Epidemiological study of tinea capitis in schoolchildren in the Nablus area (West Bank)

Trends in the epidemiology of dermatophytosis in the Middle East and North Africa region

Dermatophytosis corresponds to a broad series of infections, mostly superficial, caused by a group of keratinophilic and keratinolytic filamentous fungi called dermatophytes. These mycoses are currently considered to be a major public health concern worldwide, particularly in developing countries such as those in the Middle East and North Africa (MENA) region. Here we compiled and discussed existing epidemiologic data on these infections in the MENA region. Most of the available studies were based on conventional diagnostic strategies and were published before the last taxonomic revision of dermatophytes. This has led to misidentifications, which might have resulted in the underestimation of the real burden of these infections in the MENA countries. Our analysis of the available literature highlights an urgent need for further studies based on reliable diagnostic tools and standard susceptibility testing methods for dermatophytosis, which represents a major challenge for these countries. This is crucial for guiding appropriate interventions and activating antifungal stewardship programs in the future.

The spectrum of fungal infections with a special reference to dermatophytoses in the capital area of Kuwait during 2000-2005: a retrospective analysis

BACKGROUND

Fungal infections constitute a major health problem all over the world. Signs and symptoms induced by various dermatophytic infections are difficult to distinguish clinically from each other. So, characterization by in vitro culture is required for appropriate diagnosis and treatment as well as to study the epidemiological characteristics in a region.

OBJECTIVES

The present retrospective work was aimed to study the spectrum of fungal infections of the skin, nails and hairs in the Capital area of Kuwait over a span of 5 years and to compare the results with those reported earlier from this region and other parts of the world. PATIENTS/MATERIALS: The study was conducted on 2,730 patients referred from dermatology outpatients to mycology laboratory suspected to have fungal infection over a 5-year period. Identification of dermatophyte isolates obtained was done by conventional microscopic examination in all patients, whereas culture techniques were performed for 1,593 of them.

RESULTS

Among 2,730 patients, 1,437 were men and 1,293 were women with a men to women ratio of 1.1:1. The age ranged from 3 months to 70 years (mean age 28.5 years). The clinical diagnosis of these patients was as follows: onychomycosis; tinea corporis; tinea capitis; tinea pedis; tinea cruris; tinea manum and tinea versicolor. Potassium hydroxide (KOH) examination showed positive results in 39% of all cases, whereas positive cultures were obtained in 29% of cultured specimens. Among dermatophytes, six species were isolated: Trichophyton mentagrophytes (39%), Microsporum canis (16%), Trichophyton rubrum (10%), Epidermophyton floccosum (6.2%), Trichophyton violaceum (2.4%) and Trichophyton verrucosum (0.4%). Trichophyton mentagrophytes was isolated from all body sites. Candida and Aspergillus niger were isolated on cycloheximide-free cultures in cases with onychomycosis.

CONCLUSIONS

Cutaneous fungal infections including dermatophytes remain prevalent in this part of the world. The most common isolate was T. mentagrophytes followed by Candida species. The least isolate was T. verrucosum. Species identification in relation to factors such as time, place and population is warranted in order to implement treatment regimens and to propose potential control measures.

Dermatophyte infections in Cairo, Egypt

In this study, we examined dermatophyte infections in patients referred to the Department of Dermatology, EL-Houd El-Marsoud Hospital, Cairo, during March 2004 to June 2005. Of 506 patients enrolled in this investigation, 403 (79.6%) were clinically diagnosed as having dermatophytoses (age range 6-70 years; males 240; females 163). Species identification determined by observation of their macroscopic and microscopic characteristics was complemented with sequencing of the internal transcribed spacer ITS1-5.8S-ITS2 rDNA region. The most common dermatophyte infection diagnosed was tinea capitis (76.4%), followed by tinea corporis (22.3%) and tinea unguium (1.2%). The most frequently isolated dermatophyte species was Trichophyton violaceum, which accounted for most (71.1%) of all the recovered dermatophytes, followed by Microsporum canis (21.09%), Trichophyton rubrum (6.2%), and Microsporum boullardii (0.49%); both Epidermophyton floccosum and Trichophyton tonsurans were each only rarely isolated (0.24%).

Prevalence of tinea capitis in southern Kuwait

Tinea capitis of the scalp, an infection caused by dermatophytes, produces a significant health problem especially among school children. The object of this study was to highlight the prevalence of tinea capitis in southern Kuwait. During this retrospective study from 1998 to 2003, 1737 suspected cases were examined, 986 (58.6%) were men and 751 (43.2%) were women of which 371 cases were diagnosed as tinea capitis. Of 371 cases of tinea capitis, males comprised 54.2% and females 45.8%. Young children (up to age five) were more frequently infected than other age groups, grey type lesions were more common than other types. Microsporum canis was the most common organism noticed with 62.5% followed by Trichophyton violaceum with 19.3%, Trichophyton tonsurans with 13.1%, while Trichophyton rubrum was the least common. Tinea capitis of scalp is a significant health problem in southern Kuwait especially among young children of school age. The spread of infection can be prevented by health education, proper diagnosis and treatment.

Clinico-mycological Profile of Dermatophytosis in a Reference Centre for Leprosy and Dermatological Diseases in Addis Ababa

To assess the clinical and fungal species spectrum of dermatophyte infection in a reference centre in Addis Ababa, 539 dermatological patients with signs of dermatophytosis were investigated. Seventy-one percent were female and 29% male, aged 2-66 years (median 9). Four hundred-fifteen (77%) had at least one skin lesion. Tinea capitis was diagnosed in 138/155 males (89%) as compared to 214/384 females (40%) (p < 0.05). T. capitis was diagnosed in 69% of the 374 children. Fingernails were affected in 132/145 (91%) of onychomycosis, 118 (90%) of these patients were females and 14 males (p < 0.05). Tinea corporis was observed in 45, and other types of tinea in 12 patients. Thirty-six percent of all patients had also other skin lesions, mostly impetigo. Of 490 cultured samples 364 (74%) grew dermatophytes: Trichophyton violaceum in 84%, Trichophyton verrucosum in 9.6%, Trichophyton tonsurans in 1.4% and T. rubrum in 0.5%. Additionally, 15 isolates were identified as white variants of T. violaceum, in 3 cases confirmed by sequencing of the rDNA ITS 2 region. T. capitis in young males and T. unguium of fingernails in females were the most common manifestations of dermatophytosis in Addis Ababa, usually caused by T.violaceum.

Trichophyton Fungal Keratitis

OBJECTIVE

To report 5 cases of fungal keratitis caused by Trichophyton schoenleinii.

METHODS

Case reports.

RESULTS

Trichophyton schoenleinii is responsible for aggressive fungal keratitis that is associated with keratolysis as a result of collagenase expression by the organism. Clinically, the organism seems to be sensitive to topical natamycin but resistant to topical amphotericin B and miconazole. Two patients achieved clinical cures with medical therapy alone, but with visual outcomes of only 20/125 and hand motions because of corneal scarring. Two patients achieved clinical cures with therapeutic penetrating keratoplasty (PKP), which remained clear and provided final visual outcomes of 20/60 and 20/200. One patient developed fungal scleritis and panophthalmitis despite 2 therapeutic PKPs and required enucleation.

CONCLUSION

Trichophyton schoenleinii is a rare cause of fungal keratitis that may be associated with progressive keratolysis and perforation, scleral extension, and endophthalmitis. Therapeutic keratoplasty may be successful in achieving cure in medically unresponsive cases.

Aetiological agents of tinea capitis in Tehran (Iran)

A total of 1568 patients with suspected tinea capitis were examined for causative fungal agents between 1994 and 2001. Laboratory examination confirmed tinea capitis in 209 patients. Males were affected more frequently (67.5%) than females (32.5%) and in both sexes, those who were 3-11 years old, were more infected. Trichophyton violaceum was the most common aetiological agent (37.3%) followed by Trichophyton schoenleinii (21.5%), Microsporum canis (18.6%), Trichophyton verrocosum (14.8%), Trichophyton tonsurans (5.3%), Trichophyton rubrum (1%), Microsporum gypseum (1%) and Trichophyton mentagrophytes (0.5%). A higher incidence of the disease was found to be correlated with larger family and class size. The findings are discussed in relation to different socioeconomic and hygienic backgrounds of the children.

Prevalence of skin diseases in rural areas of Assiut Governorate, Upper Egypt

BACKGROUND

Few epidemiological surveys have been carried out to determine the prevalence of skin diseases in the population of Egypt, particularly "Upper Egypt". So it is a pressing necessity to conduct such a study in rural Assiut.

OBJECTIVES

To determine the prevalence of various skin diseases in rural Assiut.

SUBJECTS AND METHODS

A cross-sectional community-based survey was followed. The survey included 8008 rural inhabitants of all ages and both sexes from a representative of three villages of Assiut Governorate, Upper Egypt. The data were collected through personal interview and examination at homes from December 1994 to December 1996.

RESULTS

They showed that 6961 (86.93%) of the studied population had one or more skin diseases. The group with parasitic skin infestations had the highest prevalence rate (27.40%) of the total sample, of which pediculosis capitis (19.37%) was the commonest. Eczema/dermatitis group had a rate of 19.82%, with pityriasis alba forming the majority (13.49%). Pigmentary disorders were 17.68%, followed by fungal skin infections (16.17%), then naevoid disorders (16.10%), hair and scalp disorders (12.07%), bacterial skin infections (10.10%), sweat gland disorders (6.16%), acne vulgaris (5.37%). Leprosy constituted 1.6/10,000. Other various skin disorders were recorded.

CONCLUSIONS

Infective-parasitic diseases were a major problem particularly among the younger age-group and those of low socio-economic status.

Ecology of dermatophytes and other keratinophilic fungi in swimming pools and polluted and unpolluted streams

The biodiversity and richness of keratinophilic fungal communities including dermatophytes were assessed in three stream sites and three swimming pools in the Nablus district in Palestine, using hair baiting (HBT) and surface dilution plate (SDP) techniques, over 8- and 6-month periods, respectively. The effect of wastewater effluent and selected ecological factors on these fungi in relation to species diversity and population densities were also considered. Fifty keratinophilic fungal species were recovered from the aquatic habitats studied, of which 42 were recovered from stream sites and 22 from swimming pools. Of these fungi 6 were either dermatophytes (Microsporum gypseum, and Trichophyton mentagrophytes) or dermatophyte related species (Chrysosporium merdarium, Ch. tropicum, Ch. keratinophilum and T. terrestre). The most frequently isolated species in the three pools were Acremonium strictum and Cladosporium cladosporioides, using Sabouraud dextrose agar medium (SDA). The most abundant species were Acr. strictum, and Aspergillus flavus. However, only 4 species were isolated using the SDA medium amended with 5-flurocytosine (5-FC). The most frequent and abundant species in the three stream sites using SDA medium were Geotricum candidum, and Penicillium chrysogenum. The most frequent species in the three sites using the 5-FC medium, was Paecilomyces lilacinus. Using HBT, the most abundant and frequent species in the three stream sites were G. candidum, and Pa. lilacinus, on SDA medium, and Pa. lilacinus, and Gliocladium nigrovirens on the 5-FC medium. The 5-FC medium was more suitable for the isolation of dermatophytes and closely related species than the SDA medium; 6 were recovered on 5-FC, whereas only one on the SDA medium. Variation in the levels of keratinophilic fungal populations from the three stream sites sampled 5 times over an 8-month period, followed comparable fluctuation patterns. Wastewater affected fungal population densities with the highest levels in the un-polluted stream sites, and lowest in the heavily polluted sites. Swimming pools, polluted and un-polluted stream sites were found to be rich in pathogenic and potentially pathogenic fungi.

Prevalence of tinea capitis as well as of asymptomatic carriers in school children in Nablus area (Palestine)

A study of tinea capitis was carried out during October 1998, involving 8531 school children aged 6-14 years (4718 males and 3813 females), attending 12 primary schools located in urban, rural, and refugee camp communities in the Nablus district in the Palestinian Authority. A total of approximately 1389 of the school children aged 6-12 years (724 males and 665 females) were also surveyed on three occasions at 2-3 month intervals, over a 9-month period (October 1998-May 1999) using the hair brush technique, for prevalence of asymptomatic tinea capitis carriage. Twenty-three(0.27%) mycologically proven cases of tinea capitis were detected.

Tinea capitis in schoolchildren from lvory Coast (western Africa). A 1998-1999 cross-sectional study

BACKGROUND

Tinea capitis is a worldwide public health problem that poses specific therapeutic challenges. This dermatophytosis of the scalp is endemic in Africa. The objectives of this study were to determine the prevalence, the associated demographic factors, causative species, and clinical types of tinea capitis in Abidjan, Ivory Coast.

METHODS

From June 1998 to March 1999, 1913 children aged between 4 and 15 years, and schooling in seven urban primary schools of Abidjan (Ivory Coast), were examined clinically for tinea capitis. Among all children showing symptoms suggestive of scalp ringworm, hair stumps and scales were collected and exposed to direct microscopic examination using 30% potassium hydroxide solution, and cultivation on Sabouraud's dextrose agar with or without actidione.

RESULTS

Among 227 symptomatic children, cultures positive for fungi were found in 217, yielding an overall tinea capitis prevalence of 11.34% [95% Confidence Interval (CI), 9.97-12.85]. By univariate analysis, tinea capitis was significantly associated with boys [odds ratio (OR) 7.85; CI 5.22-11.81] and in children belonging to the intermediate 8-11 years age group (OR 1.93; CI 1.29-2.90). Trichophyton soudanense and Microsporum langeronii were the most prevalent etiologic agents (63.6% and 31.3%, respectively), whereas a mixture of both T. soudanense and M. langeronii was observed in a 2.8% proportion. Finally, 2.3% of isolated species were represented by T. violaceum.

CONCLUSIONS

Our survey provided evidence that tinea capitis is endemic in Ivory Coast, constituting a substantial infectious dermatological disturbance. T. soudanense was the most frequent causative agent, whereas T. violaceum was isolated for the first time in this sub-Saharan western African country.

Dermatophytosis due to Trichophyton violaceum in Tuscany from 1985 to 1997

We describe 45 cases of dermatophytosis due to Trichophyton violaceum diagnosed in Tuscany from 1985 to 1997. Diagnosis was based on direct microscope mycological examination and culture. Nine of the 45 patients were Italian, eight of whom were born and resident in Tuscany; the others were Africans who contracted the infection in their country of origin. The first case in a non-European was observed in 1985, but since 1991 isolation from foreigners has become more frequent. The increase in cases of infection by T. violaceum in our region is certainly linked to immigration. The cases of epidermomycosis in Tuscans suggests that the fungus has already become autochthonous.