women and 121 men whose average age was 43 years. Twenty-seven per cent of them had a history of systemic disease. The habit of walking and showering barefoot was the major infection-related factor. Distal and lateral subungual presentation was the most common pattern of clinical presentation. The most frequent non-dermatophyte mould was Neoscytalidium dimidiatum followed by Fusarium spp. No relationship was observed with predisposing factors previously reported in the literature. Clinical features found in this population are indistinguishable from onychomycosis caused by dermatophytes. High prevalence of N. dimidiatum found here was in contrast to a large number of studies where other types of moulds predominate.

Fusarium infection: report of 26 cases and review of 97 cases from the literature

Fusarium species is a ubiquitous fungus that causes opportunistic infections. We present 26 cases of invasive fusariosis categorized according to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria of fungal infections. All cases (20 proven and 6 probable) were treated from January 2000 until January 2010. We also review 97 cases reported since 2000. The most important risk factors for invasive fusariosis in our patients were compromised immune system, specifically lung transplantation (n = 6) and hematologic malignancies (n = 5), and burns (n = 7 patients with skin fusariosis), while the most commonly infected site was the skin in 11 of 26 patients. The mortality rates among our patients with disseminated, skin, and pulmonary fusariosis were 50%, 40%, and 37.5%, respectively. Fusarium solani was the most frequent species, isolated from 49% of literature cases. Blood cultures were positive in 82% of both current study and literature patients with disseminated fusariosis, while the remaining 16% had 2 noncontiguous sites of infection but negative blood cultures. Surgical removal of focal lesions was effective in both current study and literature cases. Skin lesions in immunocompromised patients should raise the suspicion for skin or disseminated fusariosis. The combination of medical monotherapy with voriconazole or amphotericin B and surgery in such cases is highly suggested.