Molecular identification and antifungal susceptibility of clinical fungal isolates from onychomycosis (uncommon and emerging species)

Global prevalence of onychomycosis in general and special populations: An updated perspective

BACKGROUND

Onychomycosis is a chronic nail disorder commonly seen by healthcare providers; toenail involvement in particular presents a treatment challenge.

OBJECTIVE

To provide an updated estimate on the prevalence of toenail onychomycosis.

METHODS

We conducted a literature search using PubMed, Embase and Web of Science. Studies reporting mycology-confirmed diagnoses were included and stratified into (a) populations-based studies, and studies that included (b) clinically un-suspected and (c) clinically suspected patients.

RESULTS

A total of 108 studies were included. Based on studies that examined clinically un-suspected patients (i.e., with or without clinical features suggestive of onychomycosis), the pooled prevalence rate of toenail onychomycosis caused by dermatophytes was 4% (95% CI: 3-5) among the general population; special populations with a heightened risk include knee osteoarthritis patients (RR: 14.6 [95% CI: 13.0-16.5]), chronic venous disease patients (RR: 5.6 [95% CI: 3.7-8.1]), renal transplant patients (RR: 4.7 [95% CI: 3.3-6.5]), geriatric patients (RR: 4.7 [95% CI: 4.4-4.9]), HIV-positive patients (RR: 3.7 [95% CI: 2.9-4.7]), lupus erythematosus patients (RR: 3.1 [95% CI: 1.2-6.3]), diabetic patients (RR: 2.8 [95% CI: 2.4-3.3]) and hemodialysis patients (RR: 2.8 [95% CI: 1.9-4.0]). The prevalence of onychomycosis in clinically suspected patients was significantly higher likely due to sampling bias. A high degree of variability was found in a limited number of population-based studies indicating that certain pockets of the population may be more predisposed to onychomycosis. The diagnosis of non-dermatophyte mould onychomycosis requires repeat sampling to rule out contaminants or commensal organisms; a significant difference was found between studies that performed single sampling versus repeat sampling. The advent of PCR diagnosis results in improved detection rates for dermatophytes compared to culture.

CONCLUSION

Onychomycosis is an underrecognized healthcare burden. Further population-based studies using standardized PCR methods are warranted.

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.

Central nervous system Aspergillus quadrilineatus infection in a COVID-19 patient, a case report and literature review

BACKGROUND

Viral pneumonia such as COVID-19-associated aspergillosis could increase susceptibility to fungal super-infections in critically ill patients.

METHODS

Here we report a pediatric case of Aspergillus quadrilineatus cerebral infection in a recently diagnosed COVID-19-positive patient underlying acute lymphocytic leukemia. Morphological, molecular methods, and sequencing were used to identify this emerging species.

RESULTS

Histopathological examination showed a granulomatous necrotic area containing dichotomously branching septate hyphae indicating a presumptive Aspergillus structure. The species-level identity of isolate growing on brain biopsy culture was confirmed by PCR sequencing of the β-tubulin gene as A. quadrilineatus. Using the CLSI M38-A3 broth microdilution methodology, the in vitro antifungal susceptibility testing demonstrated 0.032 μg/mL MIC for posaconazole, caspofungin, and anidulafungin and 8 μg/mL against amphotericin B. A combination of intravenous liposomal amphotericin B and caspofungin therapy for 8 days did not improve the patient's condition. The patient gradually continued to deteriorate and expired.

CONCLUSIONS

This is the first COVID-19-associated cerebral aspergillosis due to A. quadrilineatus in a pediatric patient with acute lymphocytic leukemia. However, comprehensive screening studies are highly recommended to evaluate its frequency and antifungal susceptibility profiles. Before being recommended as first-line therapy in high-risk patients, more antifungal susceptibility data are needed.

Potential Inhibitory Effect of Miltefosine against Terbinafine-Resistant Trichophyton indotineae

Several prolonged and significant outbreaks of dermatophytosis caused by Trichophyton indotineae, a new emerging terbinafine-resistant species, have been ongoing in India in recent years, and have since spread to various countries outside Asia. Miltefosine, an alkylphosphocholine, is the most recently approved drug for the treatment of both visceral and cutaneous leishmaniasis. Miltefosine in vitro activity against terbinafine-resistant and susceptible T. mentagrophytes/T. interdigitale species complex, including T. indotineae, is limited. The current study aimed to assess miltefosine's in vitro activity against dermatophyte isolates, which are the most common causes of dermatophytosis. Miltefosine, terbinafine, butenafine, tolnaftate, and itraconazole susceptibility testing was performed using Clinical and Laboratory Standards Institute broth microdilution methods (CLSI M38-A3) against 40 terbinafine-resistant T. indotineae isolates and 40 terbinafine-susceptible T. mentagrophytes/T. interdigitale species complex isolates. Miltefosine had MIC ranges of 0.063-0.5 µg/mL and 0.125-0.25 µg/mL against both terbinafine-resistant and susceptible isolates. In terbinafine-resistant isolates, the MIC₅₀ and MIC₉₀ were 0.125 µg/mL and 0.25 µg/mL, respectively, and 0.25 µg/mL in susceptible isolates. Miltefosine had statistically significant differences in MIC results when compared to other antifungal agents (p-value 0.05) in terbinafine-resistant strains. Accordingly, the findings suggest that miltefosine has a potential activity for treating infections caused by terbinafine-resistant T. indotineae. However, further studies are needed to determine how well this in vitro activity translates into in vivo efficacy.

Promising onychomycosis treatment with hypericin-mediated photodynamic therapy: case reports

BACKGROUND

Onychomycosis (OM) is a common nail plate disorder caused by dermatophyte molds, yeasts, and non-dermatophyte molds, which use keratin in the nail plate as an energy source. OM is characterized by dyschromia, increased nail thickness, subungual hyperkeratosis, and onychodystrophy, and is typically treated with conventional antifungals despite frequent reports of toxicity, fungal resistance, and OM recurrence. Photodynamic therapy (PDT) with hypericin (Hyp) as a photosensitizer (PS) stands out as a promising therapeutic modality. When excited by a specific wavelength of light and in the presence of oxygen, to lead to photochemical and photobiological reactions on the selected targets.

METHODS

OM diagnosis was made in three suspected cases, and the causative agents were identified by classical and molecular methods, and confirmed by attenuated total reflectance-Fourier transform infrared spectroscopy (ATR-FTIR). Susceptibility of planktonic cells of the clinical isolates to conventional antifungals and PDT-Hyp was evaluated, and photoacoustic spectroscopy (PAS) of Hyp permeation in nail fragments ex vivo was analyzed. Furthermore, the patients opted to undergo PDT-Hyp treatment and were subsequently followed up. The protocol was approved by the human ethics committee (CAAE, number 14107419.4.0000.0104).

RESULTS

The etiological agents of OM in patients ID 01 and ID 02 belonged to the Fusarium solani species complex, being identified as Fusarium keratoplasticum (CMRP 5514) and Fusarium solani (CMRP 5515), respectively. For patient ID 03, the OM agent was identified as Trichophyton rubrum (CMRP 5516). PDT-Hyp demonstrated a fungicidal effect in vitro, with reductions of ≥3 log₁₀ (p<0.0051 and p<0.0001), and the PAS analyses indicated that Hyp could completely permeate through both healthy and OM-affected nails. After four sessions of PDT-Hyp, mycological cure was observed in all three cases, and after seventh months, clinical cure was confirmed. PDT-Hyp showed satisfactory results in terms of efficacy and safety, and thus can be considered a promising therapy for the clinical treatment of OM.

Fractional CO2 laser - assisted methylene blue photodynamic therapy is a potential alternative therapy for onychomycosis in the era of antifungal resistance

BACKGROUND

Treatment of onychomycosis is challenging by virtue of the impact of nail disfigurement, the location of the fungi within the nail and reported antifungal resistance worldwide. Light-based technologies are promising primary or adjunctive therapeutic modalities. We aimed to compare the efficacy of photodynamic therapy and fractional CO2 laser monotherapy either alone or in combination for onychomycosis.

PATIENTS AND METHODS

This prospective randomized comparative study was conducted on 51 onychomycosis patients divided into three groups. In group A, patients were treated using 6 photodynamic therapy sessions using methylene blue and IPL (560 to 700 nm, fluence 12 J/cm2). Group B patients were treated using 6 bimonthly fractional CO2 laser sessions (10,600 nm, 1.600 mj energy and 0.6 mm density) and group C patients were treated using 6 combined fractional CO2 laser and photodynamic therapy sessions. Patients were evaluated mycologically, dermoscopically and clinically by calculation of proximal nail diameter percentage at baseline, monthly, at the end of treatment and after a 6-month follow-up period post-treatment.

RESULTS

Candida was the most commonly isolated organismin in 64.7%, 70.6% and 70.6% of the pateints in groups A, B and C, respectively. The dermoscopic findings in the total dystrophic onychomycosis was subungual hyperkeratosis in 6 patients (100%), longitudinal streaks and striae in 1 patient (16.7%). In dorsolateral subungual onychomycosis, jagged proximal edge in 31 patients (70.5%), and pigmentation in 30 patients (68.2%) were noted. In proximal subungual onychomycosis irregular matt patches were seen in 1 patient (100%). Proximal nail diameter percentage showed statistically significant improvement after treatment and 6 months follow up in the 3 studied groups. Mean increase of proximal nail diameter after treatment was highest in group C (52.94 ± 20.24), followed by group B (43.82 ± 21.03) and least in group A (35.29 ± 17.0). This difference was statistically significant (p = 0.044). Reported side effects were mild-moderate pain, discoloration and paronychia.

CONCLUSION

We conclude that fractional CO2 laser and photodynamic monotherapy, and their combination achieve high success rates, good patient satisfaction and safety profile. Fractional CO2-assisted photodynamic therapy is associated with the highest improvement over either fractional CO2 or photodynamic therapy alone.

In Vitro Combination of Terbinafine with Ketoconazole Against Aspergillus Species with Terbinafine High MIC Values Isolated From Otomycosis

Otomycosis is a common mycotic infection of the external auditory canal, and Aspergillus species are one of the most frequent causative agents worldwide. The limited antifungal arsenal, the high toxicity and side effects of antifungal agents, and the growing resistance to the currently available antifungals underscore the need for new therapeutic strategies. The present study aimed to evaluate the combined in vitro efficacy of terbinafine and ketoconazole against Aspergillus species with terbinafine high MIC values isolated from patients with otomycosis.84 Aspergillus species with high MIC values to terbinafine (≥ 4 µg/ml), consisting of A. flavus, A. tubingensis, A. niger, and A. terreus, were included in this study. The checkerboard microdilution method evaluated the in vitro interactions using the CLSI reference technique. Synergistic effects were observed for 66.67% (56/84) of all isolates (FICI ranging from 0.19 to 0.5). However, the interactions of terbinafine and ketoconazole exhibited indifference in 33.33% (28/84) of the isolates, and no antagonism was observed for any combination. The interaction of terbinafine and ketoconazole showed synergistic activity against Aspergillus species with high MIC values, suggesting that this is an alternative and promising approach for treating otomycosis.

Epidemiology of Onychomycosis in Chinese Mainland: A 30-year Retrospective Study

BACKGROUND

Onychomycosis was a common nail disease caused by dermatophytes, yeasts or molds. The prevalence of onychomycosis varied in different counties and it was necessary to understand the epidemiology in China.

OBJECTIVES

This study was conducted to investigate the epidemiology of onychomycosis in Chinese mainland in the past 30 years.

METHODS

A 30-year systemic review was carried out by searching publications investigating the prevalence of onychomycosis in Chinese mainland from 1991 to 2020.

RESULTS

A total of 90 articles involving more than 40,000 onychomycosis patients were enrolled in this study. The ratio of males to females was 1:1.32. Fingernail onychomycosis was found in 36.12% cases, toenail onychomycosis in 48.31%, and both fingernail and toenail onychomycosis in 15.57%. The most common clinical type of onychomycosis was distal lateral subungual onychomycosis (60.99%), followed by total dystrophic onychomycosis (18.91%), proximal subungual onychomycosis (10.19%) and superficial white onychomycosis (9.92%). Dermatophytes (60.59%) were the most frequently isolated pathogens, followed by yeasts (30.09%), molds (7.91%) and mixed infection (1.41%). The primary pathogens in dermatophytes, yeasts and molds were Trichophyton rubrum (49.93%), Candida albicans (10.99%) and Aspergillus (3.11%), respectively. Additionally, dermatophytes were more commonly affected males than females (63.69% vs. 51.57%), and mostly involved in toenail onychomycosis (75.63%). The infection of yeasts was higher in females than males (40.97% vs. 29.52%), often causing onychomycosis in fingernail than toenail (41.03% vs. 17.08%), and it was more common in warm and humid southern regions than northern area (34.07% vs. 24.41%).

CONCLUSION

The proportion of the causative agents changed over time, dermatophytes, especially T. rubrum had always been the predominant pathogen, followed by yeasts and molds. The distribution of fungal pathogens varied among clinical types, gender, infection sites and geography gender.

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.

Real-life applicability of the Euroarray Dermatomycosis Kit in the diagnosis of onychomycosis

BACKGROUND

Traditionally, KOH microscopy and fungal culture are the two preferred tests as gold standard for diagnosis of onychomycosis. Recently, other diagnostic methods have been developed to improve the microbiological diagnosis. The EUROArray dermatomycosis kit is a PCR-based microarray test system for the detection and direct identification of species that are most frequently involved in skin and nail infections.

OBJECTIVES

Our primary aim was to evaluate the real-life applicability of the EUROArray dermatomycosis kit in the diagnosis of onychomycoses. In addition, we compared the etiology of onychomycoses found in our patients with those described in the literature.

PATIENTS/METHODS

We prospectively studied consecutive 100 patients with suspected onychomycoses. Samples of suspect toenails were taken as part of routine medical management. Nail specimens were evaluated by means of 3 diagnostic methods: KOH preparation, culture and EUROArray dermatomycosis kit.

RESULTS

Onychomycosis was diagnosed in 47/100 patients who proved positive on at least one reference diagnostic test and in 49/100 patients who proved positive on PCR. The combination of microscopy and PCR had better sensitivity than microscopy (p=0.0397), fungal culture (p=0.0061) and PCR alone (p=0 .0117). Molds were more frequently positive in culture than in PCR (p=0.033). Dermatophytes proved positive more frequent than molds and yeasts in both culture and PCR; in particular, Trichophyton interdigitale was the most frequent pathogen.

CONCLUSIONS

In conclusion, introducing EUROArray dermatomycosis kit into the diagnostic algorithm of onychomycosis increases the sensitivity of direct microscopy and yields more rapid results than culture.

Molecular characterization and antifungal activity against non-dermatophyte molds causing onychomycosis

Onychomycosis is a fungal disease that caused by different types of fungi. Non-dermatophyte molds are a large saprophytic fungi group that live in nature and could affect traumatic nails. The aim of this study was to identify non-dermatophyte molds causing onychomycosis and evaluation of several antifungal activities against the isolates. The samples consisted of 50 non-dermatophyte molds isolated from patients with onychomycosis confirmed by direct and culture examination fungal. DNA was extracted, amplified, and sequenced. Disk diffusion method was used to evaluate itraconazole, fluconazole, ketoconazole, terbinafine, posaconazole, and econazole activity against the isolates. The species identified as: Aspergillus flavus 22 (44%), A. niger 12 (24%), A. fumigates, 3 (6%), A. sydowii 3 (6%), A. terreus 1 (2%), Penicillium commune 2 (4%), P. glabrum 2 (4%), P. chrysogenum, 1 (2%), Fusarium solani 3 (6%) and F. thapsinum 1 (2%). Most of the samples were sensitive to terbinafine, itraconazole, and econazole and 94% of the isolates were resistant to fluconazole. This study showed that Aspergillus species were the most common cause of non-dermatophyte mold onychomycosis and fluconazole was the most resistant antifungals. Care must be taken to choose the appropriate antifungal drug for a better cure.

Drug Sensitivity Profile of Fungi Isolated from Onychomycosis Patients and Evaluation of Squalene Epoxidase Mutation in One Terbinafine-Resistant Trichophyton mentagrophytes Species

Background: The resistance to treatment of onychomycosis is increasingly reported. The present study aimed to assess the antifungal activity of itraconazole, terbinafine, luliconazole, and efinaconazole against dermatophytes, molds, and also yeast isolated from patients with onychomycosis. Furthermore, the mechanism of resistance to terbinafine in resistant Trichophyton mentagrophytes species was evaluated using the squalene epoxidase (SQLE) gene sequence. Methods: A total of 71 fungal isolates were collected from 97 patients with suspected onychomycosis. The identification of fungal species was performed using conventional and molecular approaches. In vitro drug susceptibility for itraconazole, terbinafine, luliconazole, and efinaconazole was carried out using the broth microdilution method according to the CLSI-M60 and CLSI-M38 3rd ed., respectively. The SQLE gene of one terbinafine-resistant T. mentagrophytes was amplified using the specific primers. Results: Efinaconazole and luliconazole demonstrated higher effectiveness against all isolates in the study. One mismatch was detected at position 1177, which showed A → C change associated with Phe397Leu amino acid substitution of the SQLE protein in terbinafine-resistant T. mentagrophytes. Conclusion: The occurrence of resistant strains of organisms causing onychomycosis should be considered and evaluated. Furthermore, the identification of amino acid changes responsible for resistance to antifungals is a useful consideration in drug-target interaction.

Non-dermatophyte fungi in onychomycosis-Epidemiology and consequences for clinical practice

Onychomycoses are difficult-to-treat fungal infections with a high recurrence rate that relates to the anatomic and pathophysiological conditions in the nail organ and the required extended duration of treatment. Clinical-epidemiological studies demonstrated that non-dermatophyte molds and yeasts are the primary causative agents in 20%-30% of onychomycoses. Mixed infections with dermatophytes are observed as well. Therefore, the causative agents should be determined by fungal culture and the antifungal treatment regimen should reliably cover non-dermatophytes, if appropriate. Systemic-topical combination therapy involving a broad-spectrum, locally applied antifungal may increase the mycological and clinical cure rates compared to monotherapy with systemic drugs.

In vitro activities of antifungal drugs against a large collection of Trichophyton tonsurans isolated from wrestlers

BACKGROUND

Trichophyton tonsurans is the most common agent causing tinea gladiatorum in wrestlers, and limited data on susceptibility profiles of Trichophyton tonsurans are available.

OBJECTIVES

We aimed to assess the in vitro activity of the common antifungal drug against a large collection of T tonsurans.

MATERIALS/METHODS

The in vitro activities to eight common antifungal drugs (sertaconazole, itraconazole, clotrimazole, fluconazole, butenafine, tolnaftate, terbinafine and griseofulvin) against 128 clinical isolates of T tonsurans strains, obtained from wrestlers with dermatophytosis, were performed according to CLSI M38-A2 broth microdilution document.

RESULTS

The geometric mean minimum inhibitory concentration was the lowest for tolnaftate (0.022 µg/mL), followed by itraconazole (0.026 µg/mL), terbinafine (0.033 µg/mL), butenafine (0.088 µg/mL), griseofulvin (0.566 µg/mL), sertaconazole (2.875 µg/mL), clotrimazole (3.419 µg/mL) and fluconazole (12.540 µg/mL).

CONCLUSIONS

Evaluation of antifungal susceptibility of dermatophytes showed that tolnaftate and itraconazole were the most effective drugs against T tonsurans and fluconazole had the least effect.

Non-dermatophyte Mould Onychomycosis in Japan

The incidence of non-dermatophyte mould onychomycosis has been increasing worldwide for the past several decades, but it is not well recognized in Japan. Recent molecular techniques and phylogenetic analyses contributed to the identification of uncommon and emerging species. We came across 13 (0.5%) cases of non-dermatophyte onychomycosis among a total of 2,591 onychomycosis cases in 106,703 outpatients during the past 5 years (January 2015-December 2019). The cases included 5 patients with Aspergillus species, 4 patients with Fusarium species, and one patient each with Scopulariopsis brevicaulis and Botryosphaeria dothidea, respectively. Botryosphaeria dothidea is closely related phylogenetically to Neoscytalidium dimidiatum. In Japan, at the time of writing this report, there are 26 reported cases of ungual aspergillosis and 18 cases of hyalohyphomycosis caused by Fusarium species. We summarize these cases and report the symptoms and mycological features.

DNA sequence analysis of keratinophilic fungi isolated from livestock stables in the East of Iran

Background and Purpose:

Keratinophilic fungi play an important role in the decomposition of keratinous substances in nature. This capacity induces dermatomycosis in both humans and livestock. The soil of livestock stables can be a reservoir of keratinophilic fungi. Therefore, the present study was conducted to isolate and identify keratinophilic fungi in the soil of the livestock stables located in Qayen, South Khorasan Province, Iran.

Materials and Methods:

This study was conducted on 62 soil samples collected from livestock stables. The samples were cultured by means of hair bait technique (HBT). The identification of the isolates was performed based on their morphological characteristics and then confirmed by polymerase chain reaction and sequencing of the ITS regions of ribosomal DNA.

Results:

A total of 118 isolates of 7 species from 5 genera were identified. Aphanoascus verrucosu (n=70, 59.36%) was detected as the dominant keratinophilic fungus, followed by Arthroderma quadrifidum (n=13, 11.01%), A. terreus (n=12, 10.16%), Acremonium (n=12, 10.16%), A. gertleri (n=5, 4.23%), Fusarium equiseti (n=3, 2.54%), and Uncinocarpus reesii (n=3, 2.54%).

Conclusion:

Different keratinophilic fungi were isolated from the soil of livestock stables; however, A. verrucosu was found to be the dominant species.

Cryptococcus and cryptococcosis in Iran during 1969-2019: A systematic review and meta-analysis

OBJECTIVE

Limited data are available on the epidemiology and etiology of cryptococcal infections in the Middle East. We aimed to conduct the systematic review and meta-analysis to summarize the epidemiological data on prevalence of Cryptococcus species complexes in trees and their surroundings, bird guano and secretions, animals, and highlight the reported episodes of cryptococcosis in Iran.

MATERIALS AND METHODS

Twelve databases, including PubMed, Science Direct, Scopus, Proquest, Google Scholar, Embase, and the ISI Web of Science, as well as the national databases, from January 1969 to October 2019 were searched. Furthermore, gray literature (e.g., thesis, congress abstracts) was evaluated using Iran Doc and www.thesis.

RESEARCH

ac.ir. Search process was accomplished on English or Persian language articles using the following keywords: "Cryptococcus", "Cryptococcosis", "invasive fungal infection", "Humans", "Birds", "Pigeon", "Animals", "Tree", "Eucalyptus", and "Iran", both alone and in combination.

RESULTS

Overall 36 studies were eligible regarding Cryptococcus and cryptococcosis in Iran. The total prevalence rates of Cryptococcus species in the tree was 4.7% (95% CI: 2.3-7.8), and in bird guano was 20.4% (95% CI: 10.7-32.2). Cryptococcosis in animal, and human were 1.7% (95% CI: 0.01-5.1), and 2.8% (95% CI: 0.7v6.1), respectively. The highest prevalence of Cryptococcus in the trees (14.6%), and bird guano (89.4%) in Khorasan, animals (8.9%) in Chaharmahal and Bakhtiari, and human (4.4%) in Mazandaran provinces were reported.

CONCLUSIONS

Given the significant risk of Cryptococcus species for susceptible humans, mainly HIV-infected patients, it seems quite necessary to adopt concrete preventive strategies to pinpoint the environmental habitats of this yeast.

Molecular characterisation of emerging pathogens of unexplained infectious disease syndromes

Introduction: The discoveries of HIV and Helicobacter pylori in the 1980s were landmarks in identification of novel pathogens causing unexplained infectious syndromes using conventional microbiological technologies. In the last few decades, advancement of molecular technologies has provided us with more robust tools to expand our armamentarium in this microbial hunting process. Areas covered: In this article, we give a brief overview of the most important molecular technologies we use for identification of emerging microbes associated with unexplained infectious syndromes, including 16S rRNA and other conserved targets sequencing for bacteria, internal transcribed spacer (ITS) and other target gene sequencing for fungi, polymerase and other gene sequencing for viruses, as well as deep sequencing. Then, we use several representative examples to illustrate how these techniques have been used for the discoveries of a few notable bacterial, fungal and viral pathogens associated with unexplained infectious syndromes in the last 20-30 years. Expert opinion: In the past and present, characterization of emerging pathogens of unexplained infectious disease syndromes has relied on a combination of conventional culture- and phenotype-based technologies and nucleic acid amplification and sequencing. In the next era, we envisage more widespread adoption of next generation technologies that can detect both known and previously undescribed pathogens.