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Haghani I, Babaie M, Hoseinnejad A, Rezaei-Matehkolaei A, Mofarrah R, Yahyazadeh Z, Kermani F, Javidnia J, Shokohi T, Azish M, Kamyab Hesari K, Saeedi M, Ghasemi Z, Khojasteh S, Hajheydari Z, Mosayebi E, Valadan R, Seyedmousavi S, Abastabar M, Hedayati MT. High Prevalence of Terbinafine Resistance Among Trichophyton mentagrophytes/T. interdigitale Species Complex, a Cross-Sectional Study from 2021 to 2022 in Northern Parts of Iran. Mycopathologia 2024; 189:52. [PMID: 38864945 DOI: 10.1007/s11046-024-00855-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/18/2024] [Indexed: 06/13/2024]
Abstract
Treatment-resistant dermatophytosis caused by the members of the Trichophyton mentagrophytes/Trichophyton interdigitale species group (TMTISG) is increasing worldwide. We aimed to determine the prevalence of TMTISG in patients with dermatophytosis in two centers from north of Iran and detect the possible mutations in the squalene epoxidase (SQLE) gene in relevant terbinafine (TRB) resistant pathogenic isolates. From November 2021 to December 2022, 1960 patients suspected to dermatophytosis and referred to two mycology referral laboratories in the north of Iran were included in the study. Identification of all dermatophyte isolates was confirmed by RFLP of rDNA internal transcribed spacer (ITS) regions. Antifungal susceptibility testing against five common antifungals using the CLSI-M38-A3 protocol was performed. The TMTISG isolates resistant to TRB, were further analyzed to determine the possible mutations in the SQLE gene. Totally, 647 cases (33%) were positive for dermatophytosis of which 280 cases (43.3%) were identified as members of TMTISG. These were more frequently isolated from tinea corporis 131 (44.56%) and tinea cruris 116 (39.46%). Of 280 TMTISG isolates, 40 (14.3%) were resistant to TRB (MIC ≥ 4 µg/mL), all found to be T. indotineae in ITS sequencing. In SQLE sequencing 34 (85%) of TRB-resistant isolates had coincident mutations of Phe397Leu and Ala448Thr whereas four and two isolates had single mutations of Phe397Leu and Leu393Ser, respectively. Overall, the resistance of Iranian TMTISG isolates to TRB greatly occurred by a mutation of Phe397Leu in the SQLE gene as alone or in combination with Ala448Thr. Nevertheless, for the occurrence of in vitro resistance, only the presence of Phe397Leu mutation seems to be decisive.
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Affiliation(s)
- Iman Haghani
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Maryam Babaie
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Akbar Hoseinnejad
- Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Department of Medical Mycology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Rezaei-Matehkolaei
- Department of Medical Mycology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ramin Mofarrah
- Department of Dermatology, Faculty of Medicine, Sari Branch, Islamic Azad University, Sari, Iran
| | - Zahra Yahyazadeh
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Firoozeh Kermani
- Department of Parasitology and Mycology, Infectious Diseases and Tropical Medicine Research Center, Health Research Center, School of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Javad Javidnia
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Tahereh Shokohi
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Maryam Azish
- Department of Parasitology and Medical Mycology, School of Medicine, Dezful University of Medical Sciences, Dezful, Iran
| | - Kambiz Kamyab Hesari
- Department of Dermatopathology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Majid Saeedi
- Department of Pharmaceutics, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Zeinab Ghasemi
- Department of Dermatopathology, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shaghayegh Khojasteh
- Molecular Medicine Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, 7916613885, Iran
| | - Zohreh Hajheydari
- Department of Dermatology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Elham Mosayebi
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Reza Valadan
- Molecular and Cell Biology Research Center (MCBRC), Mazandaran University of Medical Sciences, Sari, Iran
| | - Seyedmojtaba Seyedmousavi
- Microbiology Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Mahdi Abastabar
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran.
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
| | - Mohammad Taghi Hedayati
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran.
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
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Mahmood HR, Shams-Ghahfarokhi M, Salehi Z, Razzaghi-Abyaneh M. Epidemiological trends, antifungal drug susceptibility and SQLE point mutations in etiologic species of human dermatophytosis in Al-Diwaneyah, Iraq. Sci Rep 2024; 14:12669. [PMID: 38830918 PMCID: PMC11148054 DOI: 10.1038/s41598-024-63425-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 05/29/2024] [Indexed: 06/05/2024] Open
Abstract
Dermatophytes show a wide geographic distribution and are the main causative agents of skin fungal infections in many regions of the world. Recently, their resistance to antifungal drugs has led to an obstacle to effective treatment. To address the lack of dermatophytosis data in Iraq, this study was designed to investigate the distribution and prevalence of dermatophytes in the human population and single point mutations in squalene epoxidase gene (SQLE) of terbinafine resistant isolates. The identification of 102 dermatophytes isolated from clinical human dermatophytosis was performed through morphological and microscopic characteristics followed by molecular analysis based on ITS and TEF-1α sequencing. Phylogeny was achieved through RAxML analysis. CLSI M38-A2 protocol was used to assess antifungal susceptibility of the isolates to four major antifungal drugs. Additionally, the presence of point mutations in SQLE gene, which are responsible for terbinafine resistance was investigated. Tinea corporis was the most prevalent clinical manifestation accounting for 37.24% of examined cases of dermatophytosis. Based on ITS, T. indotineae (50.98%), T. mentagrophytes (19.61%), and M. canis (29.41%) was identified as an etiologic species. T. indotineae and T. mentagrophytes strains were identified as T. interdigitale based on TEF-1α. Terbinafine showed the highest efficacy among the tested antifungal drugs. T. indotineae and T. mentagrophytes showed the highest resistance to antifungal drugs with MICs of 2-4 and 4 μg/mL, while M. canis was the most susceptible species. Three of T. indotineae isolates showed mutations in SQLE gene Phe397Leu substitution. A non-previously described point mutation, Phe311Leu was identified in T. indotineae and mutations Lys276Asn, Phe397Leu and Leu419Phe were diagnosed in T. mentagrophytes XVII. The results of mutation analysis showed that Phe397Leu was a destabilizing mutation; protein stability has decreased with variations in pH, and point mutations affected the interatomic interaction, resulting in bond disruption. These results could help to control the progression of disease effectively and make decisions regarding the selection of appropriate drugs for dermatophyte infections.
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Affiliation(s)
- Hussein R Mahmood
- Department of Mycology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, 14115-331, Iran
- Department of Pathological Analysis, Faculty of Sciences, University of Al-Qadisiyah, Al-Qadisiyah, Iraq
| | - Masoomeh Shams-Ghahfarokhi
- Department of Mycology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, 14115-331, Iran.
| | - Zahra Salehi
- Department of Mycology, Pasteur Institute of Iran, Tehran, 1316943551, Iran
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Hill RC, Gold JAW, Lipner SR. Comprehensive Review of Tinea Capitis in Adults: Epidemiology, Risk Factors, Clinical Presentations, and Management. J Fungi (Basel) 2024; 10:357. [PMID: 38786712 PMCID: PMC11122068 DOI: 10.3390/jof10050357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/07/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024] Open
Abstract
Tinea capitis is a fungal infection of the scalp and hair caused by dermatophyte molds, that most often affects children and may also affect adults. Previous estimates suggest that between 3% and 11% of all tinea capitis cases worldwide occur in adults, although updated epidemiological studies are needed to reassess the prevalence of tinea capitis in adult populations specifically. Postmenopausal adult women are most often affected by tinea capitis, with African American or Black women particularly at risk. Adults who experience crowded living conditions, who live in close proximity to animals, who are immunosuppressed, and/or who live in households with affected children are at greatest risk of infection. Tinea capitis can be non-inflammatory or inflammatory in nature, and the subtype affects the extent and severity of clinical symptoms. Fungal culture and potassium hydroxide preparations are the most commonly used diagnostic tools. Trichoscopy, defined as dermoscopic imaging of the scalp and hair, is a useful adjunct to the physical examination. The mainstay of therapy is oral antifungal therapy, and topical therapy alone is not recommended. Since tinea capitis infection is uncommon in adults, there are no widely accepted treatment guidelines. Rather, the same medications used for tinea capitis infection among children are recommended for adults at varying doses, including griseofulvin, and terbinafine, and, less commonly, itraconazole and fluconazole. The prognosis for tinea capitis in adults is typically excellent when prompt and adequate treatment is administered; however, delayed diagnosis or inadequate treatment can result in scarring alopecia. Over the past decade, dermatophyte infections resistant to treatment with topical and oral antifungal agents have emerged. While tinea capitis infections resistant to antifungal therapy have been rarely reported to date, antifungal resistance is rising among superficial fungal infections in general, and antifungal stewardship is necessary to ensure that resistance to treatment does not develop among dermatophytes that cause tinea capitis.
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Affiliation(s)
| | - Jeremy A. W. Gold
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA
| | - Shari R. Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, NY 10021, USA
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Caplan AS, Todd GC, Zhu Y, Sikora M, Akoh CC, Jakus J, Lipner SR, Babbush K, Acker KP, Morales AE, Rolón RMM, Westblade LF, Fonseca M, Cline A, Gold JAW, Lockhart SR, Smith DJ, Chiller T, Greendyke WG, Manjari SR, Banavali NK, Chaturvedi S. Clinical Course, Antifungal Susceptibility, and Genomic Sequencing of Trichophyton indotineae. JAMA Dermatol 2024:2818522. [PMID: 38748419 PMCID: PMC11097098 DOI: 10.1001/jamadermatol.2024.1126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/18/2024] [Indexed: 05/18/2024]
Abstract
Importance Trichophyton indotineae is an emerging dermatophyte causing outbreaks of extensive tinea infections often unresponsive to terbinafine. This species has been detected worldwide and in multiple US states, yet detailed US data on infections with T indotineae are sparse and could improve treatment practices and medical understanding of transmission. Objective To correlate clinical features of T indotineae infections with in vitro antifungal susceptibility testing results, squalene epoxidase gene sequence variations, and isolate relatedness using whole-genome sequencing. Design, Setting, and Participants This retrospective cohort study of patients with T indotineae infections in New York City spanned May 2022 to May 2023. Patients with confirmed T indotineae infections were recruited from 6 New York City medical centers. Main Outcome and Measure Improvement or resolution at the last follow-up assessment. Results Among 11 patients with T indotineae (6 male and 5 female patients; median [range] age, 39 [10-65] years), 2 were pregnant; 1 had lymphoma; and the remainder were immunocompetent. Nine patients reported previous travel to Bangladesh. All had widespread lesions with variable scale and inflammation, topical antifungal monotherapy failure, and diagnostic delays (range, 3-42 months). Terbinafine treatment failed in 7 patients at standard doses (250 mg daily) for prolonged duration; these patients also had isolates with amino acid substitutions at positions 393 (L393S) or 397 (F397L) in squalene epoxidase that correlated with elevated terbinafine minimum inhibitory concentrations of 0.5 μg/mL or higher. Patients who were treated with fluconazole and griseofulvin improved in 2 of 4 and 2 of 5 instances, respectively, without correlation between outcomes and antifungal minimum inhibitory concentrations. Furthermore, 5 of 7 patients treated with itraconazole cleared or had improvement at the last follow-up, and 2 of 7 were lost to follow-up or stopped treatment. Based on whole-genome sequencing analysis, US isolates formed a cluster distinct from Indian isolates. Conclusion and Relevance The results of this case series suggest that disease severity, diagnostic delays, and lack of response to typically used doses and durations of antifungals for tinea were common in this primarily immunocompetent patient cohort with T indotineae, consistent with published data. Itraconazole was generally effective, and the acquisition of infection was likely in Bangladesh.
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Affiliation(s)
- Avrom S. Caplan
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York
- Dermatology Service, Bellevue Hospital Center, New York, New York
| | - Gabrielle C. Todd
- Wadsworth Center Mycology Laboratory, New York State Department of Health, Albany
| | - YanChun Zhu
- Wadsworth Center Mycology Laboratory, New York State Department of Health, Albany
| | - Michelle Sikora
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York
| | - Christine C. Akoh
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York
- Dermatology Service, Bellevue Hospital Center, New York, New York
| | - Jeannette Jakus
- SUNY Downstate Health Sciences University, Department of Dermatology, Brooklyn, New York
| | - Shari R. Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, New York
| | - Kayla Babbush
- Department of Dermatology, Weill Cornell Medicine, New York, New York
| | - Karen P. Acker
- Division of Infectious Diseases, Department of Pediatrics, Weill Cornell Medicine, New York, New York
| | - Ayana E. Morales
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, New York
| | | | - Lars F. Westblade
- Division of Infectious Diseases, Department of Pediatrics, Weill Cornell Medicine, New York, New York
- Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine, New York, New York
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Maira Fonseca
- Department of Dermatology, Weill Cornell Medicine, New York, New York
- NYC Health + Hospitals/Lincoln Medical Center, Department of Dermatology, Bronx, New York, USA Department of Dermatology, Weill Cornell Medicine, New York
| | - Abigail Cline
- Department of Dermatology, Weill Cornell Medicine, New York, New York
- NYC Health + Hospitals/Lincoln Medical Center, Department of Dermatology, Bronx, New York, USA Department of Dermatology, Weill Cornell Medicine, New York
| | - Jeremy A. W. Gold
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shawn R. Lockhart
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dallas J. Smith
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Swati R. Manjari
- Division of Translational Medicine, Wadsworth Center, New York State Department of Health, Albany
| | - Nilesh K. Banavali
- Division of Translational Medicine, Wadsworth Center, New York State Department of Health, Albany
- Department of Biomedical Sciences, School of Public Health, University at Albany, Albany, New York
| | - Sudha Chaturvedi
- Wadsworth Center Mycology Laboratory, New York State Department of Health, Albany
- Department of Biomedical Sciences, School of Public Health, University at Albany, Albany, New York
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Gupta AK, Polla Ravi S, Wang T, Bakotic WL, Shemer A. Mapping the Global Spread of T. indotineae: An Update on Antifungal Resistance, Mutations, and Strategies for Effective Management. Mycopathologia 2024; 189:45. [PMID: 38734753 DOI: 10.1007/s11046-024-00856-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024]
Abstract
INTRODUCTION The global spread of Trichophyton indotineae presents a pressing challenge in dermatophytosis management. This systematic review explores the current landscape of T. indotineae infections, emphasizing resistance patterns, susceptibility testing, mutational analysis, and management strategies. METHODS A literature search was conducted in November 2023 using Embase, PubMed, Scopus, and Web of Science databases. Inclusion criteria covered clinical trials, observational studies, case series, or case reports with T. indotineae diagnosis through molecular methods. Reports on resistance mechanisms, antifungal susceptibility testing, and management were used for data extraction. RESULTS AND DISCUSSION A total of 1148 articles were identified through the systematic search process, with 45 meeting the inclusion criteria. The global spread of T. indotineae is evident, with cases reported in numerous new countries in 2023. Tentative epidemiological cut-off values (ECOFFs) suggested by several groups provide insights into the likelihood of clinical resistance. The presence of specific mutations, particularly Phe397Leu, correlate with higher minimum inhibitory concentrations (MICs), indicating potential clinical resistance. Azole resistance has also been reported and investigated in T. indotineae, and is a growing concern. Nevertheless, itraconazole continues to be an alternative therapy. Recommendations for management include oral or combination therapies and individualized approaches based on mutational analysis and susceptibility testing. CONCLUSION Trichophyton indotineae poses a complex clinical scenario, necessitating enhanced surveillance, improved diagnostics, and cautious antifungal use. The absence of established clinical breakpoints for dermatophytes underscores the need for further research in this challenging field.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada.
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada.
| | - Shruthi Polla Ravi
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada
| | - Tong Wang
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada
| | | | - Avner Shemer
- Department of Dermatology, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
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Tamimi P, Fattahi M, Firooz A, Ghaderi A, Ayatollahi A, Nasiri Kashani M, Alkhen A. Recalcitrant dermatophyte infections: identification and risk factors. Int J Dermatol 2024. [PMID: 38712801 DOI: 10.1111/ijd.17145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/03/2024] [Accepted: 03/04/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Recalcitrant dermatophytosis is an emerging phenomenon that occurs worldwide, and Trichophyton indotineae is currently the prominent cause. MATERIALS AND METHODS Skin specimens from patients with tinea infection were obtained by scrubbing and then sectioned into three fragments. Two fragments were subjected to direct microscopic examination and culture, while the third portion was utilized in the PCR method. RESULTS Isolates were morphologically identified as Trichophyton mentagrophytes/interdigitale complex (n = 60 [83.33%]), Microsporum canis (n = 8 [11.11%]), Trichophyton rubrum (n = 3 [4.16%]), and Epidermophyton floccosum (n = 1 [1.38%]). Among 60 T. mentagrophytes complex isolates, 53 (88.33%) were classified as T. indotineae and seven as T. interdigitale genotype II. The disease duration was longer in the T. indotineae group (P = 0.035). Both Gradient PCR and skin-sampling methods yield similar results in terms of positive and negative cases (P = 1.0000). The time patients stopped their medication did not impact the positive case numbers (P = 0.803). Gender had no effects on the frequency (P = 0.699). Familial contamination, dermatologic disorder, and other underlying conditions did not differ in the two group infections (P > 0.05). Steroid usage is strongly associated with the emergence of tinea infection (P < 0.04). The duration of antifungal administration had a substantial effect on the emergence of resistant organisms (P = 0.05). CONCLUSIONS Steroid usage, T. indotineae involvement, and prolonged exposure to antifungals were the solid and influential factors in recalcitrant involvement. Regarding quick and suitable diagnosis and treatment, which is essential in preventing recalcitrant cases, we suggest that direct skin sample PCR can meet the demands.
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Affiliation(s)
- Pegah Tamimi
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsa Fattahi
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Firooz
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Aliasghar Ghaderi
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Azin Ayatollahi
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mansour Nasiri Kashani
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
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Hill RC, Caplan AS, Elewski B, Gold JAW, Lockhart SR, Smith DJ, Lipner SR. Expert Panel Review of Skin and Hair Dermatophytoses in an Era of Antifungal Resistance. Am J Clin Dermatol 2024; 25:359-389. [PMID: 38494575 DOI: 10.1007/s40257-024-00848-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/19/2024]
Abstract
Dermatophytoses are fungal infections of the skin, hair, and nails that affect approximately 25% of the global population. Occlusive clothing, living in a hot humid environment, poor hygiene, proximity to animals, and crowded living conditions are important risk factors. Dermatophyte infections are named for the anatomic area they infect, and include tinea corporis, cruris, capitis, barbae, faciei, pedis, and manuum. Tinea incognito describes steroid-modified tinea. In some patients, especially those who are immunosuppressed or who have a history of corticosteroid use, dermatophyte infections may spread to involve extensive skin areas, and, in rare cases, may extend to the dermis and hair follicle. Over the past decade, dermatophytoses cases not responding to standard of care therapy have been increasingly reported. These cases are especially prevalent in the Indian subcontinent, and Trichophyton indotineae has been identified as the causative species, generating concern regarding resistance to available antifungal therapies. Antifungal-resistant dermatophyte infections have been recently recognized in the United States. Antifungal resistance is now a global health concern. When feasible, mycological confirmation before starting treatment is considered best practice. To curb antifungal-resistant infections, it is necessary for physicians to maintain a high index of suspicion for resistant dermatophyte infections coupled with antifungal stewardship efforts. Furthermore, by forging partnerships with federal agencies, state and local public health agencies, professional societies, and academic institutions, dermatologists can lead efforts to prevent the spread of antifungal-resistant dermatophytes.
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Affiliation(s)
| | - Avrom S Caplan
- Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, NY, USA
| | - Boni Elewski
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeremy A W Gold
- Centers for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, USA
| | - Shawn R Lockhart
- Centers for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, USA
| | - Dallas J Smith
- Centers for Disease Control and Prevention, Mycotic Diseases Branch, Atlanta, GA, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, 1305 York Avenue, New York, NY, 10021, USA.
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Williams SL, Toda M, Chiller T, Brunkard JM, Litvintseva AP. Effects of climate change on fungal infections. PLoS Pathog 2024; 20:e1012219. [PMID: 38814855 PMCID: PMC11139277 DOI: 10.1371/journal.ppat.1012219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Affiliation(s)
- Samantha L. Williams
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Mitsuru Toda
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Joan M. Brunkard
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Anastasia P. Litvintseva
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Gold JAW, Caplan AS, Benedict K, Lipner SR, Smith DJ. Clotrimazole-Betamethasone Dipropionate Prescribing for Nonfungal Skin Conditions. JAMA Netw Open 2024; 7:e2411721. [PMID: 38753333 PMCID: PMC11099679 DOI: 10.1001/jamanetworkopen.2024.11721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/15/2024] [Indexed: 05/19/2024] Open
Abstract
This cross-sectional study identifies the common diagnoses and physician encounter types associated with clotrimazole-betamethasone dipropionate prescriptions among Medicare enrollees in 2021.
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Affiliation(s)
- Jeremy A. W. Gold
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Avrom S. Caplan
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York
| | - Kaitlin Benedict
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shari R. Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, New York
| | - Dallas J. Smith
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
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10
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Belmokhtar Z, Djaroud S, Matmour D, Merad Y. Atypical and Unpredictable Superficial Mycosis Presentations: A Narrative Review. J Fungi (Basel) 2024; 10:295. [PMID: 38667966 PMCID: PMC11051100 DOI: 10.3390/jof10040295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 04/07/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
While typically exhibiting characteristic features, fungal infections can sometimes present in an unusual context, having improbable localization (eyelid, face, or joint); mimicking other skin diseases such as eczema, psoriasis, or mycosis fungoides; and appearing with unexpected color, shape, or distribution. The emergence of such a challenging clinical picture is attributed to the complex interplay of host characteristics (hygiene and aging population), environment (climate change), advances in medical procedures, and agent factors (fungal resistance and species emergence). We aim to provide a better understanding of unusual epidemiological contexts and atypical manifestations of fungal superficial diseases, knowing that there is no pre-established clinical guide for these conditions. Thus, a literature examination was performed to provide a comprehensive analysis on rare and atypical superficial mycosis as well as an update on certain fungal clinical manifestations and their significance. The research and standard data extraction were performed using PubMed, Medline, Scopus, and EMBASE databases, and a total of 222 articles were identified. This review covers published research findings for the past six months.
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Affiliation(s)
- Zoubir Belmokhtar
- Department of Environmental Sciences, Faculty of Natural Sciences, Djilali Liabes University of Sidi-Bel-Abbes, Sidi Bel Abbes 22000, Algeria;
- Laboratory of Plant and Microbial Valorization (LP2VM), University of Science and Technology of Oran, Mohamed Boudiaf (USTOMB), Oran 31000, Algeria
| | - Samira Djaroud
- Department of Chemistry, Djilali Liabes University of Sidi-Bel-Abbes, Sidi Bel Abbes 22000, Algeria
| | - Derouicha Matmour
- Central Laboratory, Djilali Liabes University of Medicine of Sidi-Bel-Abbes, Sidi Bel Abbes 22000, Algeria
| | - Yassine Merad
- Central Laboratory, Djilali Liabes University of Medicine of Sidi-Bel-Abbes, Sidi Bel Abbes 22000, Algeria
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11
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Khurana A, Sharath S, Sardana K, Chowdhary A. Clinico-mycological and therapeutic updates on cutaneous dermatophytic infections in the era of Trichophyton indotineae. J Am Acad Dermatol 2024:S0190-9622(24)00535-8. [PMID: 38574764 DOI: 10.1016/j.jaad.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 04/06/2024]
Abstract
Trichophyton indotineae has emerged as a novel dermatophyte species resulting in treatment recalcitrant skin infections. While the earliest reports came from India, T. indotineae has now spread to many parts of the world and is rapidly becoming a global health concern. Accurate identification of T. indotineae requires elaborate mycological investigations which is beyond the domain of routine microbiology testing. Extensive, non-inflammatory and atypical presentations are commonly seen with this novel species. T. indotineae shows an alarmingly high rate of mutations in the squalene epoxidase gene leading to lowered in vitro susceptibility to terbinafine. This has also translated into a lowered clinical response and requirement of a higher dose and much longer durations of treatment with the drug. Although the species remains largely susceptible to itraconazole, prolonged treatment durations are required to achieve cure with itraconazole. Fluconazole and griseofulvin do not have satisfactory in vitro or clinical activity. Apart from requirement of prolonged treatment durations, relapse postsuccessful treatment is a distressing and yet unexplained consequence of this "species-shift." Use of third generation azoles and combinations of systemic antifungals is unwarranted as both have not demonstrated clear superiority over itraconazole given alone, and the former is an important class of drugs for invasive mycoses.
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Affiliation(s)
- Ananta Khurana
- Department of Dermatology, Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India.
| | - Savitha Sharath
- Department of Dermatology, Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Kabir Sardana
- Department of Dermatology, Venereology and Leprosy, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Anuradha Chowdhary
- Medical Mycology Unit, Department of Microbiology, National Reference Laboratory for Antimicrobial Resistance in Fungal Pathogens, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi, India
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12
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Spivack S, Gold JAW, Lockhart SR, Anand P, Quilter LAS, Smith DJ, Bowen B, Gould JM, Eltokhy A, Gamal A, Retuerto M, McCormick TS, Ghannoum MA. Potential Sexual Transmission of Antifungal-Resistant Trichophyton indotineae. Emerg Infect Dis 2024; 30:807-809. [PMID: 38437706 PMCID: PMC10977831 DOI: 10.3201/eid3004.240115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
We describe a case of tinea genitalis in an immunocompetent woman in Pennsylvania, USA. Infection was caused by Trichophyton indotineae potentially acquired through sexual contact. The fungus was resistant to terbinafine (first-line antifungal) but improved with itraconazole. Clinicians should be aware of T. indotineae as a potential cause of antifungal-resistant genital lesions.
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Uhrlaß S, Mey S, Koch D, Mütze H, Krüger C, Monod M, Nenoff P. Dermatophytes and skin dermatophytoses in Southeast Asia-First epidemiological survey from Cambodia. Mycoses 2024; 67:e13718. [PMID: 38551112 DOI: 10.1111/myc.13718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/13/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Dermatomycoses count to the most frequent dermatoses in Cambodia. OBJECTIVES The aim of this survey was to investigate the occurrence of dermatophytes in this Southeast Asian country. METHODS From June 2017 to July 2018, skin scrapings were taken from 67 patients with superficial dermatophytosis for mycological diagnostics. Identification of dermatophytes was confirmed by sequencing of the 'internal transcribed spacer'-(ITS) region of the rDNA, and the gene of the Translation Elongation Factor (TEF)-1α. RESULTS Patients were suffering from tinea corporis and tinea inguinalis/cruris 42/67 (63%), tinea capitis/faciei 14/67 (21%), tinea corporis/capitis/faciei 6/67 (9%), tinea manuum/pedis 2/67 (3%), tinea pedis 2/67 (3%) and tinea manuum 1/67 (1%). Both, by culture and/or PCR, a dermatophyte was detected in 52 (78%) out of 67 samples. Culture positive were 42 (81%) of 52, PCR positive were 50 (96%). The following dermatophytes were found: Trichophyton (T.) rubrum, 36/52 strains (69%, 29 by culture), T. mentagrophytes/T. interdigitale (TM/TI) 9/52 (17%, six by culture) and Microsporum (M.) canis 5/52 strains (10%, by culture). One strain of Nannizzia (N.) incurvata 1/52 (2%) and N. nana 1/52 (2%) was isolated. Based on sequencing, we demonstrated that two T. mentagrophytes strains out of the nine TM/TI represented the new ITS genotype XXV Cambodia. We found one T. mentagrophytes strain genotype VIII (now, reclassified as T. indotineae). This isolate was terbinafine resistant, and it exhibited the amino acid substitution Phe397Leu in the squalene epoxidase. Three strains of T. interdigitale genotype II* were isolated. CONCLUSION This is the first survey on epidemiology of dermatophytes in Cambodia. Currently, T. rubrum represents the most frequent species in Cambodia. One Indian strain genotype VIII T. mentagrophytes was found. A highlight was the first description of the new T. mentagrophytes genotype XXV Cambodia.
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Affiliation(s)
- Silke Uhrlaß
- labopart - Medizinische Laboratorien, Rötha OT Mölbis, Germany
| | - Sithach Mey
- Department of Dermatology, Preah Kossamak Hospital, Phnom Penh, Cambodia
| | - Daniela Koch
- labopart - Medizinische Laboratorien, Rötha OT Mölbis, Germany
| | - Hanna Mütze
- labopart - Medizinische Laboratorien, Rötha OT Mölbis, Germany
| | | | - Michel Monod
- Dermatology Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Pietro Nenoff
- labopart - Medizinische Laboratorien, Rötha OT Mölbis, Germany
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Hui ST, Gifford H, Rhodes J. Emerging Antifungal Resistance in Fungal Pathogens. CURRENT CLINICAL MICROBIOLOGY REPORTS 2024; 11:43-50. [PMID: 38725545 PMCID: PMC11076205 DOI: 10.1007/s40588-024-00219-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2024] [Indexed: 05/12/2024]
Abstract
Purpose of Review Over recent decades, the number of outbreaks caused by fungi has increased for humans, plants (including important crop species) and animals. Yet this problem is compounded by emerging antifungal drug resistance in pathogenic species. Resistance develops over time when fungi are exposed to drugs either in the patient or in the environment. Recent Findings Novel resistant variants of fungal pathogens that were previously susceptible are evolving (such as Aspergillus fumigatus) as well as newly emerging fungal species that are displaying antifungal resistance profiles (e.g. Candida auris and Trichophyton indotineae). Summary This review highlights the important topic of emerging antifungal resistance in fungal pathogens and how it evolved, as well as how this relates to a growing public health burden.
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Affiliation(s)
- Sui Ting Hui
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
| | - Hugh Gifford
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Johanna Rhodes
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, UK
- Department of Medical Microbiology, Radboudumc, the Netherlands
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15
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De Paepe R, Normand AC, Uhrlaß S, Nenoff P, Piarroux R, Packeu A. Resistance Profile, Terbinafine Resistance Screening and MALDI-TOF MS Identification of the Emerging Pathogen Trichophyton indotineae. Mycopathologia 2024; 189:29. [PMID: 38483637 PMCID: PMC10940462 DOI: 10.1007/s11046-024-00835-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/25/2024] [Indexed: 03/17/2024]
Abstract
The emerging pathogen Trichophyton indotineae, often resistant to terbinafine (TRB), is known to cause severe dermatophytoses such as tinea corporis and tinea cruris. In order to achieve successful treatment for these infections, insight in the resistance profile of T. indotineae strains and rapid, reliable identification is necessary. In this research, a screening medium was tested on T. indotineae strains (n = 20) as an indication tool of TRB resistance. The obtained results were confirmed by antifungal susceptibility testing (AST) for TRB following the in vitro broth microdilution reference method. Additionally, AST was performed for eight other antifungal drugs: fluconazole, itraconazole, voriconazole, ketoconazole, griseofulvin, ciclopirox olamine, naftifine and amorolfine. Forty-five percent of the strains were confirmed to be resistant to terbinafine. The TRB resistant strains showed elevated minimal inhibitory concentration values for naftifine and amorolfine as well. DNA sequencing of the squalene epoxidase-encoding gene showed that TRB resistance was a consequence of missense point mutations in this gene, which led to amino acid substitutions F397L or L393F. MALDI-TOF MS was used as a quick, accurate identification tool for T. indotineae, as it can be challenging to distinguish it from closely related species such as Trichophyton mentagrophytes or Trichophyton interdigitale using morphological characteristics. While MALDI-TOF MS could reliably identify ≥ 95% of the T. indotineae strains (depending on the spectral library), it could not be used to successfully distinguish TRB susceptible from TRB resistant strains.
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Affiliation(s)
- Roelke De Paepe
- Mycology and Aerobiology Department, Sciensano, 1050, Brussels, Belgium.
| | - Anne-Cécile Normand
- Parasitology/Mycology Department, AP-HP, Hôpitaux de Paris, 75013, Paris, France
| | - Silke Uhrlaß
- Labopart Medical Laboratories Leipzig-Mölbis, 04571, Rötha OT Mölbis, Germany
| | - Pietro Nenoff
- Labopart Medical Laboratories Leipzig-Mölbis, 04571, Rötha OT Mölbis, Germany
| | - Renaud Piarroux
- Parasitology/Mycology Department, AP-HP, Hôpitaux de Paris, 75013, Paris, France
| | - Ann Packeu
- Mycology and Aerobiology Department, Sciensano, 1050, Brussels, Belgium
- BCCM/IHEM Fungal Collection, Mycology and Aerobiology Section, Sciensano, 1050, Brussels, Belgium
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16
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McCormick TS, Ghannoum M. Time to Think Antifungal Resistance Increased Antifungal Resistance Exacerbates the Burden of Fungal Infections Including Resistant Dermatomycoses. Pathog Immun 2024; 8:158-176. [PMID: 38486922 PMCID: PMC10939368 DOI: 10.20411/pai.v8i2.656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/07/2024] [Indexed: 03/17/2024] Open
Abstract
Increased antifungal resistance is exacerbating the burden of invasive fungal infections, as well as potentially contributing to the increase in resistant dermatomycoses. In this commentary, we focus on antifungal drug resistance, in contrast to antibacterial resistance. We provide a brief historical perspective on the emergence of antifungal resistance and propose measures for combating this growing health concern. The increase in the incidence of invasive and cutaneous fungal infections parallels advancements in medical interventions, such as immunosuppressive drugs, to manage cancer and reduce organ rejection following transplant. A disturbing relatively new trend in antifungal resistance is the observation of several fungal species that now exhibit multidrug resistance (eg, Candida auris, Trichophyton indotineae). Increasing awareness of these multidrug-resistant species is paramount. Therefore, increased education regarding potential fungus-associated infections is needed to address awareness in the general healthcare setting, which may result in a more realistic picture of the prevalence of antifungal-resistant infections. In addition to education, increased use of diagnostic tests (eg, micro and macro conventional assays or molecular testing) should be routine for healthcare providers facing an unknown fungal infection. Two critical barriers that affect the low rates for Antifungal Susceptibility Testing (AST) are low (or a lack of) sufficient insurance reimbursement rates and the low number of qualified laboratories with the capacity to perform AST. The ultimate aim is to improve the quality of patient care through fungal identification, diagnosis, and, where appropriate, susceptibility testing. Here we propose an all-encompassing call to action to address this emerging challenge.
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Affiliation(s)
- Thomas S. McCormick
- Department of Dermatology, Center for Medical Mycology, Case Western Reserve University, Cleveland, Ohio
| | - Mahmoud Ghannoum
- Department of Dermatology, Center for Medical Mycology, Case Western Reserve University, Cleveland, Ohio
- University Hospitals Cleveland Medical Center, Cleveland, Ohio
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17
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Kolarczyková D, Lysková P, Švarcová M, Kuklová I, Dobiáš R, Mallátová N, Kolařík M, Hubka V. Terbinafine resistance in Trichophyton mentagrophytes and Trichophyton rubrum in the Czech Republic: A prospective multicentric study. Mycoses 2024; 67:e13708. [PMID: 38404204 DOI: 10.1111/myc.13708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Terbinafine, an allylamine antifungal, is crucial for treating dermatophytosis by inhibiting squalene epoxidase (SQLE) in the ergosterol biosynthetic pathway. However, resistance is emerging, particularly in India and Southeast Asia, but reports of resistance spread worldwide. Despite this, comprehensive studies on terbinafine resistance in Trichophyton are still limited. OBJECTIVES This research aimed to determine the prevalence of terbinafine resistance in the Czech Republic, with a focus on Trichophyton rubrum and Trichophyton mentagrophytes, and investigate the underlying molecular mechanisms. PATIENTS/METHODS A total of 514 clinical strains of T. rubrum and 240 T. mentagrophytes collected from four Czech clinical institutions were screened for terbinafine resistance. Molecular investigations included DNA sequencing, specifically the ITS rDNA region and SQLE gene, as well as antifungal susceptibility testing following EUCAST guidelines. RESULTS While no resistance was observed in T. rubrum, 2.5% of T. mentagrophytes strains exhibited resistance, marked by the F397L mutation in SQLE. Notably, resistance surged from 1.2% in 2019 to 9.3% in 2020 but reverted to 0% in 2021. All resistant strains were identified as T. mentagrophytes var. indotineae. Resistant strains exhibited high MICs for terbinafine (≥4 mg L-1 ) but low MICs to the other seven antifungals tested except for fluconazole. CONCLUSIONS This study highlights the emergence of terbinafine-resistant T. mentagrophytes strains in the Czech Republic, with the F397L mutation being pivotal. Due to the relatively low resistance level, the current guidelines for dermatomycosis treatment in the Czech Republic remain effective, but ongoing surveillance is essential for timely adaptations if resistance patterns change.
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Affiliation(s)
- Daniela Kolarczyková
- Department of Botany, Faculty of Science, Charles University, Prague, Czech Republic
| | - Pavlína Lysková
- Department of Medical Microbiology Prague and Kladno, Public Health Institute in Ústí nad Labem, Prague, Czech Republic
| | - Michaela Švarcová
- Laboratory of Fungal Genetics and Metabolism, Institute of Microbiology, Czech Academy of Sciences, Prague, Czech Republic
- Department of Genetics and Microbiology, Faculty of Science, Charles University, Prague, Czech Republic
| | - Ivana Kuklová
- Department of Dermatology and Venereology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Radim Dobiáš
- Department of Bacteriology and Mycology, Public Health Institute Ostrava, Ostrava, Czech Republic
- Institute of Laboratory Medicine, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Naďa Mallátová
- Laboratory of Mycology and Parasitology, Hospital České Budějovice, České Budějovice, Czech Republic
| | - Miroslav Kolařík
- Laboratory of Fungal Genetics and Metabolism, Institute of Microbiology, Czech Academy of Sciences, Prague, Czech Republic
| | - Vit Hubka
- Department of Botany, Faculty of Science, Charles University, Prague, Czech Republic
- Laboratory of Fungal Genetics and Metabolism, Institute of Microbiology, Czech Academy of Sciences, Prague, Czech Republic
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18
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Teo JWP, Cheng JWS, Chew KL, Lin RTP. Whole genome characterization of Trichophyton indotineae isolated in Singapore. Med Mycol 2024; 62:myae012. [PMID: 38366631 DOI: 10.1093/mmy/myae012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/18/2024] [Accepted: 02/13/2024] [Indexed: 02/18/2024] Open
Abstract
Complete genome sequences from two Trichophyton indotineae isolates were obtained from a 23-year-old male presenting with tinea cruris after an overseas recreational water exposure and from a 53-year-old female patient with unknown travel history. Analysis of the squalene epoxidase gene and the cyp51 gene family showed an absence of mutations, correlating with phenotypic drug susceptibility. The Single Nucleotide Polymorphisms (SNPs) distance between both isolates was 92. Within the T. indotineae cluster, SNPs ranged from 7 to 182, suggesting a high genetic relatedness with other South Asian isolates. This study suggests that the prevalence of T. indotineae is under-reported and more widespread than previously thought.
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Affiliation(s)
- Jeanette W P Teo
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Janet W S Cheng
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Ka Lip Chew
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Raymond T P Lin
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
- National Public Health Laboratory, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Microbiology and Immunology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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19
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Oliveira TF, Valeriano CAT, Buonafina-Paz MDS, Souza-Motta CM, Machado AR, Neves RP, Bezerra JDP, Arantes TD, de Hoog S, Magalhães OMC. Molecular Verification of Trichophyton in the Brazilian URM Culture Collection. Mycopathologia 2024; 189:2. [PMID: 38217794 DOI: 10.1007/s11046-023-00811-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/11/2023] [Indexed: 01/15/2024]
Abstract
Trichophyton species cause dermatophytosis in humans, with a high, worldwide frequency of reports and important public health relevance. We evaluated 61 Trichophyton strains from different sources deposited in the University Recife Mycology (URM) culture collection of the Universidade Federal de Pernambuco, Brazil. Strains were phenotypically identified and confirmed by sequencing Internal Transcribed Spacers rDNA and partial beta-tubulin 2-exon. Additionally, we evaluated their susceptibility to terbinafine and itraconazole. Physiological analyses included urease activity and growth in casein medium. Phenotypic methods allowed the reliable identification of T. rubrum only, whereas, for other species, molecular methods were mandatory. All Trichophyton species exhibited susceptibility profiles to itraconazole (0.04-5.33 μg/mL) and terbinafine (0.17-3.33 μg/mL). Our analyses revealed a heterogeneous distribution of T. mentagrophytes, which does not support the current distribution within the species complex of T. mentagrophytes and its genotypes.
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Affiliation(s)
- Tatiana F Oliveira
- Departamento de Micologia Prof. Chaves Batista, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Carlos A T Valeriano
- Departamento de Micologia Prof. Chaves Batista, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - M Daniela S Buonafina-Paz
- Departamento de Micologia Prof. Chaves Batista, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Cristina M Souza-Motta
- Departamento de Micologia Prof. Chaves Batista, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Alexandre R Machado
- Departamento de Micologia Prof. Chaves Batista, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Rejane P Neves
- Departamento de Micologia Prof. Chaves Batista, Universidade Federal de Pernambuco, Recife, PE, Brazil
| | - Jadson D P Bezerra
- Laboratório de Micologia (LabMicol), Departamento de Biociências e Tecnologia, Instituto de Patologia Tropical e Saúde Pública (IPTSP), Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil.
| | - Thales D Arantes
- Laboratório de Micologia (LabMicol), Departamento de Biociências e Tecnologia, Instituto de Patologia Tropical e Saúde Pública (IPTSP), Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil
| | - Sybren de Hoog
- Center of Expertise in Mycology of Radboud University Medical Center, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Oliane M C Magalhães
- Departamento de Micologia Prof. Chaves Batista, Universidade Federal de Pernambuco, Recife, PE, Brazil
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20
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Ion A, Popa LG, Porumb-Andrese E, Dorobanțu AM, Tătar R, Giurcăneanu C, Orzan OA. A Current Diagnostic and Therapeutic Challenge: Tinea Capitis. J Clin Med 2024; 13:376. [PMID: 38256510 PMCID: PMC10816672 DOI: 10.3390/jcm13020376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 12/28/2023] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Tinea capitis is a dermatophyte scalp infection with a marked prevalence among the pediatric population. However, in the last few years, its epidemiology has changed due to increasing population migration worldwide. Host-specific and environmental factors contribute to the pathogenesis of tinea capitis. Clinically, tinea capitis may present as a subtle hair loss accompanied by scalp scaling, alopecia with scaly patches, or alopecia with black dots. A more severe form of tinea capitis is represented by kerion celsi, which clinically presents as a tender plaque covered by pustules and crusts. If left untreated, this dermatophytic infection may resolve with permanent scarring and alopecia. The pathological changes found in tinea capitis are reflected by a spectrum of clinical changes. Zoophilic infections typically prompt an extensive inflammatory reaction, while anthropophilic dermatophytoses often lack inflammation and result in more persistent lesions. Tinea capitis typically requires systemic antifungal therapy. Griseofulvin, terbinafine, itraconazole, and fluconazole are the main antifungal agents used. Currently, the duration of antifungal therapy varies based on the clinical presentation and type of dermatophyte involved. Through the reported cases and literature review, we aim to emphasize the importance of the early recognition of atypical variants of tinea capitis in immunocompetent children for the prompt initiation of systemic antifungal therapy, minimizing the need for prolonged treatment. Additionally, we emphasize the importance of regular laboratory testing during systemic antifungal therapy, particularly liver enzyme tests, to prevent adverse events, especially in cases requiring long-term treatment.
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Affiliation(s)
- Ana Ion
- Department of Dermatology, ‘Elias’ University Emergency Hospital, 011461 Bucharest, Romania; (A.I.); (A.M.D.)
| | - Liliana Gabriela Popa
- Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.T.); (C.G.); (O.A.O.)
- Department of Dermatology, ‘Elias’ University Emergency Hospital, 011461 Bucharest, Romania; (A.I.); (A.M.D.)
| | - Elena Porumb-Andrese
- Department of Dermatology, ‘Grigore T. Popa’ University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Alexandra Maria Dorobanțu
- Department of Dermatology, ‘Elias’ University Emergency Hospital, 011461 Bucharest, Romania; (A.I.); (A.M.D.)
| | - Raluca Tătar
- Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.T.); (C.G.); (O.A.O.)
- Department of Plastic Reconstructive Surgery and Burns, ‘Grigore Alexandrescu’ Clinical Emergency Hospital for Children, 011743 Bucharest, Romania
| | - Călin Giurcăneanu
- Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.T.); (C.G.); (O.A.O.)
- Department of Dermatology, ‘Elias’ University Emergency Hospital, 011461 Bucharest, Romania; (A.I.); (A.M.D.)
| | - Olguța Anca Orzan
- Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania; (R.T.); (C.G.); (O.A.O.)
- Department of Dermatology, ‘Elias’ University Emergency Hospital, 011461 Bucharest, Romania; (A.I.); (A.M.D.)
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Chiriac A, Diaconeasa A, Voicu C, Ivaniciuc M, Miulescu R, Chiriac AE, Nenoff P, Wollina U. Kerion Celsi in infants and children-A narrative review 2010-2023. Mycoses 2024; 67:e13675. [PMID: 37983862 DOI: 10.1111/myc.13675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 11/02/2023] [Indexed: 11/22/2023]
Abstract
Kerion Celsi is an inflammatory, deep fungal infection of the scalp. It is rare in neonates but gets more common in children about 3 years and older. It represents with swelling, boggy lesions, pain, alopecia and purulent secretions. Secondary bacterial infection is not unusual after maceration. Extracutaneous manifestations include regional lymphadenopathy, fever and very rare fungemia. Id-reactions can occur. Diagnosis is based on clinical suspicion, clinical examination and medical history. Diagnosis should be confirmed by microscopy, fungal culture and molecular procedures. The most common isolated fungal species are anthropophilic Trichophyton (T.) tonsurans and zoophilic Microsporum (M.) canis, while geophilic species and moulds rarely cause Kerion Celsi. Treatment is medical with systemic and topical antifungals supplemented by systemic antibiotics when necessary, while surgery needs to be avoided. Early and sufficient treatment prevents scarring alopecia. The most important differential diagnosis is bacterial skin and soft tissue infections.
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Affiliation(s)
- Anca Chiriac
- Department of Dermatology, Nicolina Medical Center, Iasi, Romania
- Apollonia University, Iasi, Romania
- Romanian Academy, P. Poni Institute of Macromolecular Chemistry, Iasi, Romania
| | - Adriana Diaconeasa
- Dermatology Ambulatory Care Center, "Grigore Alexandrescu" Clinical Emergency Hospital for Children, Bucharest, Romania
| | - Cristiana Voicu
- Department of Dermatology, MedLife Medical System, Bucharest, Romania
| | | | | | - Anca E Chiriac
- Department of Dermatology, Nicolina Medical Center, Iasi, Romania
| | - Pietro Nenoff
- Labor Leipzig-Mölbis, labopart - Medizinische Laboratorien, Rötha/OT Mölbis, Germany
| | - Uwe Wollina
- Department of Dermatology and Allergology, Städtisches Klinikum, Dresden Academic Teaching Hospital, Dresden, Germany
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22
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Song G, Kong X, Li X, Liu W, Liang G. Prior selection of itraconazole in the treatment of recalcitrant Trichophyton indotineae infection: Real-world results from retrospective analysis. Mycoses 2024; 67:e13663. [PMID: 37882456 DOI: 10.1111/myc.13663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/08/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The number of terbinafine-resistant Trichophyton indotineae is increasing in recent years while the treatment is still a matter to discuss. OBJECTIVES To explore the best therapeutic approach, we present real-world treatment of T. indotineae infection by analysing publicly available data. METHODS We have reviewed all published articles, mainly including case reports and case series, on the drug-resistant T. mentagrophytes complex by using the key search terms to search the databases. RESULTS We enrolled 25 articles from 14 countries, including 203 times of treatment information for 113 patients. The cure rate of itraconazole 200 mg per day at the fourth, eighth and the twelfth week were 27.27%, 48.48% and 54.55%, respectively, which was significantly higher than terbinafine 250 mg per day (8.77%, 24.56% and 28.07%) and even 500 mg/d terbinafine. Griseofulvin 500-1000 mg for 2-6 months may be effective while fluconazole had no record of successful treatment. Voriconazole and ravuconazole had potential therapeutic efficacy. Topical therapy alone showed limited therapeutic efficacy, but the combination with oral antifungals can be alternative. CONCLUSION Oral itraconazole 200 mg per day for 4-8 weeks was the most effective treatment out of these commonly used antifungal drugs, and can be prior selection.
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Affiliation(s)
- Ge Song
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- Department of Dermatology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xue Kong
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- Department of Dermatology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xiaofang Li
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- Department of Dermatology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Weida Liu
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- Department of Dermatology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Guanzhao Liang
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, China
- Department of Dermatology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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23
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Gupta AK, Polla Ravi S, Talukder M, Mann A. Effectiveness and safety of oral terbinafine for dermatophyte distal subungual onychomycosis. Expert Opin Pharmacother 2024; 25:15-23. [PMID: 38221907 DOI: 10.1080/14656566.2024.2305304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/10/2024] [Indexed: 01/16/2024]
Abstract
INTRODUCTION Terbinafine has been a cornerstone in dermatophyte infection treatment. Despite its global efficacy, the emergence of terbinafine resistance raises concerns, requiring ongoing vigilance. AREAS COVERED This paper focuses on evaluating the efficacy and safety of terbinafine in treating dermatophyte toenail infections. Continuous and pulse therapies, with a 24-week continuous regimen and a higher dosage of 500 mg/day have demonstrated superior efficacy to the FDA approved regimen of 250 mg/day x 12 weeks. Pulse therapies, though showing comparable effectiveness, present debates with regards to their efficacy as conflicting findings have been reported. Safety concerns encompass hepatotoxicity, gastrointestinal, cutaneous, neurologic, hematologic and immune adverse-effects, and possible drug interactions, suggesting the need for ongoing monitoring. EXPERT OPINION Terbinafine efficacy depends on dosage, duration, and resistance patterns. Continuous therapy for 24 weeks and a dosage of 500 mg/day may enhance outcomes, but safety considerations and resistance necessitate individualized approaches. Alternatives, including topical agents and alternative antifungals, are to be considered for resistant cases. Understanding the interplay between treatment parameters, adverse effects, and resistance mechanisms is critical for optimizing therapeutic efficacy while mitigating resistance risks. Patient education and adherence are vital for early detection and management of adverse effects and resistance, contributing to tailored and effective treatments.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Research Department, Mediprobe Research Inc, London, Ontario, Canada
| | | | - Mesbah Talukder
- Research Department, Mediprobe Research Inc, London, Ontario, Canada
- School of Pharmacy, BRAC University, Dhaka, Bangladesh
| | - Avantika Mann
- Research Department, Mediprobe Research Inc, London, Ontario, Canada
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24
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Oladzad V, Nasrollahi Omran A, Haghani I, Nabili M, Seyedmousavi S, Hedayati MT. Multi-drug resistance Trichophyton indotineae in a stray dog. Res Vet Sci 2024; 166:105105. [PMID: 38065018 DOI: 10.1016/j.rvsc.2023.105105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/30/2023] [Accepted: 12/01/2023] [Indexed: 01/01/2024]
Abstract
A 2.5-year-old stray dog showed signs of hair loss, mild skin crusting, and redness on extremities and trunk. The etiologic agent was confirmed as Trichophyton indotineae by sequencing of ITS region. Using the Clinical and Laboratory Standards Institute (CLSI M38-A3) guideline, antifungal susceptibility testing showed multidrug resistance phenotype against terbinafine (16 μg/mL-1), itraconazole, and some other tested antifungals (minimum inhibitory concentration, MIC≥16 μg/mL-1). However, luliconazole was found to be active in- vitro (0.016 μg/mL-1). Upon further studies, sequencing of SQLE gene showed an amino acids substitution of Phe397Leu and Ala448Thr, which is potentially linked to terbinafine resistance in Trichophyton species.
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Affiliation(s)
- Vahid Oladzad
- Department of Mycology, Faculty of Medical Sciences, Tonekabon Branch, Islamic Azad University, Tonekabon, Iran
| | - Ayatollah Nasrollahi Omran
- Department of Mycology, Faculty of Medical Sciences, Tonekabon Branch, Islamic Azad University, Tonekabon, Iran.
| | - Iman Haghani
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran; Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mojtaba Nabili
- Department of Medical Laboratory Sciences, Faculty of Medical Sciences, Sari Branch, Islamic Azad University, Sari, Iran
| | - Seyedmojtaba Seyedmousavi
- Microbiology Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, United States of America
| | - Mohammad Taghi Hedayati
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran; Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.
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25
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Lockhart SR, Smith DJ, Gold JAW. Trichophyton indotineae and other terbinafine-resistant dermatophytes in North America. J Clin Microbiol 2023; 61:e0090323. [PMID: 38014979 PMCID: PMC10729746 DOI: 10.1128/jcm.00903-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Dermatophyte infections (a.k.a. ringworm, tinea) affect an estimated 20%-25% of the world's population. In North America, most dermatophytoses are caused by Trichophyton rubrum or Trichophyton mentagrophytes species complexes. Severe and antifungal-resistant dermatophytoses are a growing global public health problem. A new species of the T. mentagrophytes species complex, Trichophyton indotineae, has recently emerged and is notable for the severe infections it causes, its propensity for antifungal resistance, and its global spread. In this issue of the Journal of Clinical Microbiology, C. F. Cañete-Gibas, J. Mele, H. P. Patterson, et al. (J Clin Microbiol 61:e00562-23, 2023, https://doi.org/10.1128/JCM.00562-23) summarize the results of speciation and AFST performed on North American dermatophyte isolates received at a fungal diagnostic reference laboratory. Within their collection, 18.6% of isolates were resistant to terbinafine (a first-line oral antifungal for dermatophytoses), and similar proportions of T. rubrum and T. indotineae demonstrated terbinafine resistance. The authors also found that T. indotineae has been present in North America since at least 2017. These findings highlight the importance of increased surveillance efforts to monitor trends in severe and antifungal-resistant dermatophytoses and the need for antifungal stewardship efforts, the success of which is contingent upon improving laboratory capacity for dermatophyte speciation and AFST.
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Affiliation(s)
- Shawn R. Lockhart
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Dallas J. Smith
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jeremy A. W. Gold
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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26
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Lockhart SR, Chowdhary A, Gold JAW. The rapid emergence of antifungal-resistant human-pathogenic fungi. Nat Rev Microbiol 2023; 21:818-832. [PMID: 37648790 DOI: 10.1038/s41579-023-00960-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/01/2023]
Abstract
During recent decades, the emergence of pathogenic fungi has posed an increasing public health threat, particularly given the limited number of antifungal drugs available to treat invasive infections. In this Review, we discuss the global emergence and spread of three emerging antifungal-resistant fungi: Candida auris, driven by global health-care transmission and possibly facilitated by climate change; azole-resistant Aspergillus fumigatus, driven by the selection facilitated by azole fungicide use in agricultural and other settings; and Trichophyton indotineae, driven by the under-regulated use of over-the-counter high-potency corticosteroid-containing antifungal creams. The diversity of the fungi themselves and the drivers of their emergence make it clear that we cannot predict what might emerge next. Therefore, vigilance is critical to monitoring fungal emergence, as well as the rise in overall antifungal resistance.
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Affiliation(s)
- Shawn R Lockhart
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Anuradha Chowdhary
- Medical Mycology Unit, Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
- National Reference Laboratory for Antimicrobial Resistance in Fungal Pathogens, Medical Mycology Unit, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Jeremy A W Gold
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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27
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Gupta AK, Cooper EA, Wang T, Polla Ravi S, Lincoln SA, Piguet V, McCarthy LR, Bakotic WL. Detection of Squalene Epoxidase Mutations in United States Patients with Onychomycosis: Implications for Management. J Invest Dermatol 2023; 143:2476-2483.e7. [PMID: 37236595 DOI: 10.1016/j.jid.2023.04.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/11/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023]
Abstract
Resistance to oral terbinafine, the most commonly used antifungal to treat dermatophytosis and onychomycosis worldwide, is being increasingly reported. In this study, we aimed to investigate the species distribution and prevalence of squalene epoxidase mutations among toenail dermatophyte isolates. Samples from 15,683 patients suspected of onychomycosis visiting the offices of dermatologists and podiatrists in the United States were analyzed. Clinical information was reviewed, and dermatophyte species with or without squalene epoxidase mutations were detected using multiplex real-time PCRs. The frequency of dermatophytes was 37.6%; of isolates belonging to the Trichophyton genus, 88.3% were the T. rubrum complex, and 11.2% were the T. mentagrophytes complex. Individuals aged >70 years exhibited higher infection rates for the T. mentagrophytes complex. The overall mutation rate among Trichophyton spp. was 3.7%, with a higher mutation rate detected in the T. mentagrophytes complex (4.3 vs. 3.6%). Commonly detected mutations were T1189C/Phe397Leu (34.5%), T1306C/Phe415Ser (16.0%), and C1191A/Phe397Leu (11.0%). Squalene epoxidase gene mutations associated with decreased terbinafine susceptibility have been identified in United States patients with toenail onychomycosis. Physicians should be aware of the risk factors for resistance development and engage in antifungal stewardship practices such as directed diagnosis and treatment of dermatophytosis and onychomycosis.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Mediprobe Research, London, Ontario, Canada.
| | | | - Tong Wang
- Mediprobe Research, London, Ontario, Canada
| | | | | | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Dermatology, Women's College Hospital, Toronto, Ontario, Canada
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28
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Yamada T, Nojo H, Kano R. Long Amplification PCR (LA-PCR) Detection of Azole Resistant Trichophyton indotineae. Mycopathologia 2023; 188:1085-1088. [PMID: 37751125 DOI: 10.1007/s11046-023-00793-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/30/2023] [Indexed: 09/27/2023]
Abstract
Trichphyton indotineae, a species newly designated in 2020 independent of T. interdigitale, comprises highly terbinafine (TRF)-resistant dermatophytosis that is epidemic in North India and spreding to worldwide. Some clinical isolates of T. indotineae have been resistance both TRF and azoles that might be caused the treatment failure. To detect the azole resistance strains, we developed a long amplification PCR (LA-PCR) detection method for the tandem repeat of the CYP51B (encoding sterol 14a-demethylase gene) in T. indotineae. Contrasting the drug susceptibility test results with the LA-PCR results confirmed a trend toward low susceptibility to azole antifungal agents in strains with amplifications of 9.5 kbp or greater (3 or more copies of CYP51B). Our results suggest that the method could be detected rapidly of low-susceptibility strains to azole antifungal agents.
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Affiliation(s)
- Tsuyoshi Yamada
- Teikyo University Institute of Medical Mycology (TIMM), 359 Otsuka, Hachioji, Tokyo, 192-0395, Japan
| | - Honoka Nojo
- Teikyo University Institute of Medical Mycology (TIMM), 359 Otsuka, Hachioji, Tokyo, 192-0395, Japan
| | - Rui Kano
- Teikyo University Institute of Medical Mycology (TIMM), 359 Otsuka, Hachioji, Tokyo, 192-0395, Japan.
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29
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Kottferová L, Molnár L, Major P, Sesztáková E, Kuzyšinová K, Vrabec V, Kottferová J. Hedgehog Dermatophytosis: Understanding Trichophyton erinacei Infection in Pet Hedgehogs and Its Implications for Human Health. J Fungi (Basel) 2023; 9:1132. [PMID: 38132733 PMCID: PMC10744110 DOI: 10.3390/jof9121132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Pet hedgehogs, which are increasingly favoured companions, have garnered attention due to their potential as carriers of zoonotic diseases. These small insectivorous mammals, native to Europe, Asia, and Africa, are commonly kept as pets. The encroachment of humans into hedgehog habitats has brought these animals closer to people, raising concerns about disease transmission. This article reviews the current knowledge regarding zoonotic disease associated with pet hedgehogs, with a particular focus on mycotic infections caused by Trichophyton erinacei. Data from various regions and hedgehog species are synthesised to assess the significance of pet hedgehogs as potential reservoirs and transmitters of zoonotic pathogens. Our study highlights the importance of understanding the health risks associated with pet hedgehogs and underscores the need for continued research to mitigate zoonotic disease transmission from these potentially disease-carrying companions.
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Affiliation(s)
- Lucia Kottferová
- Clinic of Birds, Exotic and Free Living Animals, University of Veterinary Medicine and Pharmacy, Komenského 73, 04181 Košice, Slovakia; (L.K.); (L.M.); (E.S.); (K.K.); (V.V.)
| | - Ladislav Molnár
- Clinic of Birds, Exotic and Free Living Animals, University of Veterinary Medicine and Pharmacy, Komenského 73, 04181 Košice, Slovakia; (L.K.); (L.M.); (E.S.); (K.K.); (V.V.)
| | - Peter Major
- Clinic of Birds, Exotic and Free Living Animals, University of Veterinary Medicine and Pharmacy, Komenského 73, 04181 Košice, Slovakia; (L.K.); (L.M.); (E.S.); (K.K.); (V.V.)
| | - Edina Sesztáková
- Clinic of Birds, Exotic and Free Living Animals, University of Veterinary Medicine and Pharmacy, Komenského 73, 04181 Košice, Slovakia; (L.K.); (L.M.); (E.S.); (K.K.); (V.V.)
| | - Katarína Kuzyšinová
- Clinic of Birds, Exotic and Free Living Animals, University of Veterinary Medicine and Pharmacy, Komenského 73, 04181 Košice, Slovakia; (L.K.); (L.M.); (E.S.); (K.K.); (V.V.)
| | - Vladimír Vrabec
- Clinic of Birds, Exotic and Free Living Animals, University of Veterinary Medicine and Pharmacy, Komenského 73, 04181 Košice, Slovakia; (L.K.); (L.M.); (E.S.); (K.K.); (V.V.)
| | - Jana Kottferová
- Department of Public Veterinary Medicine and Animal Welfare, University of Veterinary Medicine and Pharmacy, Komenského 73, 04181 Košice, Slovakia;
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30
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Si H, Li Y, Huang Z, Cui Y, Li S. Erythroderma combined with deeper dermal dermatophytosis due to Trichophyton rubrum in a patient with myasthenia gravis: first case report and literature review. BMC Infect Dis 2023; 23:789. [PMID: 37957543 PMCID: PMC10644414 DOI: 10.1186/s12879-023-08752-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Dermatophytes are the most common causative pathogens of mycoses worldwide and usually cause superficial infections. However, they can enter deep into the dermis lead to invasive dermatophytosis such as deeper dermal dermatophytosis on rare occasions. Erythroderma is a severe dermatological manifestation of various diseases resulting in generalized skin redness, but erythroderma due to fungi infections is barely reported. In this article, we reported the first case of erythroderma combined with deeper dermal dermatophytosis due to Trichophyton rubrum (T. rubrum) in a patient with myasthenia gravis. CASE PRESENTATION A 48-year-old man was hospitalized because of erythema with scaling and nodules covering his body for a month. The patient had a history of myasthenia gravis controlled by regularly taking prednisolone for > 10 years and accompanied by onychomycosis and tinea pedis lasting > 8 years. Based on histopathological examinations, fungal cultures, and DNA sequencing results, the patient was finally diagnosed with dermatophyte-induced erythroderma combined with deeper dermal dermatophytosis caused by T. rubrum. After 2 weeks of antifungal treatment, the patient had recovered well. CONCLUSIONS This case report shows that immunosuppressed patients with long histories of superficial mycoses tend to have a higher risk of developing invasive dermatophytic infections or disseminated fungal infections. Dermatologists should be alert to this condition and promptly treat the superficial dermatophytosis.
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Affiliation(s)
- Henan Si
- Department of Dermatology and Venerology, First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Yang Li
- Department of Dermatology and Venerology, First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Zhiyang Huang
- Department of Dermatology and Venerology, First Hospital of Jilin University, Changchun, Jilin, 130021, China
| | - Yan Cui
- Department of Dermatology and Venerology, First Hospital of Jilin University, Changchun, Jilin, 130021, China.
| | - Shanshan Li
- Department of Dermatology and Venerology, First Hospital of Jilin University, Changchun, Jilin, 130021, China.
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31
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Gupta AK, Polla Ravi S, Wang T, Cooper EA, Lincoln SA, Foreman HC, Bakotic WL. Antifungal Resistance, Susceptibility Testing and Treatment of Recalcitrant Dermatophytosis Caused by Trichophyton indotineae: A North American Perspective on Management. Am J Clin Dermatol 2023; 24:927-938. [PMID: 37553539 DOI: 10.1007/s40257-023-00811-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 08/10/2023]
Abstract
There is an ongoing epidemic of chronic, relapsing dermatophytoses caused by Trichophyton indotineae that are unresponsive to one or multiple antifungal agents. Although this new species may have originated from the Indian subcontinent, there has been a notable increase of its reporting in other countries. Based on current literature, antifungal susceptibility testing (AFST) showed a large variation of terbinafine minimum inhibitory concentrations (MICs) (0.04 to ≥ 32 µg/ml). Elevated terbinafine MICs can be attributed to mutations in the squalene epoxidase gene (single mutations: Leu393Phe, Leu393Ser, Phe397Leu, and double mutations: Leu393Phe/Ala448Thr, Phe397Leu/Ala448Thr). Itraconazole MICs had a lower range when compared with that of terbinafine (0.008-16 µg/ml, with most MICs falling between 0.008 µg/ml and < 1 µg/ml). The interpretation of AFST results remains challenging due to protocol variations and a lack of established breakpoints. Adoption of molecular methods for resistance detection, coupled with AFST, may provide a better evaluation of the in vitro resistance status of T. indotineae. There is limited information on treatment options for patients with confirmed T. indotineae infections by molecular diagnosis; preliminary evidence generated from case reports and case series points to itraconazole as an effective treatment modality, while terbinafine and griseofulvin are generally not effective. For physicians working outside of endemic regions, there is currently an unmet need for standardized clinical trials to establish treatment guidelines; in particular, combination therapy of oral and topical agents (e.g., itraconazole and ciclopirox), as well as with other azoles (i.e., fluconazole, voriconazole, ketoconazole), warrants further investigation as multidrug resistance is a possibility for T. indotineae.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto School of Medicine, Toronto, ON, Canada.
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada.
| | - Shruthi Polla Ravi
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada
| | - Tong Wang
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada
| | - Elizabeth A Cooper
- Mediprobe Research Inc., 645 Windermere Road, London, ON, N5X 2P1, Canada
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32
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Dashti Y, Alobaid K, Al-Rashidi S, Dashti M, AbdulMoneim MH, Al-Enezi M, Abou-Chakra N, Jørgensen KM. Autochthonous case of Trichophyton indotineae in Kuwait. J Mycol Med 2023; 33:101432. [PMID: 37666031 DOI: 10.1016/j.mycmed.2023.101432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/26/2023] [Accepted: 08/28/2023] [Indexed: 09/06/2023]
Abstract
Trichophyton indotineae is an emerging dermatophyte that has remarkable impact on public health worldwide. In addition to producing severe extensive skin lesions, this species is frequently resistant to terbinafine, used as a first line agent. As a result, the infection is often refractory, making treatment very challenging. The current report describes the first case of Trichophyton indotineae infection in Kuwait. The infected woman had no recent travel history. She failed to respond to several courses of antifungals, but finally responded to voriconazole. The report suggests that T. indotineae is under recognised, hence, active surveillance of dermatophytes is warranted.
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Affiliation(s)
- Yousef Dashti
- Department of Dermatology, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | - Khaled Alobaid
- Department of Mycology, Mycology Reference Laboratory, Mubarak Al-Kabeer Hospital, Block 4, Street Number: 103, Post code 46304, Jabriya, Kuwait.
| | - Shahad Al-Rashidi
- Department of Dermatology, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | - Maryam Dashti
- Department of Dermatology, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | | | - Manar Al-Enezi
- Department of Dermatology, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
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Nenoff P, Stahl M, Schaller M, Burmester A, Monod M, Ebert A, Uhrlaß S. [Recurrent tinea corporis generalisata due to Terbinafine-resistant Trichophyton rubrum strain : Long-term treatment with super bioavailability itraconazole]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2023; 74:864-873. [PMID: 37823916 DOI: 10.1007/s00105-023-05232-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/07/2023] [Indexed: 10/13/2023]
Abstract
For more than 30 years, an 82-year-old man has been suffering from tinea corporis generalisata in the sense of Trichophyton rubrum syndrome. The patient received long-term treatment with terbinafine. Fluconazole had no effect. There was an increase in liver enzymes with itraconazole. Super bioavailability (SUBA) itraconazole was initially not tolerated. A therapy attempt with voriconazole was successful, but was stopped due to side effects. The Trichophyton (T.) rubrum strain isolated from skin scales was tested for terbinafine resistance using the breakpoint method and found to be (still) sensitive. Sequencing of the squalene epoxidase (SQLE) gene revealed a previously unknown point mutation of the codon for isoleucine ATC→ACC with amino acid substitution I479T (isoleucine479 threonine). Long-term therapy with terbinafine 250 mg had been given every 3 days since 2018. In addition, bifonazole cream, ciclopirox solution, and occasionally terbinafine cream were used. The skin condition was stable until an exacerbation of the dermatophytosis in 2021. There were erythematosquamous, partly atrophic, centrifugal, scaly, confluent plaques on the integument and the extremities. Fingernails and toenails had white to yellow-brown discoloration, and were hyperkeratotic and totally dystrophic. T. rubrum was cultured from skin scales from the integument, from the feet, from nail shavings from the fingernails and also toenails and detected by PCR. In the breakpoint test, the T. rubrum isolates from tinea corporis and nail samples showed a minimum inhibitory concentration (MIC) of 0.5 µg ml-1 (terbinafine resistance in vitro). Sequencing of the SQLE gene of the T. rubrum isolate revealed evidence of a further point mutation that led to amino acid substitution I479V (isoleucine 479 valine). Long-term therapy was started with SUBA itraconazole: 14 days 2 × 1 capsule daily, then twice weekly administration of 2 × 50 mg. During breaks in therapy, the mycosis regularly flared up again. Finally, 50 mg SUBA itraconazole was given 5 days a week, which completely suppressed the dermatophytosis. Topically, ciclopirox and miconazole cream were used alternately. In conclusion, in the case of recurrent and therapy-refractory dermatophytoses caused by T. rubrum, terbinafine resistance must also be considered in individual cases. An in vitro resistance test and point mutation analysis of the squalene epoxidase gene confirms the diagnosis. Itraconazole, also in the form of SUBA itraconazole, is the drug of choice for the oral antifungal treatment of these patients.
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Affiliation(s)
- Pietro Nenoff
- Labor Leipzig-Mölbis, labopart - Medizinische Laboratorien, Mölbiser Hauptstr. 8, 04571, Rötha/OT Mölbis, Deutschland.
| | - Maren Stahl
- Hautärztin Dr. med. Maren Stahl, Osterode am Harz, Deutschland
| | | | - Anke Burmester
- Klinik für Hautkrankheiten, Universitätsklinikum Jena, Jena, Deutschland
| | - Michel Monod
- Dermatology Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Schweiz
| | - Andreas Ebert
- Labor Leipzig-Mölbis, labopart - Medizinische Laboratorien, Mölbiser Hauptstr. 8, 04571, Rötha/OT Mölbis, Deutschland
| | - Silke Uhrlaß
- Labor Leipzig-Mölbis, labopart - Medizinische Laboratorien, Mölbiser Hauptstr. 8, 04571, Rötha/OT Mölbis, Deutschland
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Urmila Y, Gopal KVT, Turpati NR, Karri SB, Raju PVK. A Clinico-Mycological and Histopathological Study of Recurrent Dermatophytosis. Indian Dermatol Online J 2023; 14:799-806. [PMID: 38099009 PMCID: PMC10718100 DOI: 10.4103/idoj.idoj_670_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 04/09/2023] [Accepted: 04/10/2023] [Indexed: 12/17/2023] Open
Abstract
Background A few recent studies have shown fungal elements within the hair follicle epithelium, which may act as a reservoir and responsible for recurrent dermatophytosis. Objectives To assess the clinical patterns, mycological profile, and histopathology of recurrent dermatophytosis and to determine the prevalence of fungal hyphae in the hair follicle epithelium and other appendages. Materials and Methods One hundred and fifty clinically diagnosed cases of recurrent dermatophytic infection were included. Skin samples were taken for direct microscopy, fungal culture, and histopathological analysis. Haematoxylin and eosin and special staining with periodic acid Schiff (PAS) and Gomori's methenamine silver (GMS) were performed to detect the fungal hyphae in the skin and hair follicle epithelium. Results The most common clinical pattern observed was tinea corporis et cruris in 64 patients (42.66%). On direct microscopy and fungal culture, positive results were obtained in 116 cases (77.33%) and 78 (52%) cases, respectively. Presence of fungal hyphae in the stratum corneum, hair follicle, and acrosyringium was seen in 107 patients (71.33%), 47 patients (31.33%), and five patients (3.33%), respectively. Out of the 52 cases with hair follicle and eccrine gland involvement, history of fixed drug combinations (FDC) cream use was present in 42 cases (80.76%) and absent in ten cases (19.24%) (P = 0.000062). Limitations Skin samples were taken only from a single skin lesion. Higher incidence of follicular invasion may have been detected if multiple biopsy samples were taken. Conclusion Hair follicle/eccrine sweat gland involvement was observed in nearly one-third of the patients, which may act as a reservoir and may be responsible for recurrence and chronicity. Histopathology should be considered as an important adjuvant tool in recurrent dermatophytosis to establish the extent of the infection, which guides the further management.
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Affiliation(s)
- Y Urmila
- Department of Dermatology, Maharajah's Institute of Medical Sciences, Nellimarla, Vizianagaram, Andhra Pradesh, India
| | - K. V. T. Gopal
- Department of Dermatology, Maharajah's Institute of Medical Sciences, Nellimarla, Vizianagaram, Andhra Pradesh, India
| | - Narayana Rao Turpati
- Department of Dermatology, Maharajah's Institute of Medical Sciences, Nellimarla, Vizianagaram, Andhra Pradesh, India
| | - Sudhir Babu Karri
- Consultant Pathologist, Department of Pathology, Vijaya Diagnostic Center, Visakhapatnam, Andhra Pradesh, India
| | - P. V. K. Raju
- Department of Dermatology, Maharajah's Institute of Medical Sciences, Nellimarla, Vizianagaram, Andhra Pradesh, India
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Caplan AS, Zakhem GA, Pomeranz MK. Trichophyton mentagrophytes Internal Transcribed Spacer Genotype VIII. JAMA Dermatol 2023; 159:1130. [PMID: 37418257 DOI: 10.1001/jamadermatol.2023.2645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
This case report describes large, annular, scaly, and erythematous plaques in the axillae and legs extending from the groin as well as involvement of the chest surrounding the areola.
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Affiliation(s)
- Avrom S Caplan
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York
| | - George A Zakhem
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York
| | - Miriam Keltz Pomeranz
- The Ronald O. Perelman Department of Dermatology, NYU Grossman School of Medicine, New York, New York
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Dev PP, Bansal S, Bhargava A. Revisiting the pathogenesis of dermatophytosis: A cross-sectional analytic study of serum levels of interleukins-2, 8, 10 and 17. Mycoses 2023; 66:876-881. [PMID: 37309232 DOI: 10.1111/myc.13625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/27/2023] [Accepted: 06/02/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Given the current epidemic-like scenario of dermatophyte infections, it is prudent to revisit the immunopathogenesis of dermatophytosis. Comprehending the intricate interactions among interleukins can aid in understanding the recent trends in infection. There is a paucity of literature on the various cytokine levels observed in the serum of patients suffering from various dermatophytoses. AIM To study serum cytokine levels of interleukins 2, 8, 10 and 17 in patients with dermatophytosis. METHODS A cross-sectional analytic study was conducted on 64 cases of clinical dermatophyte infections (KOH confirmed) and 64 controls. The clinico-epidemiological profile of the cases was studied. By using a solid phase sandwich ELISA (enzyme-linked immunosorbent assay), the serum levels of interleukins 2, 8, 10 and 17 were measured and compared between cases and controls. Serum interleukin-2, 8, 10 and 17 levels were studied among cases based on mode of onset, duration of illness, treatment history, site of infection and multiple other morphological characteristics of the infection. RESULTS The cases had statistically higher levels of interleukins-8, 10 and 17 in comparison with controls. The levels of interleukin-8 were significantly lower (p < .05) among those who had received oral antifungals. In cases where the lesion had scaling, the serum levels of interleukin-10 were significantly higher (p < .05). The lesional hyperpigmentation was significantly (p < .05) associated with low levels of interleukin-17. Also, interleukin-17 was significantly (p < .05) elevated in patients with lesions in the abdomen. CONCLUSION It is the first time that serum interleukin levels are studied in dermatophytosis. There is an immunological dysfunction specific to dermatophytoses initiated by their infection. Key factor in this dysfunction is the elevation of IL-10, contributing to persistent infection. In turn, causing an increase in IL-17, promoting inflammation and tissue damage. This cycle of elevated IL-10 and IL-17 can further exacerbate the infection and lead to chronicity. The activity of IL-2 and the Th1 immune pathway is reduced by two opposing immune pathways: the Th17 and Th2 axes.
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Affiliation(s)
- Prabin P Dev
- Department of Dermatology and STD, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Shikha Bansal
- Department of Dermatology and STD, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Aradhana Bhargava
- Apex Regional STD Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Das A. Dermatophytosis: Newer Insights. Indian J Dermatol 2023; 68:491. [PMID: 38099099 PMCID: PMC10718233 DOI: 10.4103/ijd.ijd_830_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023] Open
Affiliation(s)
- Anupam Das
- From the Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India E-mail:
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38
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Messina F, Santiso G, Romero M, Bonifaz A, Fernandez M, Marin E. First case report of tinea corporis caused by Trichophyton indotineae in Latin America. Med Mycol Case Rep 2023; 41:48-51. [PMID: 37706043 PMCID: PMC10495376 DOI: 10.1016/j.mmcr.2023.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 09/15/2023] Open
Abstract
A case of tinea corporis by Trichophyton indotineae observed in Argentina is presented. The patient had a history of having spent 18 months in Tulum, Mexico. She was suffering from tinea corporis in the anterior region of both thighs and the gluteal area. A mycological study was performed and T. mentagrophytes complex was isolated. The fungus was later identified as T. indotineae by DNA sequencing and treatment with SUBA-itraconazole was initiated with good clinical response.
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Affiliation(s)
- Fernando Messina
- Mycology Unit, FJ Muñiz Infectious Diseases Hospital, Uspalllata 2272, Autonomous City of Buenos Aires, C1282, Argentina
| | - Gabriela Santiso
- Mycology Unit, FJ Muñiz Infectious Diseases Hospital, Uspalllata 2272, Autonomous City of Buenos Aires, C1282, Argentina
| | - Mercedes Romero
- Mycology Unit, FJ Muñiz Infectious Diseases Hospital, Uspalllata 2272, Autonomous City of Buenos Aires, C1282, Argentina
| | - Alexandro Bonifaz
- Head of the Department of Mycology, Dermatology Service, General Hospital of Mexico " Dr. Eduardo Liceaga”, Calle Dr. Balmis 148, Mexico City, CP6720, Mexico
| | - Marisa Fernandez
- Tropical and Travel Medicine, FJ Muñiz Infectious Diseases Hospital, Uspalllata 2272, Autonomous City of Buenos Aires, C1282, Argentina
| | - Emmanuel Marin
- Mycology Unit, FJ Muñiz Infectious Diseases Hospital, Uspalllata 2272, Autonomous City of Buenos Aires, C1282, Argentina
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Chatterjee M, Datta D. Trichophyton: Changing Nomenclature and Practical Implications. Indian J Dermatol 2023; 68:503-507. [PMID: 38099132 PMCID: PMC10718245 DOI: 10.4103/ijd.ijd_827_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023] Open
Abstract
Trichophyton interdigitale had been regarded as anthropophilic, mainly causing non-inflammatory tinea unguium and tinea pedis. T. mentagrophytes, thought to be zoophilic, were regarded as responsible for more inflammatory dermatophytosis. Indian terbinafine-resistant strains, identified with ribosomal internal transcribed spacer as 'genotype VIII', have recently been termed Trichophyton indotineae based on clinical and mycological features. Some of these have shown selective azole resistance as well. Phenotypic studies have shown some similarities and some differences between Trichophyton indotineae, T. mentagrophytes, and T. interdigitale, which are optimally distinguished with HMG locus analyses as three main genotypic groups containing the type strains of T. indotineae (CBS 146623), T. interdigitale (CBS 428.63), and T. mentagrophytes (IHEM 4268) and having approximate differences in geographic distribution. Trichophyton interdigitale was prevalently isolated from superficial infections on exposed body sites such as the scalp and face, while also feet and nails. Trichophyton mentagrophytes has a similar predilection but are also often found on the trunk and genitals. Trichophyton indotineae is mostly restricted to the trunk and groin. T. indotineae lesions are generally highly inflammatory, strongly associated with tinea cruris, corporis, and faciei and less commonly with fingernail onychomycosis and tinea pedis. They cause papulosquamous, pustular, pseudo-imbricata (tinea faciei), lichenoid, and pityriasis rosea (tinea corporis of the neck) types of lesions and spread rapidly to multiple sites and cause painful lesions with itching or burning. Lipolytic abilities of T. mentagrophytes and T. interdigitale are very similar and are higher than those of T. indotineae, which is associated with a higher prevalence of T. mentagrophytes on the human scalp, which is relatively rich in lipids. Keratin degradation is significantly larger in T. interdigitale due to location (tinea pedis and tinea unguium). Identification of T. indotineae through culture alone may not be sufficient for effective treatment decision-making; genetic analysis for resistance profiles is needed for optimum treatment selection. In India, steroid-induced suppression of local cellular immunity as well as an altered cutaneous microbiome provided a window of opportunity for the unique, multidrug-resistant species Trichophyton indotineae.
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Affiliation(s)
- Manas Chatterjee
- Brigadier Armed Forces Medical Services (Pens), Base Hospital Delhi Cantt, India
| | - Debatri Datta
- Consultant Dermatologist, Oliva Skin and Hair Clinic, Kolkata, West Bengal, India
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Crotti S, Cruciani D, Spina S, Piscioneri V, Natalini Y, Pezzotti G, Sabbatucci M, Papini M. A Terbinafine Sensitive Trichophyton indotineae Strain in Italy: The First Clinical Case of tinea corporis and onychomycosis. J Fungi (Basel) 2023; 9:865. [PMID: 37754973 PMCID: PMC10532841 DOI: 10.3390/jof9090865] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 09/28/2023] Open
Abstract
Trichophyton indotineae is an emerging dermatophyte species that plays a relevant role in human healthcare. It has been associated with severe chronic skin infections and a high level of terbinafine resistance. T. indotineae is endemic to India, Iran, and Iraq but several cases have been reported in Europe, recently. In this manuscript, the authors report the first clinical description of a tinea corporis and onychomycosis due to T. indotineae. The patient was a 42-year-old female from India that has lived in Umbria (Central Italy) for the last two years. Firstly, a dermatological examination suggested dermatophytosis: mycology isolation from cultures and macro- and microscopical features identified the colonies as belonging to the T. mentagrophytes/T. interdigitale species complex. Subsequently, ITS1/ITS4 end-point PCR and Sanger sequencing identified the strain as T. indotineae. Lastly, a DermaGenius® Resistance Multiplex real-time PCR assay was carried out, targeting the mutations in the SQLE gene to establish terbinafine resistance or susceptibility of the strain. The melting curve observed was compatible with wild-type positive control, identifying the strain as T. indotineae terbinafine-sensitive. An oral terbinafine treatment was associated with a topical ciclopirox nail solution, resulting in remission in its clinical manifestation. On 3 July 2023, the local Prevention Service notified the case to the Ministry of Health that then reported the information at national and international levels.
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Affiliation(s)
- Silvia Crotti
- Centro Specialistico Patologie Micotiche, Istituto Zooprofilattico Sperimentale dell’Umbria e delle Marche “Togo Rosati” (IZSUM), 06126 Perugia, Italy; (S.C.); (S.S.); (V.P.); (G.P.)
| | - Deborah Cruciani
- Centro Specialistico Patologie Micotiche, Istituto Zooprofilattico Sperimentale dell’Umbria e delle Marche “Togo Rosati” (IZSUM), 06126 Perugia, Italy; (S.C.); (S.S.); (V.P.); (G.P.)
| | - Sara Spina
- Centro Specialistico Patologie Micotiche, Istituto Zooprofilattico Sperimentale dell’Umbria e delle Marche “Togo Rosati” (IZSUM), 06126 Perugia, Italy; (S.C.); (S.S.); (V.P.); (G.P.)
| | - Vincenzo Piscioneri
- Centro Specialistico Patologie Micotiche, Istituto Zooprofilattico Sperimentale dell’Umbria e delle Marche “Togo Rosati” (IZSUM), 06126 Perugia, Italy; (S.C.); (S.S.); (V.P.); (G.P.)
| | - Ylenia Natalini
- Clinica Dermatologica di Terni, Università degli Studi di Perugia, 06123 Perugia, Italy; (Y.N.); (M.P.)
| | - Giovanni Pezzotti
- Centro Specialistico Patologie Micotiche, Istituto Zooprofilattico Sperimentale dell’Umbria e delle Marche “Togo Rosati” (IZSUM), 06126 Perugia, Italy; (S.C.); (S.S.); (V.P.); (G.P.)
| | - Michela Sabbatucci
- Department of Infectious Diseases, Istituto Superiore di Sanità, 00161 Roma, Italy;
- Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi di Pisa, 56126 Pisa, Italy
| | - Manuela Papini
- Clinica Dermatologica di Terni, Università degli Studi di Perugia, 06123 Perugia, Italy; (Y.N.); (M.P.)
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Su H, Jiang W, Verweij PE, Li L, Zhu J, Han J, Zhu M, Deng S. The in vitro Activity of Echinocandins Against Clinical Trichophyton rubrum Isolates and Review of the Susceptibility of T. rubrum to Echinocandins Worldwide. Infect Drug Resist 2023; 16:5395-5403. [PMID: 37621698 PMCID: PMC10444579 DOI: 10.2147/idr.s423735] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/12/2023] [Indexed: 08/26/2023] Open
Abstract
Introduction The emergence of resistance in Trichophyton rubrum to azoles and terbinafine has become increasingly evident in recent years, necessitating the development of novel antifungal drugs and the exploration of new indications for existing agents. Methods In this study, we retrospectively evaluated the in vitro antifungal activity of 3 echinocandins (anidulafungin, caspofungin, and micafungin) against 73 clinical isolates of T. rubrum collected from a teaching hospital in Shanghai, China, using EUCAST E.DEF 9.3.1 with minor modification. We also reviewed the susceptibility of T. rubrum to echinocandins globally by literature searching. Results Our findings revealed that micafungin exhibited the lowest modal minimum effective concentration (MEC) value (0.08 mg/L, n = 28) and the lowest geometric mean (GM) MEC value (0.014 mg/L) among the 73 isolates of T. rubrum tested, followed by anidulafungin with a modal MEC value of 0.016 mg/L (n = 67) and a GM of 0.018 mg/L. Caspofungin displayed a higher modal MEC value of 0.5 mg/L (n = 35) and a GM of 0.308 mg/L. Despite variations in methodologies, similar results were obtained from the review of five relevant studies included in our analysis. Discussion Echinocandins exhibited excellent in vitro activity against T. rubrum isolates, with micafungin and anidulafungin demonstrating greater potency than caspofungin. These findings suggest that echinocandins could be considered as potential treatment options for managing recalcitrant dermatophytoses resulting from the emergence of resistance. However, it is important to note that the clinical efficacy of these in vitro findings has yet to be established and warrants further investigation.
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Affiliation(s)
- Huilin Su
- Department of Dermatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
- Department of Medical Microbiology and Center of Expertise in Mycology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Weiwei Jiang
- Department of Dermatology, Hospital affiliated to the 72nd Army of Chinese PLA, Huzhou, People’s Republic of China
| | - Paul E Verweij
- Department of Medical Microbiology and Center of Expertise in Mycology, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Medical Microbiology and Center of Expertise in Mycology, CWZ Hospital, Nijmegen, the Netherlands
| | - Li Li
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Junhao Zhu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Jiande Han
- Department of Dermatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Min Zhu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Shuwen Deng
- Department of Medical Microbiology, The People’s Hospital of SND, Suzhou, People’s Republic of China
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Kong X, Song G, Mei H, Zheng H, Tang C, de Hoog S, Li X, She X, Liu W, Liang G. The Domestic Isolation of Terbinafine- and Itraconazole-Resistant Trichophyton indotineae in Chinese Mainland. Mycopathologia 2023; 188:383-393. [PMID: 37335400 DOI: 10.1007/s11046-023-00761-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/03/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Trichophyton indotineae, a new species of dermatophytes, has become a significant concern in treating dermatophytosis due to the high level of terbinafine resistance reported in India and even worldwide. OBJECTIVES This study aimed to report the terbinafine- and itraconazole-resistant T. indotineae in Chinese mainland, by identifying the phylogenetic classification of the isolate strain, and detecting the drug resistance, gene mutation and expression. PATIENTS/METHODS The skin scales of the patient were cultured on SDA and the isolate was authenticated by DNA sequencing and MALDI-TOF MS. Antifungal susceptibility testing was performed following the M38-A2 CLSI protocol to examine the MICs values of terbinafine, itraconazole, fluconazole, etc. The strain was screened for mutations in the squalene epoxidase (SQLE) gene by Sanger sequencing and detected the expression of CYP51A and CYP51B by qRT-PCR. RESULTS A multi-resistant ITS genotype VIII sibling of the T. mentagrophytes complex (T. indotineae) was isolated in Chinese mainland. The strain harbored high terbinafine MIC of > 32 μg/mL and itraconazole MIC of 1.0 μg/mL, which was identified a mutation in the squalene epoxidase gene with amino acid substitution (Phe397Leu, mutation 1191C > A). In addition, overexpression of CYP51A and CYP51B was observed. With multiple relapses, the patient finally achieved clinical cure by itraconazole pulse therapy and topical clotrimazole cream for 5 weeks. CONCLUSIONS The first domestic strain of terbinafine- and itraconazole-resistant T. indotineae from a patient in Chinese mainland was isolated. Itraconazole pulse therapy can be an effective method for the treatment of T. indotineae.
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Affiliation(s)
- Xue Kong
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, 210042, China
- Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, 210042, China
| | - Ge Song
- Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, China
| | - Huan Mei
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, 210042, China
| | - Hailin Zheng
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, 210042, China
| | - Chao Tang
- Center of Expertise in Mycology, Radboud University Medical Center, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Sybren de Hoog
- Center of Expertise in Mycology, Radboud University Medical Center, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Xiaofang Li
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, 210042, China
- Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, 210042, China
| | - Xiaodong She
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, 210042, China
- Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, 210042, China
| | - Weida Liu
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, 210042, China.
- Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, 210042, China.
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, 21166, China.
| | - Guanzhao Liang
- Department of Medical Mycology, Institute of Dermatology and Hospital for Skin Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Nanjing, 210042, China.
- Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing, 210042, China.
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Hiruma J, Nojo H, Tsuchihashi H, Noguchi H, Hiruma M, Harada K, Kano R. Internal Transcribed Spacer Region Typing of Trichophyton interdigitale Isolated from Japanese Patients. Mycopathologia 2023; 188:395-399. [PMID: 37347367 DOI: 10.1007/s11046-023-00763-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/09/2023] [Indexed: 06/23/2023]
Abstract
Trichophyton interdigitale, an anthropophilic species, is one of the main causative agents of tinea unguium and tinea pedis. T. interdigitale and the zoophilic species T. mentagrophytes are morphologically and physiologically very similar. Isolates of the T. interdigitale/T. mentagrophytes complex from around the world have been classified into more than 10 internal transcribed spacer (ITS) genotypes. In this study, we isolated T. interdigitale from Japanese patients and investigated which ITS type was more common. The ITS regions of 29 clinical isolates of T. interdigitale and one clinical isolate of T. mentagrophytes were sequenced. The phylogenetic analysis of the ITS region sequences revealed that the 29 isolates of T. interdigitale belong to ITS type II of T. interdigitale. The one clinical isolate of T. mentagrophytes was in the same cluster with ITS type II* of T. mentagrophytes. One terbinafine-resistant strain of T. interdigitale also belonged to ITS type II of T. interdigitale.
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Affiliation(s)
- Junichiro Hiruma
- Teikyo University Institute of Medical Mycology (TIMM), 359 Otsuka, Hachioji, Tokyo, 192-0395, Japan
- Department of Dermatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Honoka Nojo
- Teikyo University Institute of Medical Mycology (TIMM), 359 Otsuka, Hachioji, Tokyo, 192-0395, Japan
| | - Hitoshi Tsuchihashi
- Department of Dermatology, Juntendo University School of Medicine, 3-1-3, Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Hiromitsu Noguchi
- Noguchi Dermatology Clinic, 964-1, Uejima, Kashima-Machi, Kamimashiki-gun, Kumamoto, 861-3106, Japan
| | - Masataro Hiruma
- Ochanomizu Institute for Medical Mycology and Allergology, 403, 2-48-8 Ikebukuro, Toshima-ku, Tokyo, 171-0014, Japan
| | - Kazutoshi Harada
- Department of Dermatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Rui Kano
- Teikyo University Institute of Medical Mycology (TIMM), 359 Otsuka, Hachioji, Tokyo, 192-0395, Japan.
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44
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Russo G, Toutous Trellu L, Fontao L, Ninet B. Towards an Early Clinical and Biological Resistance Detection in Dermatophytosis: About 2 Cases of Trichophyton indotineae. J Fungi (Basel) 2023; 9:733. [PMID: 37504722 PMCID: PMC10381761 DOI: 10.3390/jof9070733] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 06/03/2023] [Accepted: 06/19/2023] [Indexed: 07/29/2023] Open
Abstract
Trichophyton indotineae causes resistant dermatophytosis to terbinafine. The global spread of terbinafine-resistant Trichophyton indotineae strains with mutations in the squalene epoxidase gene is a major issue. This emerging species is now more frequently isolated in Europe and we report here two cases of T. indotineae tinea corporis in Switzerland, one with in vitro resistance to terbinafine and a second with in vitro susceptibility but a clinical resistance. Mycology isolation from cultures and sequencing ITS gene were used to confirm T. indotineae infection. In vitro antifungal susceptibility was tested in a microplate with a colorimetric detection of fungal viability for the determination of the minimal inhibitory concentration (MIC). Facing these emerging resistances and since there are a limited number of antifungal agents available to treat dermatophytosis, the early detection of terbinafine resistance should be a prerequisite in the management of T. indotineae infections.
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Affiliation(s)
- Giuseppe Russo
- Division of Dermatology and Venereology, University Hospital of Geneva, CH-1205 Geneva, Switzerland
| | - Laurence Toutous Trellu
- Division of Dermatology and Venereology, University Hospital of Geneva, CH-1205 Geneva, Switzerland
| | - Lionel Fontao
- Division of Dermatology and Venereology, University Hospital of Geneva, CH-1205 Geneva, Switzerland
- Laboratory of Dermatology, Division of Laboratory Medicine, University Hospital of Geneva, CH-1205 Geneva, Switzerland
| | - Béatrice Ninet
- Laboratory of Dermatology, Division of Laboratory Medicine, University Hospital of Geneva, CH-1205 Geneva, Switzerland
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45
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Nikkholgh S, Pchelin IM, Zarei Mahmoudabadi A, Shabanzadeh-Bardar M, Gharaghani M, Sharifzadeh A, Mokhtari Hooyeh M, Mohammadi R, Nouripour-Sisakht S, Katiraee F, Rezaei-Matehkolaei A. Sheep serve as a reservoir of Trichophyton mentagrophytes genotype V infection. Med Mycol 2023; 61:myad066. [PMID: 37429606 DOI: 10.1093/mmy/myad066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/29/2023] [Accepted: 07/07/2023] [Indexed: 07/12/2023] Open
Abstract
Human infections by Trichophyton mentagrophytes occur mainly due to contact with diseased animals. In Iran, T. mentagrophytes genotype V is the most prevalent variant of the fungus. We aimed to determine the animal reservoir of T. mentagrophytes genotype V infection. The study was done on a total of 577 dermatophyte strains obtained from animals with signs of dermatophytosis and human patients. The list of extensively sampled animals included sheep, cows, cats and dogs. For human cases, epidemiological data were collected. All dermatophyte isolates from animals along with 70 human isolates morphologically similar to T. verrucosum and T. mentagrophytes genotype V were identified by rDNA internal transcribed spacer region restriction fragment length polymorphism analysis and DNA sequencing. A total of 334 animal dermatophyte strains were identified as Microsporum canis, T. mentagrophytes genotype V, T. verrucosum, Nannizzia gypsea, T. mentagrophytes genotype II*, T. mentagrophytes genotype VII, T. quinckeanum, and N. fulva. All clinical isolates identified as T. mentagrophytes genotype V originated from skin and scalp infections. Almost all veterinary isolates of T. mentagrophytes genotype V were cultured from sheep, but epidemiological data on animal-to-human transmission of T. mentagrophytes genotype V infection were limited and we found evidence in favor of interhuman transmission. In Iran, sheep maintain T. mentagrophytes genotype V population and therefore serve as animal reservoir of respective infections. The role of sheep as the source of human dermatophytosis due to T. mentagrophytes genotype V isolates is yet to be proven.
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Affiliation(s)
- Sivash Nikkholgh
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 61357-15794, Iran
| | - Ivan M Pchelin
- Department of Molecular Microbiology, Institute of Experimental Medicine, Saint Petersburg 197022, Russia
| | - Ali Zarei Mahmoudabadi
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 61357-15794, Iran
| | - Mahbubeh Shabanzadeh-Bardar
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 61357-15794, Iran
| | - Maral Gharaghani
- Medicinal Plants Research Center, Yasuj University of Medical Sciences, Yasuj 75919-94799, Iran
| | - Aghil Sharifzadeh
- Department of Microbiology and Immunology, Faculty of Veterinary Medicine, University of Tehran, Tehran 14199-63114, Iran
| | - Mohammadreza Mokhtari Hooyeh
- Department of Microbiology and Immunology, Faculty of Veterinary Medicine, University of Tehran, Tehran 14199-63114, Iran
| | - Rasoul Mohammadi
- Department of Medical Parasitology and Mycology, School of Medicine, Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan 81746-73461, Iran
| | | | - Farzad Katiraee
- Department of Pathobiology, Faculty of Veterinary Medicine, University of Tabriz, Tabriz 51666-16471, Iran
| | - Ali Rezaei-Matehkolaei
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 61357-15794, Iran
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Chanyachailert P, Leeyaphan C, Bunyaratavej S. Cutaneous Fungal Infections Caused by Dermatophytes and Non-Dermatophytes: An Updated Comprehensive Review of Epidemiology, Clinical Presentations, and Diagnostic Testing. J Fungi (Basel) 2023; 9:669. [PMID: 37367605 DOI: 10.3390/jof9060669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 05/31/2023] [Accepted: 06/10/2023] [Indexed: 06/28/2023] Open
Abstract
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.
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Affiliation(s)
- Pattriya Chanyachailert
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok 10700, Thailand
| | - Charussri Leeyaphan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok 10700, Thailand
| | - Sumanas Bunyaratavej
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok 10700, Thailand
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Caplan AS, Chaturvedi S, Zhu Y, Todd GC, Yin L, Lopez A, Travis L, Smith DJ, Chiller T, Lockhart SR, Alroy KA, Greendyke WG, Gold JAW. Notes from the Field: First Reported U.S. Cases of Tinea Caused by Trichophyton indotineae - New York City, December 2021-March 2023. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2023; 72:536-537. [PMID: 37167192 DOI: 10.15585/mmwr.mm7219a4] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
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48
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Shenoy M, Poojari S, Rengasamy M, Vedmurthy M, Barua S, Dhoot D, Barkate H. Management of Dermatophytosis: Real-World Indian Perspective. Indian Dermatol Online J 2023; 14:347-356. [PMID: 37266073 PMCID: PMC10231727 DOI: 10.4103/idoj.idoj_643_22] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/04/2023] [Accepted: 01/21/2023] [Indexed: 06/03/2023] Open
Abstract
Background In spite of the availability of multiple consensus statements on dermatophytosis management, different treatment approaches have been experienced in India and require more scrutiny to further update guidelines and improve patient care. Aim To determine the different approaches in dermatophytosis diagnosis and management among dermatologists in India. Materials and Methods A web-based questionnaire was created and validated by five panelists with experience of >15 years in dermatophytosis and then circulated to about 2,000 dermatologists in India in September 2021 for a real-world management scenario. Results Out of 2,000 dermatologists, 459 responded. About half of the dermatologists (51%) routinely conduct potassium hydroxide mount (KOH) at the initiation of therapy. Similarly, about 53% of dermatologists initiate the management of dermatophytosis with combination therapy in all types of dermatophytosis for 4-6 weeks depending upon severity. Different types of combinations are being practiced, such as either two systemic and one topical, two topicals and one systemic, but the combination of one systemic and one topical (69%) is the most commonly practiced. Itraconazole (100 mg twice a day) and luliconazole are the most commonly prescribed antifungal medications. In case of non-response to routine dose of systemic anti-fungals, about 72% of dermatologists up dose them. Most of them continue these drugs for additional 1-2 weeks after clearance of the disease. Additionally, keratolytics and moisturizers are commonly prescribed. Additionally, 62% advise liver function tests (LFTs) at the initiation of therapy, whereas 72% advise monitoring adverse effects due to systemic antifungal drugs during treatment. Conclusion Combination therapy stood out as the need of the hour in the current menace of dermatophytosis with timely monitoring of laboratory tests for adverse events due to the use of systemic antifungals for a longer duration.
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Affiliation(s)
- Manjunath Shenoy
- Department of Dermatology, Yenepoya Medical College, Mangalore, Karnataka, India
| | - Shital Poojari
- Department of Dermatology, K J Somaiya Medical College, Mumbai, Maharashtra, India
| | - Madhu Rengasamy
- Department of Dermatology, Venerology and Leprosy, Madras Medical College, Chennai, Tamil Nadu, India
| | - Maya Vedmurthy
- Consultant Dermatologist, Apollo Hospital, Chennai, Tamil Nadu, India
| | - Shyamanta Barua
- Department of Dermatology, Assam Medical College and Hospital, Dibrugarh, Assam, India
| | - Dhiraj Dhoot
- Department of Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
| | - Hanmant Barkate
- Department of Global Medical Affairs, Glenmark Pharmaceuticals Ltd, Mumbai, Maharashtra, India
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49
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Haghani I, Akhtari J, Yahyazadeh Z, Espahbodi A, Kermani F, Javidnia J, Hedayati MT, Shokohi T, Badali H, Rezaei-Matehkolaei A, Aghili SR, Al-Rawahi A, Al-Harrasi A, Abastabar M, Al-Hatmi AMS. Potential Inhibitory Effect of Miltefosine against Terbinafine-Resistant Trichophyton indotineae. Pathogens 2023; 12:pathogens12040606. [PMID: 37111492 PMCID: PMC10146699 DOI: 10.3390/pathogens12040606] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 04/29/2023] Open
Abstract
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.
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Affiliation(s)
- Iman Haghani
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Javad Akhtari
- Immunogenetics Research Center, Department of Medical Nanotechnology, School of Advanced Technologies in Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Zahra Yahyazadeh
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Amirreza Espahbodi
- Student Research Committee, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Firoozeh Kermani
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Javad Javidnia
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Mohammad Taghi Hedayati
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Tahereh Shokohi
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Hamid Badali
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Molecular Microbiology & Immunology, South Texas Center for Emerging Infectious Diseases, The University of Texas at San Antonio, San Antonio, TX 78249-0600, USA
| | - Ali Rezaei-Matehkolaei
- Department of Medical Mycology, School of Medicine, Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz 61357-15794, Iran
| | - Seyed Reza Aghili
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Ahmed Al-Rawahi
- Natural & Medical Sciences Research Centre, University of Nizwa, Nizwa 616, Oman
| | - Ahmed Al-Harrasi
- Natural & Medical Sciences Research Centre, University of Nizwa, Nizwa 616, Oman
| | - Mahdi Abastabar
- Invasive Fungi Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
- Department of Medical Mycology, School of Medicine, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Abdullah M S Al-Hatmi
- Natural & Medical Sciences Research Centre, University of Nizwa, Nizwa 616, Oman
- Center of Expertise in Mycology, Radboud University Medical Center/Canisius Wilhelmina Hospital, 6532 SZ Nijmegen, The Netherlands
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50
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Dermatophytic Biofilms: Characteristics, Significance and Treatment Approaches. J Fungi (Basel) 2023; 9:jof9020228. [PMID: 36836342 PMCID: PMC9960790 DOI: 10.3390/jof9020228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/29/2022] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
Microbes are found in the environment, possibly more often as biofilms than in planktonic forms. Biofilm formation has been described for several important fungal species. The presence of a dermatophytoma in a dermatophytic nail infection was the basis for the proposal that dermatophytes form biofilms as well. This could explain treatment failure and recurrent dermatophytic infections. Several investigators have performed in vitro and ex vivo experiments to study the formation of biofilms by dermatophytes and their properties. The nature of the biofilm structure itself contributes to fungal protection mechanisms against many harmful external agents, including antifungals. Thus, a different approach should be carried out regarding susceptibility testing and treatment. Concerning susceptibility testing, methods to evaluate either the inhibition of biofilm formation, or the ability to eradicate it, have been introduced. As for treatment, in addition to classical antifungal agents, some natural formulations, such as plant extracts or biosurfactants, and alternative approaches, such as photodynamic therapy, have been proposed. Studies that connect the results of the in vitro and ex vivo experimentation with clinical outcomes are required in order to verify the efficacy of these approaches in clinical practice.
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