Species distribution and antifungal susceptibility profiles of clinical and environmental Fusarium isolates from Mexico: A multicenter study

Fusarium spp. has emerged as an opportunistic etiological agent with clinical manifestations varying from localized infections to deep-seated systemic disease. It is also a phytopathogen of economic impact. There are few reports on the species diversity of this genus, and no comprehensive studies on the epidemiology nor the antifungal susceptibility of Fusarium in Mexico. The present multicentric study aims to shed light on the species distribution and antifungal susceptibility patterns of 116 strains of Fusarium isolated from clinical and environmental samples. Isolates were identified by standard phenotypic characteristics and by sequencing of the ITS (internal transcribed spacer), TEF1 (translation elongation factor 1-α), RPB2 (RNA polymerase II core subunit), and/or CAM1 (calmodulin) regions. Susceptibility tests were carried out against 15 antifungals of clinical and agricultural use. Regarding Fusarium distribution, we identified 27 species belonging to eight different species complexes. The most frequently isolated species for both clinical and environmental samples were F. falciforme (34%), F. oxysporum sensu stricto (12%), F. keratoplasticum (8%), and F. solani sensu stricto (8%). All Fusarium isolates showed minimum inhibitory concentrations (MICs) equal to or above the maximum concentration evaluated for fluconazole, 5-fluocytosine, caspofungin, micafungin, and anidulafungin. All isolates had a MIC of ≤16 µg/mL for voriconazole, with a mode of 4 µg/mL. F. verticillioides appeared to be the most susceptible to all antifungals tested.

Global guideline for the diagnosis and management of cryptococcosis: an initiative of the ECMM and ISHAM in cooperation with the ASM

Cryptococcosis is a major worldwide disseminated invasive fungal infection. Cryptococcosis, particularly in its most lethal manifestation of cryptococcal meningitis, accounts for substantial mortality and morbidity. The breadth of the clinical cryptococcosis syndromes, the different patient types at-risk and affected, and the vastly disparate resource settings where clinicians practice pose a complex array of challenges. Expert contributors from diverse regions of the world have collated data, reviewed the evidence, and provided insightful guideline recommendations for health practitioners across the globe. This guideline offers updated practical guidance and implementable recommendations on the clinical approaches, screening, diagnosis, management, and follow-up care of a patient with cryptococcosis and serves as a comprehensive synthesis of current evidence on cryptococcosis. This Review seeks to facilitate optimal clinical decision making on cryptococcosis and addresses the myriad of clinical complications by incorporating data from historical and contemporary clinical trials. This guideline is grounded on a set of core management principles, while acknowledging the practical challenges of antifungal access and resource limitations faced by many clinicians and patients. More than 70 societies internationally have endorsed the content, structure, evidence, recommendation, and pragmatic wisdom of this global cryptococcosis guideline to inform clinicians about the past, present, and future of care for a patient with cryptococcosis.

Review Article White Piedra: Review of 131 cases

This study analyzes the clinical characteristics of patients diagnosed with White Piedra through a systematic review of cases in the literature. A sample of 131 subjects was considered, of which 91.6% were female and most were 18 years of age or younger. Most studies were conducted in Brazil, followed by India, and Mexico. The most common etiologic agent found was Trichosporon spp (34.3%). Most affected patients were asymptomatic (94.6%) and predisposing factors included long hair, use of a hair band or hair accessories, and wet hair. The most common clinical feature was the presence of nodules. The evaluation of treatment effectiveness was hindered by the scarcity of follow-up information in the majority of the studies. It is concluded that White Piedra infection is more common in young women and is associated with hair-related factors.

Factors Associated with Candidiasis in Pemphigus Vulgaris Patients: Results from a Retrospective Study in Two Second-Care Level Hospitals in Mexico

BACKGROUND

Infections are a major cause of morbidity and mortality in patients with pemphigus vulgaris (PV). One of the most common infections in these patients is candidiasis. This is probably due to the use of systemic immunosuppressants, including oral and intravenous corticosteroids, mainly in megadoses (pulse therapy), although it is unknown if there are other associated factors, in addition to immunosuppressive treatment. We determine the factors associated with candidiasis in PV patients in two second-care level hospitals in Mexico.

METHODS

We reviewed 100 cases with PV. Cases were randomly selected from the databases of two second-care level hospitals between January 2010 and December 2019 (10 years). The primary endpoint was the incidence of candidiasis in patients with PV.

RESULTS

One hundred patients with PV were enrolled in this retrospective study. Candidiasis was observed in 79 patients (79%). A maximum corticosteroid dose of 55 mg/day during the last year (p = 0.001) and a higher neutrophil/lymphocyte ratio were associated with candidiasis in patients with PV (p = 0.001).

CONCLUSION

Risk factors favoring candidiasis in patients with PV are not only related to the use of corticosteroids, but also to demographic factors, the activity of the disease, and the systemic inflammation associated with autoimmunity.

Necrotizing pneumonia due to Saprochaete capitata in a patient with diabetes mellitus. Case report

Saprochaete capitata is a yeast-like fungus of the Dipodascaceae family, capable of colonizing the skin and the respiratory and gastrointestinal tracts. We present a 56-year-old man with diabetes mellitus who was admitted to the hospital presenting with fever, cough and hemoptysis. The diagnosis of necrotizing pneumonia was made by direct microscopy of the bronchoalveolar lavage fluid showed and Saprochaete capitata was identified by Matrix-Assisted Laser Desorption/Ionization Time-Of-Flight (MALDI-TOF MS®). Treatment consisted of itraconazole 200 mg every 12 hours orally for 30 days, leading to clinical and radiological improvement. Saprochaete capitata infection is a rare cause of pulmonary mycoses.

First case report of tinea corporis caused by Trichophyton indotineae in Latin America

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.

An Overview of Trichobacteriosis (Trichomycosis): An Underdiagnosed Disease

Trichobacteriosis (trichomycosis) is an asymptomatic infection at the axillary hair level caused by a bacterium of Corynebacterium spp. The aim of this study is to identify the clinical, epidemiological, and microbiological characteristics of previously reported cases. A review was conducted including the cases of trichomycosis (trichobacteriosis) reported in the PubMed database up to June 2023. Twenty-nine articles were included, involving 365 patients in total. A higher incidence was observed in men, representing 94% of the cases, most of which were in the age range of 20-50 years. The most frequently affected clinical topography was the axillar (90% of the cases). Most of the patients presented change in hair texture and bromhidrosis, some other frequent clinical manifestations were hyperhidrosis, hair color change, and cromhidrosis; 6% of the patients were asymptomatic. The etiological agent most frequently identified was Corynebacterium spp., the flavescens variety being the most prevalent. The most common form of treatment was shaving and topical clindamycin. In conclusion, trichobacteriosis is an infection that most frequently affects men at the axillary level; it manifests clinically with few symptoms and usually has a good response to treatment.

Mixed oral candidiasis in type 2 diabetic patients: Identification and spectrum of sensitivity

Introduction

Patients with type 2 diabetes mellitus are susceptible to acquire Candida spp. infections, sometimes involving more than one species. The resistance of some species to antimycotic agents can cause treatment failure.

Objectives

To determine the frequency and clinical varieties of mixed oral candidiasis in patients with type 2 diabetes mellitus, the involved species, and its sensitivity spectra when exposed to antifungals used as candidiasis treatment.

Material and methods

We developed an analytical cross-sectional study with 72 patients with type 2 diabetes mellitus with hyperglycemia (HbA1C ≥ 7%) and an oral candidiasis diagnosis. The causal species of oral candidiasis were identified through microbiological techniques, and sensitivity tests were carried out using the diffusion method in a plate with strips (E-test ®).

Results

We included 72 patients in the study, 32 (44%) males and 40 (56%) females. Patients were divided into three age groups: young adults (17%), adults (74%), and older adults (9%). The mean age of the patients was 51 years. No significant differences were found between mixed oral candidiasis and groups (sex and age), or between mixed oral candidiasis and gender, glycosylated hemoglobin level (HbA1C), antihyperglycemic treatment, or type 2 diabetes mellitus time of diagnosis. We found a correlation between the adult group and development of mixed or simple oral candidiasis. The results showed eight (13%) cases of mixed oral candidiasis: seven with a coinfection of two species and one with a coinfection of three species. The identified species were Candida albicans, C. glabrata, C. dubliniensis, C. kefyr, C. tropicalis, and C. krusei. Most of these species presented sensitivity against ketoconazole and fluconazole, and higher resistance to itraconazole.

Conclusions

Mixed oral candidiasis occurs in approximately 10% of the patients with type 2 diabetes mellitus and its treatment can be ineffective when the etiological agent is not identified.

An update on the development of novel antifungal agents for eumycetoma

Eumycetoma, a chronic subcutaneous mycosis, responds poorly to the available antifungal treatments and patients often require extensive surgical resection or amputation of the affected limb. More effective treatments are needed for eumycetoma. This article will describe some of the approaches being used to develop and evaluate new treatments for eumycetoma, summarise the latest developments and discuss the challenges that lie ahead.

Diagnosis and Treatment of Pulmonary Coccidioidomycosis and Paracoccidioidomycosis

Coccidioidomycosis (CM) and paracoccidioidomycosis (PCM) are systemic mycoses that are highly endemic in Latin America and have recently been included on the World Health Organization (WHO) Fungal Priority Pathogens List. Coccidioides immitis and Coccidioides posadasii are recognized as etiological agents of CM, with peculiarities in their geographic distribution. The genus Paracoccidioides now includes Paracoccidioides lutzii and the Paracoccidioides brasiliensis complex, which encompasses four phylogenetic species. In both diseases, pulmonary signs and symptoms are the main reasons for patients to seek medical assistance, and they are frequently misdiagnosed as tuberculosis. In this paper, we present a critical view of the strategies for diagnosis and clinical management of CM and PCM. Over the past few decades, there has been an increase in the number of reports of endemic fungal infections in areas previously thought to be "non-endemic" due to climate change and increased travel, among other factors. Learning to recognize their main epidemiological aspects and clinical manifestations is crucial so that clinicians can include them in the differential diagnosis of lung disease and avoid late diagnosis.

Physiological characterization and molecular identification of Saccharomycopsis fibuligera as the etiological agent of a skin lesion

Routine laboratory methods are not effective in identifying cryptic species resulting in the underreporting of infections caused by non-Candida yeasts. This paper presents the physiological characteristics and antifungal susceptibility of Saccharomycopsis fibuligera 12-771, isolated from a tinea-like lesion. Isolate 12-771 was identified by ITS and D1/D2 analysis as S. fibuligera. The isolate presented an auxonogram profile similar to Candida utilis, as well as protease, esterase and hemolysin activity. MICs were of 0.25 ​μg/mL for amphotericin B, 1-2 ​μg/mL for echinocandins, and 16 ​μg/mL for fluconazole. This work represents the first record in America of S. fibuligera as an infectious agent.

Diagnostics to support mycetoma management-Development of two target product profiles

OBJECTIVE

Mycetoma is a neglected tropical disease caused by more than 70 different microorganisms and identified by the WHO as one of the high-priority diseases for developing diagnostic tests. To ensure the production of diagnostic assays for use by clinical staff in endemic regions, target product profiles (TPPs) were designed.

METHODS

We describe the development of two TPPs: one for a diagnostic test able to identify the causative agent of mycetoma and another that would determine when treatment could be stopped. The TPPs were developed by considering product use, design, performance, product configuration and costs.

RESULTS

Version 1.0 TPPs for two uses were posted by WHO for a 1-month online public consultation on 25 October 2021, and the final TPP was posted online on 5 May 2022.

CONCLUSION

A major difficulty encountered in developing both TPPs was the large number of agents able to cause mycetoma and the lack of specific biomarkers for most of them.

Encapsulated eumycetoma caused by Biatriospora mackinnonii

Eumycetoma is a chronic infection due to filamentous fungi. Herein, we report a case of eumycetoma presenting as a subcutaneous encapsulated lesion on the right leg with no previous traumatic implantation. From microscopic morphological characteristics and molecular analysis, the pathogenic fungal species were identified as Biatriospora mackinnonii. Surgical excision of the entire lesion was performed to reduce the fungal load and improve antifungal therapy response.

Current situation of endemic mycosis in the Americas and the Caribbean: Proceedings of the first international meeting on endemic mycoses of the Americas (IMEMA)

BACKGROUND

The Americas are home to biologically and clinically diverse endemic fungi, including Blastomyces, Coccidioides, Emergomyces, Histoplasma, Paracoccidioides and Sporothrix. In endemic areas with high risk of infection, these fungal pathogens represent an important public health problem.

OBJECTIVES

This report aims to summarise the main findings of the regional analysis carried out on the status of the endemic mycoses of the Americas, done at the first International Meeting on Endemic Mycoses of the Americas (IMEMA).

METHODS

A regional analysis for the Americas was done, the 27 territories were grouped into nine regions. A SWOT analysis was done.

RESULTS

All territories reported availability of microscopy. Seventy percent of territories reported antibody testing, 67% of territories reported availability of Histoplasma antigen testing. None of the territories reported the use of (1-3)-β-d-glucan. Fifty two percent of territories reported the availability of PCR testing in reference centres (mostly for histoplasmosis). Most of the territories reported access to medications such as trimethoprim-sulfamethoxazole, itraconazole, voriconazole and amphotericin B (AMB) deoxycholate. Many countries had limited access to liposomal formulation of AMB and newer azoles, such as posaconazole and isavuconazole. Surveillance of these fungal diseases was minimal.

CONCLUSIONS

A consensus emerged among meeting participants, this group concluded that endemic mycoses are neglected diseases, and due to their severity and lack of resources, the improvement of diagnosis, treatment and surveillance is needed.

S6.4c Primary cutaneous implantation coccidioidomycosis

S6.4 One health approach for endemic mycoes in the Americas, September 22, 2022, 4:45 PM - 6:15 PM

 

Objective

To present a series of cases of primary cutaneous coccidioidomycosis, to highlight this mycosis that can start as cutaneous implantation, after trauma, and to emphasize the classification criteria.

Methods

A series of cases of primary cutaneous coccidioidomycosis will be presented, all of them confirmed by mycological studies, fresh examinations, stains, and cultures, as well as their molecular identification; also confirmed by histopathology.

Results

A series of 22 cases of primary cutaneous coccidioidomycosis is presented, 16 (72.8%) in men, 6 (27.2%) in women. With an average age of 35.2 years, with the lowest case in a 14-year-old child and the highest at 72 years. All from rural and endemic areas. A total of 11 (50%) with fieldwork and the rest due to various injuries. The etiological agent was isolated in all of them: Coccidiodes posadasii in 16 (72.8%), C. immits in 3 and one by Coccidiodes sp. 20 cases were managed with itraconazole, with an average of 8 months and two more with a cycle of amphotericin B and subsequent itraconazole. Clinical and mycological cure was obtained in all.

Discussion

Primary cutaneous coccidioidomycosis, is considered an implantation mycosis, similar to other endemic ones, it occurs between 2%-10% of cases. It begins after trauma that inoculates the fungus, such as a primary chancre. To confirm that it is a primary form, Wilson's criteria must be met: the presence of skin trauma, regional lymphadenopathy, no evidence of pulmonary involvement, positive intradermal reaction, and low antibody titers. It may present auto involution and in immunosuppressed patients, it can spread.

Conclusion

The initial cutaneous form of coccidioidomycosis is rare, usually seen in patients living in endemic areas, and usually present in patients with rural occupations. It has a variety of clinical forms, being confused with many diseases. Its diagnosis is simple, being the biopsy the most used, and it must be confirmed by mycological tests. It has a good prognosis and its main management is with itraconazole.

S6.2d Dermatophytosis due to Trichophyton erinacei caused by contact with African hedgehogs as family pets

S6.2 Resurgence of dermatophytic infections, September 22, 2022, 4:45 PM - 6:15 PM

 

Objective

To present a series of cases of various types of dermatophytosis caused by Trichophyton erinacei, caused by contact with African hedgehogs.

Methods

Patients with clinical suspicion of ringworm caused by T. erinacei were included in the study. Each patient underwent a mycological study, with direct examinations (KOH), cultures in Sabouraud dextrose agar medium with and without antibiotics. With the cultures obtained, molecular identification was made using the PCR technique and Matrix Assisted Laser Desorption Ionization Time of Flight (MALDI-TOF) proteomics. Once confirmed, the patients were given treatment and follow-up. When the pets (hedgehogs) were accessible, they were cultured with a cytobrush and the quills removed.

Results

In a period of 3.5 years, 16 verified cases were incorporated, 13 were females (72%) and 3 males (18%), the average age was 18.2 years, with the smallest case being 8 years old and the oldest 45 years old. The tineas manifested as follows: tinea manus 11 cases (68.7%); 2 respective cases of tinea corporis and tinea capitis (18.1 respectively) and one case of Majocchi's granuloma. The average evolution was 1.5 months with the case older than 3 months and the younger 15 days. All cases were given terbinafine at variable times and doses (according to weight and age) and clinical and mycological cure was obtained.

Discussion

Tineas can have epidemiological changes that are favored by a variety of factors, in general, pet ringworms are due to common domestic animals such as dogs and cats. Due to changing fashions, children and adolescents in recent years have changed pets such as hamsters, and recently hedgehogs, especially African variety (Atelerix albiventris) the latter may have T. erinacei as part of their skin microbiota, a similar dermatophyte or that was part of the T. mentagrophyes complex, in general of low virulence, however, its antigenic variants are little recognized by humans, which makes them present in a very inflammatory form, particularly in the hands, due to the handling of the animal, as well as the deeper inoculation (in the dermis) by the spikes left by the inoculum. So, they can generate deep tineas such as Majocchi's granuloma. In general, they respond well to systemic antifungals such as terbinafine and itraconazole, and sometimes the use of topical or systemic steroids is necessary.

Conclusions

This series of cases is a good example of how a change of habits when having pets can introduce new etiological agents that are poorly recognized antigenically, which give rise to more inflammatory and sometimes profound tineas.

Evaluation of the synergistic antifungal activity of micafungin and voriconazole plus sertraline against Candida auris

Candida auris is an emerging global public health threat. It is an opportunistic yeast that usually affects critically ill patients in healthcare settings and is characterized by reduced susceptibility to multiple antifungal classes. Combination therapy with antifungals and repurposed drugs is a feasible alternative to overcome this problem. The aim of this study was to examine the in vitro interactions and potential synergy of micafungin (MFG) and voriconazole (VRC) plus the antidepressant sertraline (SRT) against clinical isolates of C. auris. Conventional antifungal testing was first performed with the three drugs according to the CLSI methodology. Drug interactions were determined by the checkerboard microdilution assay using the fractional inhibitory concentration (FIC) index. Synergistic interactions were noted with the combination of MFG and SRT plus VRC with FIC values of 0.37 to 0.49 for some strains. Indifferent interactions were observed when MFG was combined with SRT with just one exception (FIC 0.53). No antagonism was observed for any combination. The combination of VRC with MCF or SRT may be relevant for treating C. auris infections.

Eumycetoma Causative Agents are Inhibited in vitro by Luliconazole, Lanoconazole and Ravuconazole

Introduction

Eumycetoma is a subcutaneous mutilating disease that can be caused by many different fungi. Current treatment consists of prolonged itraconazole administration in combination with surgery. In many centres, due to their slow growth rate, the treatment for eumycetoma is often started before the causative agent is identified. This harbours the risk that the causative fungus is not susceptible to the given empirical therapy. In the open‐source drug program MycetOS, ravuconazole and luliconazole were promising antifungal agents that were able to inhibit the growth of Madurella mycetomatis, the most common causative agent of mycetoma. However, it is currently not known whether these drugs inhibit the growth of other eumycetoma causative agents.

Materials and methods

Here, we determined the in vitro activity of luliconazole, lanoconazole and ravuconazole against commonly encountered eumycetoma causative agents. MICs were determined for lanoconazole, luliconazole and ravuconazole against 37 fungal isolates which included Madurella species, Falciformispora senegalensis, Medicopsis romeroi and Trematosphaeria grisea and compared to those of itraconazole.

Results

Ravuconazole, luliconazole and lanoconazole showed high activity against all eumycetoma causative agents tested with median minimal inhibitory concentrations (MICs) ranging from 0.008–2 µg/ml, 0.001–0.064 µg/ml and 0.001–0.064 µg/ml, respectively. Even Ma. fahalii and Me. romeroi, which are not inhibited in growth by itraconazole at a concentration of 4 µg/ml, were inhibited by these azoles.

Conclusion

The commonly encountered eumycetoma causative agents are inhibited by lanoconazole, luliconazole and ravuconazole. These drugs are promising candidates for further evaluation as potential treatment for eumycetoma.

Screening the pandemic response box identified benzimidazole carbamates, Olorofim and ravuconazole as promising drug candidates for the treatment of eumycetoma

Eumycetoma is a chronic subcutaneous neglected tropical disease that can be caused by more than 40 different fungal causative agents. The most common causative agents produce black grains and belong to the fungal orders Sordariales and Pleosporales. The current antifungal agents used to treat eumycetoma are itraconazole or terbinafine, however, their cure rates are low. To find novel drugs for eumycetoma, we screened 400 diverse drug-like molecules from the Pandemic Response Box against common eumycetoma causative agents as part of the Open Source Mycetoma initiative (MycetOS). 26 compounds were able to inhibit the growth of Madurella mycetomatis, Madurella pseudomycetomatis and Madurella tropicana, 26 compounds inhibited Falciformispora senegalensis and seven inhibited growth of Medicopsis romeroi in vitro. Four compounds were able to inhibit the growth of all five species of fungi tested. They are the benzimidazole carbamates fenbendazole and carbendazim, the 8-aminoquinolone derivative tafenoquine and MMV1578570. Minimal inhibitory concentrations were then determined for the compounds active against M. mycetomatis. Compounds showing potent activity in vitro were further tested in vivo. Fenbendazole, MMV1782387, ravuconazole and olorofim were able to significantly prolong Galleria mellonella larvae survival and are promising candidates to explore in mycetoma treatment and to also serve as scaffolds for medicinal chemistry optimisation in the search for novel antifungals to treat eumycetoma.

The emergence of COVID-19 associated mucormycosis: a review of cases from 18 countries

Reports of COVID-19-associated mucormycosis have been increasing in frequency since early 2021, particularly among patients with uncontrolled diabetes. Patients with diabetes and hyperglycaemia often have an inflammatory state that could be potentiated by the activation of antiviral immunity to SARS-CoV2, which might favour secondary infections. In this Review, we analysed 80 published and unpublished cases of COVID-19-associated mucormycosis. Uncontrolled diabetes, as well as systemic corticosteroid treatment, were present in most patients with COVID-19-associated mucormycosis, and rhino-orbital cerebral mucormycosis was the most frequent disease. Mortality was high at 49%, which was particularly due to patients with pulmonary or disseminated mucormycosis or cerebral involvement. Furthermore, a substantial proportion of patients who survived had life-changing morbidities (eg, loss of vision in 46% of survivors). Our Review indicates that COVID-19-associated mucormycosis is associated with high morbidity and mortality. Diagnosis of pulmonary mucormycosis is particularly challenging, and might be frequently missed in India.

Oral involvement in mucormycosis. A retrospective study of 55 cases

INTRODUCTION

Mucormycosis with oral involvement (OIM) is a rare opportunistic and lethal mycosis, which has increased in the last decade and is generally associated with uncontrolled diabetes and neutropenia.

METHODS

A retrospective study of cases with OIM was carried out in a tertiary-care center. Mycological and histological examinations were performed, and the isolated organisms were identified by morphology and molecular biology.

RESULTS

Fifty-five OIM patients were included, with a median age of 38 years (61.8% males). The most frequent associated disease was type-2 diabetes mellitus (61%), followed by neutropenia due to acute lymphocytic leukemia (27%). The main presentation was palatal and mandibular ulcers (92.7%) and, to a lesser extent, gingival and lingual necrosis. The diagnosis was established by mycological and histopathological studies. The most frequent fungi isolated was Rhizopus arrhizus (67.2%).

CONCLUSION

OIM is a rapidly progressing disease, therefore, an early diagnosis and the proper control of predisposing factors is necessary, and consequently, contributing to improve the outcome of mucormycosis.

Ocular Sporotrichosis

Sporotrichosis is a subacute or chronic mycosis predominant in tropical and subtropical regions. It is an infection of subcutaneous tissue caused by Sporothrix fungus species, but occasionally resulting in an extracutaneous condition, including osteoarticular, pulmonary, nervous central system, and ocular disease. Cases of ocular sporotrichosis are rare, but reports have been increasing in recent decades. Ocular infections usually occur in hyperendemic areas of sporotrichosis. For its classification, anatomic criteria are used. The clinical presentation is the infection in the ocular adnexal and intraocular infection. Ocular adnexa infections include palpebral, conjunctivitis, and infections of the lacrimal sac. Intraocular infection includes exogenous or endogenous endophthalmitis. Most infections in the ocular adnexal have been reported in Brazil, China and Peru, and intraocular infections are limited to the USA and Brazil. Diagnosis is performed from Sporothrix isolation in the mycological examination from ocular or skin samples. Both sporotrichosis in the ocular adnexa and intraocular infection can mimic several infectious and non-infectious medical conditions. Ocular adnexa infections are treated with potassium iodide and itraconazole. The intraocular infection is treated with amphotericin B. This review describes the clinical findings and epidemiological, diagnosis, and treatment of ocular sporotrichosis.

Unusual Inflammatory Tinea Infections: Majocchi's Granuloma and Deep/Systemic Dermatophytosis

PURPOSE OF REVIEW

Inflammatory tinea is an uncommon group of dermatophyte entities that predominantly cause fungal infection of the skin and hair. This review intends to present all of the available evidence regarding its epidemiology, etiopathogenesis, clinical features, and diagnostic methods as well as treatments recommended for various inflammatory tinea infections. This article provides a review of Majocchi's granuloma and dermatophytic or Hadida's disease.

RECENT FINDINGS

The new phylogenetic classification of dermatophytes includes nine genera, and those that affect humans are Trichophyton, Microsporum, Epidermophyton, and Nannizzia. Furthermore, molecular advancements have revealed impaired antifungal immune responses caused by inflammatory tinea, which are detailed in this article.

SUMMARY

The common denominator in these pathologies is the presence of impaired immune responses and, consequently, an impaired inflammatory response by the host. It is necessary to be familiar with these immunological characteristics in order to use the appropriate diagnostic methods and to provide adequate treatment.

Development and evaluation of a multiplex qPCR assay for rapid diagnostics of emerging sporotrichosis

Sporothrix schenckii and related species are the agents of human and animal sporotrichosis. Routine diagnoses using classical mycological approaches are unspecific due to overlapping phenotypes. As the frequency and prevalence of sporotrichosis increases worldwide, developing specific, sensitive and cost-effective diagnostic tools is essential to understand the distribution patterns, map-affected areas and promote specific public health strategies to mitigate future outbreaks. Polymorphisms among the β-tubulin gene were exploited to speciate S. brasiliensis, S. schenckii and S. globosa in a one-tube multiplex probe-based qPCR assay. A panel of 84 Sporothrix revealed 100% specificity (AUC = 1.000, 95% CI = 0.971-1.000, p < .0001) without cross-reacting with other medically relevant fungi, human, feline or murine DNA. Speciation via multiplex qPCR matched phylogenetic identification (Kappa = 1.0; 95% CI = 1.0-1.0; very good agreement), supporting its use as a reliable alternative to DNA sequencing. Remarkably, the lower limit of detection was 3 copies of the target for all species. As a proof of concept, we used swabs of wound exudate of 70 cats suspected of sporotrichosis to reveal an overwhelming occurrence of S. brasiliensis in 69 specimens (sensitivity = 98.57%; 95%CI: 92.3-100.0 and specificity = 100%; 95% CI = 78.2-100). In comparison to culture, qPCR showed a larger area under the curve (AUC = 0.993±0.007; 95% CI = 0.944-1.000; p < .0001; Youden's index = 0.9857), supporting that qPCR is an essential tool for accurately detect Sporothrix DNA directly from clinical samples, thus accelerating the diagnosis of sporotrichosis. Moreover, our multiplex qPCR system has the potential to increase diagnostic capacity in Sporothrix-affected areas, helping the local animal health agent or veterinarian to quickly identify and isolate new cases, which will likely benefit thousands of patients infected every year worldwide.

A new duplex PCR assay for the rapid screening of mating-type idiomorphs of pathogenic Sporothrix species

Sporothrix schenckii and allied species are thermodimorphic fungi widely distributed in nature which causes human and animal sporotrichosis, the most common subcutaneous mycosis globally. Sporotrichosis is acquired after a traumatic inoculation of soil or plant material contaminated with Sporothrix propagules or through bites and scratches from diseased cats. In Ascomycota, the master regulators of sex are MAT genes that lie in a single mating-type locus, in Sporothrix these are determined by two nonhomologous alleles, MAT1-1 and MAT1-2. We assessed the whole-genome sequences of medically relevant Sporothrix to develop a single-tube duplex PCR assay to screen S. brasiliensis, S. schenckii, S. globosa, and S. luriei idiomorphs (MAT1-1 or MAT1-2) and understand the distribution and incidence of mating-type strains from natural populations. Using our duplex PCR assay, a 673 bp amplicon (α-box protein) was consistently amplified from all MAT1-1 isolates, while a 291 bp fragment was only amplified from the isolates harboring MAT1-2 (HMG box). Molecular evidence suggests heterothallism (self-sterility) as the unique mating strategy among the species evaluated. The mating-type identity of 93 isolates revealed a nearly equal distribution (1:1 ratio) of mating type alleles within species but deviating between different outbreak areas. Remarkably, for S. brasiliensis in Rio de Janeiro, we report an overwhelming occurrence of MAT1-2 (1:13 ratio; χ² = 10.286, P = 0.0013) opposing the high prevalence MAT1-1 in the Rio Grande do Sul (10:1 ratio; χ² = 7.364, P = 0.0067). Therefore, the population structure of Sporothrix species refers from paucity to regular cycles of sexual recombination in most of the studied regions. Our PCR-based mating-type diagnostic assay is proposed here as an important marker to track the geographical expansion during the long-lasting outbreak of cat-transmitted sporotrichosis driven by S. brasiliensis.

Trends in the molecular epidemiology and population genetics of emerging Sporothrix species

Sporothrix (Ophiostomatales) comprises species that are pathogenic to humans and other mammals as well as environmental fungi. Developments in molecular phylogeny have changed our perceptions about the epidemiology, host-association, and virulence of Sporothrix. The classical agent of sporotrichosis, Sporothrix schenckii, now comprises several species nested in a clinical clade with S. brasiliensis, S. globosa, and S. luriei. To gain a more precise view of outbreaks dynamics, structure, and origin of genetic variation within and among populations of Sporothrix, we applied three sets of discriminatory AFLP markers (#3 EcoRI-GA/MseI-TT, #5 EcoRI-GA/MseI-AG, and #6 EcoRI-TA/MseI-AA) and mating-type analysis to a large collection of human, animal and environmental isolates spanning the major endemic areas. A total of 451 polymorphic loci were amplified in vitro from 188 samples, and revealed high polymorphism information content (PIC = 0.1765-0.2253), marker index (MI = 0.0001-0.0002), effective multiplex ratio (E = 15.1720-23.5591), resolving power (Rp = 26.1075-40.2795), discriminating power (D = 0.9766-0.9879), expected heterozygosity (H = 0.1957-0.2588), and mean heterozygosity (Havp  = 0.000007-0.000009), demonstrating the effectiveness of AFLP markers to speciate Sporothrix. Analysis using the program structure indicated three genetic clusters matching S. brasiliensis (population 1), S. schenckii (population 2), and S. globosa (population 3), with the presence of patterns of admixture amongst all populations. AMOVA revealed highly structured clusters (PhiPT = 0.458-0.484, P < 0.0001), with roughly equivalent genetic variability within (46-48 %) and between (52-54 %) populations. Heterothallism was the exclusive mating strategy, and the distributions of MAT1-1 or MAT1-2 idiomorphs were not significantly skewed (1:1 ratio) for S. schenckii (χ2 = 2.522; P = 0.1122), supporting random mating. In contrast, skewed distributions were found for S. globosa (χ2 = 9.529; P = 0.0020) with a predominance of MAT1-1 isolates, and regional differences were highlighted for S. brasiliensis with the overwhelming occurrence of MAT1-2 in Rio de Janeiro (χ2 = 14.222; P = 0.0002) and Pernambuco (χ2 = 7.364; P = 0.0067), in comparison to a higher prevalence of MAT1-1 in the Rio Grande do Sul (χ2 = 7.364; P = 0.0067). Epidemiological trends reveal the geographic expansion of cat-transmitted sporotrichosis due to S. brasiliensis via founder effect. These data support Rio de Janeiro as the centre of origin that has led to the spread of this disease to other regions in Brazil. Our ability to reconstruct the source, spread, and evolution of the ongoing outbreaks from molecular data provides high-quality information for decision-making aimed at mitigating the progression of the disease. Other uses include surveillance, rapid diagnosis, case connectivity, and guiding access to appropriate antifungal treatment.

Disseminated mucocutaneous trichosporonosis in a patient with histiocytic sarcoma

Trichosporon asahii is the causal agent of trichosporonosis. Patients with immunosuppression or hematological malignancies are at higher risk of infection. Skin and mucosal involvement appear as fast-growing papulonodular lesions and necrotic ulcers. Internal organ dissemination is lethal. Therapeutic success depends on the underlying disease. Here, the authors present the first case of disseminated mucocutaneous trichosporonosis in a patient with a post-mortem diagnosis of histiocytic sarcoma, a rare and aggressive haematolymphoid neoplasm. Regretfully, death occurred despite treatment with liposomal amphotericin B and supportive measures, showcasing the fatality of both diseases.

Thoracic actinomycetoma: a retrospective clinical-epidemiological study of 64 cases

BACKGROUND

Actinomycetoma is a chronic granulomatous infection that follows traumatic implantation. Thoracic actinomycetoma (TA) is rare and may lead to severe complications.

METHODS

A retrospective study of cases of TA diagnosed from 1985 to 2019 was carried out. Each case underwent direct examination, culture and biopsy.

RESULTS

Sixty-four cases (12.8%) were included, with a male predominance (84.3%); the main occupation was peasant farmer (71.8%) and the main site was the back (76.5%). Vertebral involvement was observed in 21.8% and pulmonary involvement in 7.8%. Nocardia brasiliensis was the main aetiological agent (53 cases, 74.5%).

CONCLUSIONS

TA is a poorly studied disease that can cause neurological and lung complications.

Species distribution and antifungal susceptibility patterns of Aspergillus isolates from clinical specimens and soil samples in Mexico

This study aimed to assess the species distribution and antifungal susceptibility patterns of 200 strains of Aspergillus isolated from clinical specimens (n = 146) and soil samples (n = 54) in Mexico. ITS, β-tubulin, and calmodulin DNA sequencing was performed for species identification. Broth microdilution susceptibility testing for amphotericin B, voriconazole, posaconazole, itraconazole, isavuconazole, anidulafungin, caspofungin, and micafungin was done according to CLSI for all strains. A. fumigatus was most frequently recovered from clinical specimens, while A. niger was commonly encountered in soil, both followed by A. flavus in second place. A total of 60 (30%) cryptic species were identified, with A. tubingensis and A. tamarii being the most commonly found. The decreased susceptibility to amphotericin B and azoles was 32% for both, and were mainly led by A. fumigatus, whereas this percentage decreased to 9% for caspofungin particularly in A. terreus. More than 75% of cryptic species were susceptible in vitro to all antifungals. Multi-azole decreased susceptibility was detected only in 7 isolates. Given that antifungal resistance in Aspergillus spp. is an increasing worldwide threat that causes major challenges in the clinical management of aspergillosis, these data highlight the need for continuous epidemiological surveillance of these pathogens for the implementation of locally-adequate treatment strategies.

Efficacy of imiquimod 5% cream as first-line management in cutaneous leishmaniasis caused by Leishmania mexicana

Cutaneous leishmaniasis (CL) involves several differential diagnoses as it lacks a gold standard diagnostic test. Its diagnosis is easier in endemic regions; however, many cases come from travelers to endemic areas. A 22-year-old patient, who had recently visited Oaxaca, Mexico, developed two asymptomatic ulcers weeks later on the left auricle and the nose. Leishmania mexicana was identified using polymerase chain reaction. The patient was treated with imiquimod 5% cream three times/week, providing favorable results after 12 weeks, without relapse 2 months after therapy. To our knowledge, this is the first case of CL due to L. mexicana effectively treated with imiquimod.

Clinical-therapeutic study on the efficacy and safety of thalidomide in the management of discoid lupus erythematosus. A single-centre, retrospective study

Thalidomide is a second-line treatment for discoid lupus erythematosus (DLE). The efficacy of this treatment, the minimum effective doses, and safety is poorly documented in the literature. The aim of the study was to determine the efficacy and tolerance of thalidomide as first or second line of therapy for discoid lupus erythematosus. We present a retrospective single-centre study of 68 patients with DLE treated with thalidomide from 2003 to 2019. The inclusion criteria were the presence of clinical lesions suggestive of DLE, confirmed by histological examination and direct immunofluorescence. The mean age at diagnosis was 37.45 years (range 18-65 years). Thalidomide was started an average of 2.25 years after the diagnosis of DLE, as second-line therapy in 85% of the cases (58 patients), and as first-line therapy in 10 patients (15%). Fifty-six patients improved with thalidomide (82%), 39 cases achieved complete remission and 17 partial remissions. The mean duration of follow-up with thalidomide was 8.4 months (range 3-25 months). Five patients discontinued thalidomide due to adverse events. The most frequent side effect was headache (23.5%). Thalidomide is effective and safe in DLE patients as first or second-line treatment with a good safety profile.

Deep mycoses and pseudomycoses of the foot: a single-center retrospective study of 160 cases, in a tertiary-care center in Mexico

BACKGROUND

Deep mycoses and pseudomycoses (DMP) may cause significant disability and even death; however, the reports regarding these diseases, mainly affecting the foot, are scarce.

OBJECTIVE

To describe the epidemiological, clinical, and diagnostic characteristics of DMP of the foot in 160 patients.

METHODS

A retrospective and observational study of DMP affecting the foot was carried out in a tertiary-care center in Mexico for 20 years (from January 2000 to December 2019). Cases with confirmatory microbiological studies were included; the identification of the isolated fungi was based on the forms of reproduction. For actinomycetes, morphological analysis in an automated system ATB Vitek® 1574 (Biomèrieux) was used. The fungi were identified by PCR, using several primers from the ITS regions and for actinomycetes in the 16S rRNA region. Data from histopathological studies were also collected.

RESULTS

One hundred and sixty proven cases of DMP of the foot were included. The cases were categorized into nine types of infections including mycetoma (actinomycetoma and eumycetoma) in 102 cases (63.7%); sporotrichosis in 21 cases (13.1%); chromoblastomycosis, 18 cases (11.2%); phaeohyphomycosis, 3 cases (1.8%); histoplasmosis, 12 cases (7.5%); coccidioidomycosis 2 cases (1.2%) and botryomycosis and nocardiosis with one case respectively (0.6%). Most cases developed after traumatic implantation (147 cases, 91.8%). One hundred fifteen cases (71.8%) were men. The evolution was chronic in 125 cases (78.2%); bone involvement was observed in 64 cases (40%). Parasitic forms were observed In 139 cases (86.8%). The isolation and identification of the etiological agents were confirmed in all cases.

CONCLUSION

The main DMP affecting the foot were infections due to traumatic implantation; most were endemic mycoses. The clinical characteristics and the evolution of the diseases are easily misdiagnosed, and thus, diagnostic tests are usually required.

Actinomycetoma by Actinomadura madurae: Clinical Characteristics and Treatment of 47 Cases

Context:

Mycetoma is a chronic, granulomatous disease caused by fungi (eumycetoma) or aerobic filamentous actinomycetes (actinomycetoma). Actinomadura madurae is one of the most frequent actinomycetes.

Aim:

The study aims to provide an update on clinical, diagnostic, therapeutic, and outcome data for patients with actinomycetoma in a single center in Mexico.

Settings and Design:

This was a retrospective study of 47 cases diagnosed with actinomycetoma.

Subjects and Methods:

The cases were selected from a total of 536 mycetoma obtained during 35 years (from 1985 to 2019). Clinical data were retrieved from the clinical records of our department. Microbiological data were obtained from our Mycology laboratory.

Statistical Analysis:

Frequencies and percentages were used for categorical variables. Normality was determined with the Kolmogorov–Smirnov test. We used means and medians to describe the variables.

Results:

Forty-seven patients with actinomycetoma were included; female:male ratio 1.9:1; median age 38 years. The foot was the most affected region in 76.5% of cases. The bone invasion was observed in 89%. The time between symptoms onset and diagnosis was 5.5 years. Grain detection by direct examination was positive in 95% of cases. The most commonly used, as well as the most effective treatment scheme was streptomycin + sulfamethoxazole-trimethoprim with dapsone. Sixty-three percent (30 patients) achieved clinical and mycological cure, and 10.6% (5 patients) had treatment failure.

Conclusions:

We highlight the importance of designing therapeutic strategies to standardize treatments and gain more experience to improve the care of these patients.

Tinea gladiatorum due to Trichophyton tonsurans in a school wrestling team in Mexico: A case series

Background and Purpose:

Tinea gladiatorum is a type of dermatophytosis that occurs in combat athletes, such as wrestlers and judo fighters, as a result of Trichophyton species. Herein, we aimed to present a small outbreak of tinea gladiatorum in a high school in Mexico.

Materials and Methods:

Seven individuals belonging to the school fighting team were mycologically studied with direct examinations and cultures. In four cases, T. tonsurans was isolated and identified by morphological and proteomic methods (Matrix-assisted laser desorption/ionization- time-of-flight mass spectrometry). Out of the four subjects, two cases had clinical lesions presented as tinea corporis, and two cases were healthy carriers. Trichophyton tonsurans was also isolated from one of the four training mats (25%). All positive patients were treated with systemic or topical antifungals and achieved clinical and mycological cure.

Conclusion:

We report the first outbreak of tinea gladiatorum caused by T. tonsurans among a group of high school wrestlers in Mexico.

Physiological characterization and molecular identification of some rare yeast species causing onychomycosis

INTRODUCTION

Onychomycosis are infections with a variety of etiological agents. Although dermatophytes are responsible for most infections, yeasts are gaining importance as agents of these pathologies. The use of antifungals has increased the incidence of what had been considered rare or novel pathogens. We reidentify three rare yeasts from a culture collection of onychomycosis agents by matrix-assisted laser desorption/ionization time of flight/mass spectrometry (MALDI-TOF/MS) and sequencing the internal transcribed spacer (ITS) regions or the intergenic spacer (IGS) 1 region of ribosomal DNA (rDNA), and present their enzymatic and antifungal susceptibility profiles.

MATERIAL AND METHODS

We performed a phenotypical characterization and molecular identification of five yeast isolates. We tested the urease, gelatinase, DNase, phospholipase, protease, and esterase activities, as well as the hemolytic activity. We evaluated the antifungal susceptibility to amphotericin B, fluconazole, anidulafungin and caspofungin.

RESULTS

Phenotypic methods could not identify the isolates. MALDI-TOF/MS was able to properly identify Candida duobushameulonii. The five isolates were successfully identified by sequence analysis as Candida duobushaemulonii, Meyerozyma caribbica and Cutaneotrichosporon dermatis. Candida duobushameulonii showed hemolytic, phospholipase, and protease activities. Meyerozyma caribbica was positive for gelatinase and protease activities. All antifungals exhibited minimum inhibitory concentrations (MICs) ≤2μg/mL against both species. The three isolates of Cutaneotrichosporon dermatis showed urease, DNase, and esterase activities, and resistance to echinocandins (MICs ≥8μg/mL), while amphotericin B and fluconazole exhibited low MICs against these isolates (0.50-2μg/mL).

DISCUSSION

Sequencing of the ITS or IGS1 regions of rDNA remains the best method for identifying cryptic species over other commercially available systems. More reports are needed to define the enzymatic and antifungal profiles for these species. This is the first report of Meyerozyma caribbica and Cutaneotrichosporon dermatis as etiological agents of onychomycosis.

Recent advances on mycotic keratitis caused by dematiaceous hyphomycetes

Dematiaceous hyphomycetes (DH) are darkly pigmented fungi ubiquitously found all over the world as plant pathogens and saprophytes, and many of the members of this group have emerged as opportunistic pathogens. These fungi are responsible for a wide variety of infections including mycotic keratitis, which is considered as one of the major causes of corneal blindness, particularly in tropical and subtropical countries with an annual global burden of about 1 000 000 patients. The infection is more common in workers working in an outdoor environment. Moreover, trauma is found to be the most important predisposing cause of mycotic keratitis. Considerable delay in diagnosis and scarcity of effective pharmacological drugs are the major factors responsible for increased morbidity and visual impairment. Considering the crucial role of DH in mycotic keratitis, in the present review, we have focused on major DH with special emphasis on their pathogenicity, diagnosis and treatment strategies.

Mucormycosis at a tertiary-care center in Mexico. A 35-year retrospective study of 214 cases

BACKGROUND

Mucormycosis is a rare, invasive disease associated with high mortality rates, produced by opportunistic pathogens related to the Mucorales order and characterised by a diverse range of clinical forms; acute rhino-orbital-cerebral and pulmonary symptoms are the most reported ones.

OBJECTIVES

To report the experience of mucormycosis observed in a tertiary-care hospital in Mexico for 35 years.

METHODS

This was a retrospective, descriptive and observational study on mucormycosis at a tertiary-care hospital in Mexico from January 1985 to December 2019. Demographic and clinical data and mycological and histopathological records were selected.

RESULTS

Two hundred fourteen proven cases of mucormycosis for 35 years at a tertiary-care hospital in Mexico were included. Most of the cases were male patients with a median age of 45 years. The two most associated underlying diseases were diabetes mellitus (76.6%) and haematologic malignancy (15.4%). The three primary clinical forms were as follows: rhino-orbito-cerebral (75.9%), cutaneous (8.41%) and pulmonary (7.47%) mucormycosis. The most isolated agents were Rhizopus arrhizus (58.4%) and Lichtheimia corymbifera (12.3%). The overall therapeutic response was 58.5%, and the best response was observed with amphotericin B deoxycholate and surgical debridement.

CONCLUSION

Mucormycosis is an emerging disease, and its incidence has increased at our hospital over the years. In this study, the rhino-cerebral clinical type was the most frequent in patients with uncontrolled diabetes; the main aetiological agent was R. arrhizus. Early diagnosis, control of the underlying disease and prompt management may increase the survival rate.

Subcutaneous Mycoses in Travelers

Purpose of Review

The increase in international travel in recent decades has contributed to the risk of acquiring diseases considered endemic to a region or country and the change in the epidemiology of these diseases. Endemic mycoses that may be acquired by travelers in the short or long term are endemic subcutaneous mycoses such as sporotrichosis and lobomycosis, while endemic systemic mycoses are a group of serious diseases including histoplasmosis and coccidioidomycosis. Herein, we review the current knowledge and highlight the most important aspects of these fungal infections in travelers.

Recent Findings

The most relevant advances in the study of these mycoses involve the epidemiological distribution; human mycoses can be fatal and there are few antifungal drugs available, increasing drug resistance, and a risk of emerging fungal diseases associated with climate change, as well as the increasing virulence, and the diagnostic strategies that may be limited in many countries.

Summary

Although endemic mycoses are relatively rare, they should be considered as potentially travel-related illnesses. A recent or late trip to an endemic country may guide the clinical suspicion, an early diagnosis, and the institution of effective therapy.

Mucormycosis with cutaneous involvement. A retrospective study of 115 cases at a tertiary care hospital in Mexico

BACKGROUND/OBJECTIVES

Cutaneous mucormycosis is an emerging opportunistic mycosis caused by Mucorales. It can be divided into primary caused by trauma and secondary by extension of rhino-cerebral and disseminated cases. The objective is to present a retrospective study of cases of mucormycosis with cutaneous involvement.

METHODS

A retrospective and descriptive study was carried out. Mucormycosis patients were included and divided into two groups: a) Primary Cutaneous and b) Secondary Cutaneous. Mycological tests were performed; the agents were identified by morphology and molecular studies (PCR and sequencing); some cases underwent histopathology. Clinical data and response to treatment were collected.

RESULTS

115 cases were included, 18 of primary, and 97 of secondary cutaneous mucormycosis. Primary cutaneous mucormycosis was most associated with adhesive bands (44.4%) and trauma from traffic accidents (33.3%). The principal clinical form was extensive and deep necrotic ulcers. Secondary cutaneous mucormycosis cases were rhino-cerebral with uncontrolled diabetes (81.4%) The most frequent clinical presentation was necrosis of the eyelid and the nose (65.9%). In both groups, the principal agent was Rhizopus arrhizus, 38.8% and 74.2% respectively. The most effective treatment was the combination of amphotericin B with surgical debridement. The clinical and mycological cure was achieved in 31.0% of primary cases, and 44.4% for secondary cases.

CONCLUSION

Primary cutaneous mucormycosis is caused by implantation of the Mucorales due to trauma or rupture of the cutaneous barrier-breach, and secondary cutaneous mucormycosis develops as part of the rhino-cerebral process. The response to treatment depends on the extension and depth, as well as the predisposing factors.

Oral involvement in mucormycosis. A retrospective study of 55 cases

INTRODUCTION

Mucormycosis with oral involvement (OIM) is a rare opportunistic and lethal mycosis, which has increased in the last decade and is generally associated with uncontrolled diabetes and neutropenia.

METHODS

A retrospective study of cases with OIM was carried out in a tertiary-care center. Mycological and histological examinations were performed, and the isolated organisms were identified by morphology and molecular biology.

RESULTS

Fifty-five OIM patients were included, with a median age of 38 years (61.8% males). The most frequent associated disease was type-2 diabetes mellitus (61%), followed by neutropenia due to acute lymphocytic leukemia (27%). The main presentation was palatal and mandibular ulcers (92.7%) and, to a lesser extent, gingival and lingual necrosis. The diagnosis was established by mycological and histopathological studies. The most frequent fungi isolated was Rhizopus arrhizus (67.2%).

CONCLUSION

OIM is a rapidly progressing disease, therefore, an early diagnosis and the proper control of predisposing factors is necessary, and consequently, contributing to improve the outcome of mucormycosis.

Endemic mycoses: epidemiology and diagnostic strategies

INTRODUCTION

The global frequency of endemic mycoses has considerably increased, mainly due to environmental changes, population growth in endemic areas, and the increase in HIV-related immunosuppressed status. Among the most frequent endemic mycoses are coccidioidomycosis in semi-desert climates, and paracoccidioidomycosis, and histoplasmosis in tropical climates. The inoculum can enter the host through the airway or directly through the skin. Lymphatic and hematogenous spread may involve the skin.

AREAS COVERED

In this article, we provide up-to-date epidemiological and diagnostic data on major (histoplasmosis, paracoccidioidomycosis, coccidioidomycosis, blastomycosis) and minor (talaromycosis, adiaspiromycosis, emergomycosis) endemic mycoses.

EXPERT OPINION

Endemic mycoses include diseases with a localized endemic area, and a few of them converge. These mycoses all have in common the airway involvement and can cause pulmonary symptoms following initial asymptomatic infection. Among the risk groups to acquire these mycoses are travelers from endemic areas, archeologists, speleologists, and immigrants. Promising and useful diagnostic tools have been developed in endemic mycoses; however, most of them are not standardized or available in low-income countries.