Abridged version of the AWMF guideline for the medical clinical diagnostics of indoor mould exposure: S2K Guideline of the German Society of Hygiene, Environmental Medicine and Preventive Medicine (GHUP) in collaboration with the German Association of Allergists (AeDA), the German Society of Dermatology (DDG), the German Society for Allergology and Clinical Immunology (DGAKI), the German Society for Occupational and Environmental Medicine (DGAUM), the German Society for Hospital Hygiene (DGKH), the German Society for Pneumology and Respiratory Medicine (DGP), the German Mycological Society (DMykG), the Society for Pediatric Allergology and Environmental Medicine (GPA), the German Federal Association of Pediatric Pneumology (BAPP), and the Austrian Society for Medical Mycology (ÖGMM)

This article is an abridged version of the AWMF mould guideline "Medical clinical diagnostics of indoor mould exposure" presented in April 2016 by the German Society of Hygiene, Environmental Medicine and Preventive Medicine (Gesellschaft für Hygiene, Umweltmedizin und Präventivmedizin, GHUP), in collaboration with the above-mentioned scientific medical societies, German and Austrian societies, medical associations and experts. Indoor mould growth is a potential health risk, even if a quantitative and/or causal relationship between the occurrence of individual mould species and health problems has yet to be established. Apart from allergic bronchopulmonary aspergillosis (ABPA) and mould-caused mycoses, only sufficient evidence for an association between moisture/mould damage and the following health effects has been established: allergic respiratory disease, asthma (manifestation, progression and exacerbation), allergic rhinitis, hypersensitivity pneumonitis (extrinsic allergic alveolitis), and increased likelihood of respiratory infections/bronchitis. In this context the sensitizing potential of moulds is obviously low compared to other environmental allergens. Recent studies show a comparatively low sensitizing prevalence of 3-10% in the general population across Europe. Limited or suspected evidence for an association exist with respect to mucous membrane irritation and atopic eczema (manifestation, progression and exacerbation). Inadequate or insufficient evidence for an association exist for chronic obstructive pulmonary disease, acute idiopathic pulmonary hemorrhage in children, rheumatism/arthritis, sarcoidosis and cancer. The risk of infection posed by moulds regularly occurring indoors is low for healthy persons; most species are in risk group 1 and a few in risk group 2 (Aspergillus fumigatus, A. flavus) of the German Biological Agents Act (Biostoffverordnung). Only moulds that are potentially able to form toxins can be triggers of toxic reactions. Whether or not toxin formation occurs in individual cases is determined by environmental and growth conditions, above all the substrate. In the case of indoor moisture/mould damage, everyone can be affected by odour effects and/or mood disorders. However, this is not a health hazard. Predisposing factors for odour effects can include genetic and hormonal influences, imprinting, context and adaptation effects. Predisposing factors for mood disorders may include environmental concerns, anxiety, condition, and attribution, as well as various diseases. Risk groups to be protected particularly with regard to an infection risk are persons on immunosuppression according to the classification of the German Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, KRINKO) at the Robert Koch- Institute (RKI) and persons with cystic fibrosis (mucoviscidosis); with regard to an allergic risk, persons with cystic fibrosis (mucoviscidosis) and patients with bronchial asthma should be protected. The rational diagnostics include the medical history, physical examination, and conventional allergy diagnostics including provocation tests if necessary; sometimes cellular test systems are indicated. In the case of mould infections the reader is referred to the AWMF guideline "Diagnosis and Therapy of Invasive Aspergillus Infections". With regard to mycotoxins, there are currently no useful and validated test procedures for clinical diagnostics. From a preventive medicine standpoint it is important that indoor mould infestation in relevant dimension cannot be tolerated for precautionary reasons. With regard to evaluating the extent of damage and selecting a remedial procedure, the reader is referred to the revised version of the mould guideline issued by the German Federal Environment Agency (Umweltbundesamt, UBA).

Medical diagnostics for indoor mold exposure

In April 2016, the German Society of Hygiene, Environmental Medicine and Preventative Medicine (Gesellschaft für Hygiene, Umweltmedizin und Präventivmedizin (GHUP)) together with other scientific medical societies, German and Austrian medical societies, physician unions and experts has provided an AWMF (Association of the Scientific Medical Societies) guideline 'Medical diagnostics for indoor mold exposure'. This guideline shall help physicians to advise and treat patients exposed indoors to mold. Indoor mold growth is a potential health risk, even without a quantitative and/or causal association between the occurrence of individual mold species and health effects. Apart from the allergic bronchopulmonary aspergillosis (ABPA) and the mycoses caused by mold, there is only sufficient evidence for the following associations between moisture/mold damages and different health effects: Allergic respiratory diseases, asthma (manifestation, progression, exacerbation), allergic rhinitis, exogenous allergic alveolitis and respiratory tract infections/bronchitis. In comparison to other environmental allergens, the sensitizing potential of molds is estimated to be low. Recent studies show a prevalence of sensitization of 3-10% in the total population of Europe. The evidence for associations to mucous membrane irritation and atopic eczema (manifestation, progression, exacerbation) is classified as limited or suspected. Inadequate or insufficient evidence for an association is given for COPD, acute idiopathic pulmonary hemorrhage in children, rheumatism/arthritis, sarcoidosis, and cancer. The risk of infections from indoor molds is low for healthy individuals. Only molds that are capable to form toxins can cause intoxications. The environmental and growth conditions and especially the substrate determine whether toxin formation occurs, but indoor air concentrations are always very low. In the case of indoor moisture/mold damages, everyone can be affected by odor effects and/or impairment of well-being. Predisposing factors for odor effects can be given by genetic and hormonal influences, imprinting, context and adaptation effects. Predisposing factors for impairment of well-being are environmental concerns, anxieties, conditioning and attributions as well as a variety of diseases. Risk groups that must be protected are patients with immunosuppression and with mucoviscidosis (cystic fibrosis) with regard to infections and individuals with mucoviscidosis and asthma with regard to allergies. If an association between mold exposure and health effects is suspected, the medical diagnosis includes medical history, physical examination, conventional allergy diagnosis, and if indicated, provocation tests. For the treatment of mold infections, it is referred to the AWMF guidelines for diagnosis and treatment of invasive Aspergillus infections. Regarding mycotoxins, there are currently no validated test methods that could be used in clinical diagnostics. From the perspective of preventive medicine, it is important that mold damages cannot be tolerated in indoor environments.

White-nose syndrome fungus (Geomyces destructans) in bats, Europe

Unlike bats in North America, bats in Europe are not killed by this fungus.

White-nose syndrome is an emerging disease in North America that has caused substantial declines in hibernating bats. A recently identified fungus (Geomyces destructans) causes skin lesions that are characteristic of this disease. Typical signs of this infection were not observed in bats in North America before white-nose syndrome was detected. However, unconfirmed reports from Europe indicated white fungal growth on hibernating bats without associated deaths. To investigate these differences, hibernating bats were sampled in Germany, Switzerland, and Hungary to determine whether G. destructans is present in Europe. Microscopic observations, fungal culture, and genetic analyses of 43 samples from 23 bats indicated that 21 bats of 5 species in 3 countries were colonized by G. destructans. We hypothesize that G. destructans is present throughout Europe and that bats in Europe may be more immunologically or behaviorally resistant to G. destructans than their congeners in North America because they potentially coevolved with the fungus.

Pediatric tinea capitis: recognition and management

Tinea capitis (ringworm of the head) is the most common dermatophytosis of childhood with an increasing incidence worldwide. If suspected clinically, further diagnostic procedures, including direct microscopy and culture, should be performed. Other scalp alterations, such as seborrheic dermatitis, atopic eczema, psoriasis, alopecia areata, folliculitis, and pseudopelade, may mimic ringworm of the head and must be identified. A proven fungal infection of scalp skin and hairs warrants immediate initiation of systemic treatment. At present, only oral griseofulvin is approved for therapy of scalp ringworm in children by health authorities. However, the advent of several newer antifungal agents such as itraconazole, fluconazole, and terbinafine has broadened the therapeutic armamentarium in recent years. These agents offer shorter treatment intervals, and their adverse effects and drug interaction profiles appear to be well within acceptable limits. In patients with tinea capitis, systemic therapy at weight-dependent dosages for an appropriate amount of time in conjunction with topical supportive measures will help to prevent disfiguring hair loss, permanent formation of scar tissue, spread of fungal organisms to other cutaneous regions, and infection of other persons.

Ringversuch ?Innenraumrelevante Schimmelpilze?

In co-ordination with the Umweltbundesamt Berlin, the Landesgesundheitsamt Baden-Wurttemberg (LGA) initiated external quality assurance in the diagnosis of indoor fungi in autumn 2001. Four of six fungal strains commonly found indoors have to be fully identified (on the genus and species level). There are two distributions per year; the six distributions hitherto carried out resulted in correct identification by 46-89% of laboratories (40-71 participants, total 148). It is clear from the results that repeat participants were more successful. In addition to the pure cultures sent out we offered actual samples (two air samples, one wood material, one sample of house dust, hitherto); 43- 69% of participating laboratories also took part in this facultative investigation of actual samples and 29-62% were successful. Results that differed considerably revealed problems while treating and evaluating actual samples. Therefore, activities in this field should be enhanced. In conclusion, external quality assurance in the diagnosis of indoor fungi is a useful management aid in the maintenance and improvement of laboratory performance.

[Strategies and targets for establishing a multicenter trial: "Identification of indoor relevant moulds"]

Quality control is universally recognised as fundamentally important in ensuring that diagnostic laboratories are performing appropriate tests at acceptable levels of competence. Therefore, the working group "Quality assurance--Fungi in Indoor Environments" which was initiated by the Public Health Service Baden-Württemberg (LGA BW) started with the external quality assurance in the diagnosis of indoor fungi in autumn 2001. Up to now we carried out the third mailing based on pure cultures. The results are reported and will be discussed. Exchanging experience on the international level is intended.

[Chronic mucocutaneous candidosis with severe esophageal stricture]

Since seven years, the 23-year-old woman suffered from severe dysphagia and cutaneous Candida-granulomas on the right side of the head, the nose and both hands. The therapy with different oral antimycotics was ineffective. Intravenously and orally administered high-dose fluconazole has induced healing of the mucocutaneous lesions. The esophageal stenosis, most likely caused by esophageal candidosis, was found as the origin of dysphagia. It was successfully treated by fluconazole and endoscopic dilatations.

[Tinea capitis et corporis due to Microsporum canis in an immunocompromised female adults patient]

Tinea capitis as well as tinea corporis in adults may occur under conditions of immunosuppression. If suspected clinically, direct microscopy and examination by culture is indispensable. Therapeutic intervention should start without delay. A proven fungal infection of scalp hairs warrants immediate initiation of systemic treatment. Hereby prevention of disfiguring hair loss, permanent formation of scar tissue, spread of fungal organisms to other cutaneous regions as well as infection of other persons is possible.

[Tinea capitis. Therapeutic options in the post-griseofulvin era]

Tinea capitis is the most common dermatophyte infection during childhood. In Germany, only griseofulvin is approved for therapy by regulatory agencies. In recent years, several newer antifungal agents such as itraconazole, fluconazole and terbinafine have broadened the therapeutic armamentarium and are used for the treatment of childhood tinea capitis. Itraconazole and terbinafine seem to be equally or more effective in treatment of tinea capitis within a shorter period of time than griseofulvin. Fluconazole is probably also effective for this indication, although supporting data is limited. Encountered side effects as well as interactions with other drugs appear to be well within acceptable limits for all three drugs. In conclusion, systemic therapy of scalp ringworm with itraconazole and terbinafine, as well as perhaps fluconazole, seems to be an equivalent or a superior therapeutic approach as compared to the use of griseofulvin. For the future, regulatory approval for the use of these newer antifungal agents in tinea capitis of childhood is recommended.

Optimizing the therapeutic approach in tinea capitis of childhood with itraconazole

BACKGROUND

Tinea capitis is the most common dermatophytosis of childhood with increasing incidence. Whereas griseofulvin is considered by many as the mainstay of treatment, newer oral antifungal agents, including fluconazole, itraconazole and terbinafine have demonstrated higher efficacy, resulting in shorter treatment durations.

OBJECTIVES

We aimed to determine the optimum regimen for the treatment of childhood tinea capitis with itraconazole.

METHODS

A mycological culture outcome-dependent combination of a 28-day continuous and facultative additional 14-day courses with itraconazole was used in 42 children (20 girls; 22 boys) aged 12-140 months (mean 66) with tinea capitis due to Microsporum canis (n = 26) and Trichophyton violaceum (n = 16). The drug was given orally according to the patients' body weight (50 mg daily for < 20 kg; 100 mg daily for > or = 20 kg) over 4 weeks. Direct microscopy and fungal culture as a parameter for efficacy were repeated 2 weeks after termination of treatment. Assessment of efficacy was based on the evaluation of results from light microscopy and culture at 8 weeks after initiation of treatment, and in the case of a further positive mycological culture at 14 and 20 weeks, respectively. A positive fungal culture at these times resulted in an additional course for 2 weeks with the initially chosen itraconazole dosage.

RESULTS

In 34 of 42 patients a single 4-week course of itraconazole resulted in a complete mycological cure of lesions as demonstrated by light microscopy and mycological culture. Four of 42 patients had to be treated by a second itraconazole course for 2 weeks, and four children received a third course of itraconazole for 2 weeks until all lesions showed negative direct microscopy and mycological culture. No abnormal haematological or biochemical results occurred. Apart from transient, completely reversible indigestion in two children, no side-effects were observed.

CONCLUSIONS

A culture-based 28-day continuous therapeutic regimen plus facultative cultural outcome-dependent additional 14-day courses of a body weight-adapted dosage of itraconazole in tinea capitis due to M. canis and T. violaceum is discussed; this offers the advantage of an effective therapy with complete negative direct microscopy as well as negative cultural results, within a shorter active treatment period (cf. previous studies with continuous administration of itraconazole).

[Contagious impetigo--pathogen spectrum and therapeutic consequences]

OBJECTIVE

The aim of this prospective study was to compare the clinical picture of contagious impetigo (C.I.) with the causative organism and to generate data of the susceptibility of bacteria as the basis for adequate therapy.

PATIENTS AND METHODS

In 126 patients with C.I. (86 children, 66 of them younger than 10 years) bacterial swabs were taken and antibiotic sensitivity testing for isolated organisms was tested.

RESULTS

In all cases in which contents of vesicles or pustules were analysed, Staphylococcus aureus was the only pathogen isolated. In non-bullous variants of C.I. Staphylococcus aureus was the most often isolated organism as well. Both staphylococci and streptococci were isolated in 12 cases, whereas in just 9 cases streptococci were the only pathogen detected. All Staphylococcus aureus isolates were sensitive to flucloxacillin and cefotaxime. Erythromycin-resistance amounted to more than 20 percent. The percentage of resistant staphylococci against the predominantly topically applied antibiotics fusidinic acid and mupirocin was 2 and 0 per cent, respectively.

CONCLUSION

For all manifestations of C.I. Staphylococcus aureus is at present the leading organism which has to be taken into consideration for treatment. If oral antibiotic therapy is indicated, penicillinase-stable penicillins or cephalosporins, preferably of the cefalexin-type, are the drugs of choice. Macrolides are no longer recommended for initiating of C.I. treatment.

In vitro evaluation of voriconazole against clinical isolates of yeasts, moulds and dermatophytes in comparison with itraconazole, ketoconazole, amphotericin B and griseofulvin

The in vitro activity of voriconazole (UK-109, 496), a new antifungal triazole derivative, against 650 clinical isolates of yeasts, moulds and dermatophytes was compared with that of itraconazole, ketoconazole, amphotericin B and griseofulvin. The geometric means of the minimum inhibitory concentrations (MICs) of voriconazole were 0.05 microgram ml-1 against yeasts (n = 187), 0.58 microgram ml-1 against moulds (n = 260) and 0.08 microgram ml-1 against dermatophytes (n = 203). The overall activity of voriconazole against yeasts and moulds was good, being similar to that of itraconazole, ketoconazole and amphotericin B. Voriconazole was highly effective against Aspergillus fumigatus (mean MIC 0.23 microgram ml-1) and other Aspergillus species and showed noteworthy activity (mean MICs 0.08-0.78 microgram ml-1) against emerging and less common clinical isolates of opportunistic moulds, such as Alternaria spp., Cladosporium spp., Acremonium spp., Chrysosporium spp. and Fusarium spp. On the other hand, voriconazole was less active in vitro than the comparative agents studied against various species of zygomycetes, such as Mucor spp., Rhizopus spp. and Absidia spp. Voriconazole and the other two azoles, itraconazole and ketoconazole, were more active than griseofulvin in vitro against most dermatophytes tested.

In vitro activity of voriconazole against yeasts, moulds and dermatophytes in comparison with fluconazole, amphotericin B and griseofulvin

Voriconazole (CAS 137234-62-9, UK-109,496), a new antifungal triazole derivative, was studied in vitro against 650 clinical isolates, representing yeasts, moulds and dermatophytes, and was compared with fluconazole (CAS 86386-73-4), amphotericin B (CAS 1397-89-3), and griseofulvin (CAS 126-07-8). The mean minimum inhibitory concentrations (MICs) of voriconazole were 0.06 microgram/ml against yeasts (n = 187), 0.74 microgram/ml against moulds (n = 260) and 0.10 microgram/ml against dermatophytes (n = 203). Data from these in vitro studies showed that voriconazole was more potent than fluconazole against most species studied, but particularly against the isolates of moulds and dermatophytes. Overall, voriconazole and amphotericin B indicated comparably good activity against yeasts and moulds. Voriconazole was highly potent against 13 Aspergillus species studied (mean MIC 0.35 microgram/ml) and also showed noteworthy activity (mean MICs 0.08-0.78 microgram/ml) against emerging and less common clinical isolates of opportunistic moulds such as of Alternaria spp., Cladosporium spp., Acremonium spp., Chrysosporium spp., and Fusarium spp. In addition, voriconazole was more active in vitro than griseofulvin against most dermatophytes tested. The in vitro results confirmed that voriconazole has indeed a broad antifungal spectrum and could also be effective against a wide range of fungal infections in patients.

Comparison of the in vitro activity of fluconazole against Candida albicans and dermatophytes

Fluconazole (CAS 86386-73-4, Diflucan, Fungata is an antimycotic agent of established value in the treatment of systemic infections with yeasts; more recently this drug has been used in the oral treatment of dermatomycoses. The in vitro activity of fluconazole against 51 strains of C. albicans and 207 isolates of four different species of dermatophytes was therefore measured and the results collated. The mean minimal inhibitory concentrations (MIC) show that in vitro fluconazole is a significantly stronger inhibitor of the proliferation of C. albicans (0.34 micrograms/ml) than of the dermatophytes T. rubrum (6.4 micrograms/ml), T. mentagrophytes (23.9 micrograms/ml), M. canis (18.3 micrograms/ml) and E. floccosum (3.5 micrograms/ml). On the other hand, the distribution of the MIC values shows that the sensitivity to fluconazole within a single species is also very variable. It is evident that the concentrations of fluconazole reached particularly in the stratum corneum of the skin after oral therapy are adequate to inhibit the growth of the yeasts and of the dermatophytes examined.

Bioavailability of fluconazole in the skin after oral medication

Fluconazole is an antimycotic drug which until now has been used mostly in the systemic therapy of yeast infections. We have now demonstrated the presence of this drug in various skin structures. After administration of 50 mg of fluconazole per day for 12 days to healthy volunteers, the following mean drug concentrations were measured: serum 1.81 micrograms ml-1, sweat 4.58 micrograms ml-1, dermis-epidermis (without stratum corneum) 2.77 micrograms g-1 and stratum corneum 73 micrograms g-1. Thus, 4 h after the last dose the antimycotic attains a 40-fold higher concentration in the stratum corneum than in serum. One week after ending the oral treatment, 5.8 micrograms g-1 fluconazole was present in stratum corneum. After daily ingestion of 200 mg of fluconazole for 5 days there was a further increase in the mean concentration of fluconazole in stratum corneum, to 127 micrograms g-1. Even 4-5 months after completing the oral treatment, fluconazole was detectable in the head hair and toenails of healthy volunteers. Fluconazole is eliminated from the stratum corneum about 2-3 times more slowly than from serum or plasma. After oral administration fluconazole evidently accumulated rapidly and intensively into the stratum corneum. The concentrations then attained or exceeded the in vitro minimal inhibitory concentrations of fluconazole for most of the dermatophytes and yeasts which are involved in cutaneous mycoses.

Chemical composition and structure of cell wall teichoic acids of staphylococci

The cell wall teichoic acid structures of 22 staphylococci including 13 type strains were determined. Most of the strains contain a poly(polyolphosphate) teichoic acid with glycerol and/or ribitol as polyol component. The polyolphosphate backbone is partially substituted with various combinations of sugars and/or amino sugars. Most of the substituents occur in a monomeric form but some strains also contain dimers of N-acetylglucosamine as substituents. Staphylococcus hyicus subsp. hyicus NCTC 10350 and S. sciuri DSM 20352 revealed rather complex cell wall teichoic acids. They consist of repeating sequences of phosphate-glycerol-phosphate-N-acetylglucosamine. The amino sugar component is present in this case as a monomer or an oligomer (n less than or equal to 3). Moreover, the glycerol residues are partially substituted with N-acetylglucosamine. The cell wall teichoic acid of S. auricularis is a poly(N-acetylglucosaminyl-phosphate) polymer similar to that found in S. caseolyticus ATCC29750. The cell wall teichoic acid structures for type strains of S. auricularis, S. capitis, S. cohnii, S. haemolyticus, S. hominis, S. hyicus subsp. hyicus, S. sciuri, S. xylosus and S. warneri were determined for the first time in detail. The structures of some of the previously described teichoic acids had to be revised (S. epidermidis, S. simulans, S. aureus phage type 187).

Threo-beta-hydroxyornithine: a natural constituent of the peptidoglycan of Corynebacterium species Co 112

Peptidoglycan of Corynebacterium species Co 112 (DSM 20606) exhibits an unknown amino acid. The amino acid was isolated from cell wall hydrolysates and identified as threo-beta-hydroxyornithine. This amino acid is found in the interpeptide bridge of the peptidoglycan of Corynebacterium sp. Co 112. The primary structure of this peptidoglycan is rather similar to that of Microbacterium liquefaciens. The only difference is the replacement of ornithine by threo-beta-hydroxyornithine. The mode of linkage of threo-beta-hydroxyornithine indicates that it is present as D-isomer.

[Skin reactions to isolated bacterial cell wall components, bacterial peptidoglycan in particular]

To elucidate the pathogenetic mechanism of bacterial-allergical diseases and of reactions provoked by bacterial test substances (e.g. the intracutaneous test), it is necessary to analyse carefully various factors involved in these reactions. To try to separate toxic from immunological reactions minute amounts of peptidoglycan in four different preparations were applied to humans by intracutaneous injections. Peptidoglycan, an immunologically well defined wall components of almost all bacteria and which is therefore ubiquitous, was isolated from staphylococci and streptococci. The skin reactions were evaluated by macroscopical, microscopical and immunohistological observations, as well as by electromicroscopy and statistical means. Several findings indicate the involvement of immunological factors in the observed skin reactions. In some cases no measurable reaction was seen, whereas in others typical skin reactions occurred. Similar reactions were produced by the antigenically related peptidoglycans isolated from Staphylococcus aureus and Staphylococcus epidermis. These reactions differed, however, from those elicited by peptidoglycan preparations from Streptococcus pyogenes type A. Patients with chronic bacterial infections and who were injected by four bacterial preparations demonstrated a significant increase in delayed hypersensitivity reaction compared with two other groups of patients (atopic patients without chronic infection). Because of the very low test dose, necrotic skin reactions, which occur in animal experiments, were not observed.

Migration inhibition of peritoneal macrophages by peptidoglycan

Previous studies have shown that peptidoglycans from group A and B streptococci inhibit the migration of peritoneal exudate cells from non-sensitized rats and guinea pigs. In the present studies peptidoglycans from S. aureus and S. epidermidis were found to inhibit the migration of cells to the same extent as group A streptococcal peptidoglycan. In contrast, HSA-pentapeptide, an immunologically active synthetic analog of the peptide moiety of peptidoglycan which is free of the intrinsic toxicity of naturally occurring peptidoglycans, did not induce migration inhibition of peritoneal exudate cells from non-sensitized guinea pigs. Sensitization of animals with 200 mug HSA-pentapeptide emulsified in incomplete Freund's adjuvant significantly reduced the inhibitory effect of streptococcal and staphylococcal peptidoglycan; HSA-pentapeptide again showed no activity. However, when HSA-pentapeptide was tested against cells from animals sensitized with 200 mug HSA-pentapeptide incorporated in complete Freund's adjuvant, a strong inhibition of migration was evident. Skin tests performed in these animals, in contrast to the dermonecrotic reaction elicited by streptococcal or staphylococcal peptidoglycan, revealed a characteristic delay hypersensitivity to HSA-pentapeptide.