Screening for asymptomatic carriage of Trichophyton tonsurans in household contacts of patients with tinea capitis: results of 209 patients from South London

BACKGROUND

There is currently an epidemic of tinea capitis in urban areas of developed countries caused by Trichophyton tonsurans. Recurrence or re-infection with dermatophyte is not uncommon after adequate oral treatment. Asymptomatic carriers who are household contacts may partly explain this observation by forming a reservoir for infection.

PATIENTS/METHODS

Two-hundred and nine household contacts of patients with tinea capitis were examined and screened for asymptomatic carriage of dermatophyte.

RESULTS

Only 7.2% had clinically evident disease yet 44.5% had silent fungal carriage on the scalp. Children under 16 years were much more likely to be carriers than adults (P < 0.001) and males were less likely than females to be affected (P < 0.01).

CONCLUSION

This evidence poses questions about factors relevant in transmission of dermatophytes. The authors propose that all household contacts of patients with tinea capitis should be offered screening to eradicate a potential reservoir of infection.

Epidemiology of tinea capitis in Europe: current state and changing patterns

Tinea capitis (scalp ringworm) is the most common dermatophyte infection of the scalp affecting mainly children and rarely adults. The epidemiology of tinea capitis varies within different geographical areas throughout the world. It may occur sporadically or epidemically and an increase in its incidence has been noted over the last few decades. The aim of the study is to obtain a general overview of the current state and changing pattern of tinea capitis in Europe. According to the literature, there has been a significant increase in the incidence of tinea capitis and a change in the pattern of infectious agents in particular. Microsporum canis, a zoophilic dermatophyte, is still the most common reported causative agent of tinea capitis in Europe. The countries reporting the highest incidence of M. canis infections are mainly in the Mediterranean but also bordering countries like Austria, Hungary, Germany and Poland. Besides the increase in Microsporum-induced tinea capitis, there is a shift towards anthrophilic tinea capitis mainly in urban areas in Europe. The largest overall increase with anthropophilic dermatophytes has been noted with Trichophyton tonsurans mainly in the UK and with Trichophyton soudanense and Microsporum audouinii in France. The occurrence of anthropophilic infections seems to be geographically restricted and is possibly linked to the immigration from African countries. Children (aged 3-7 years with no predilection of gender) remain the most commonly affected, but recently an increase of tinea capitis has been observed in adults and in the elderly. The results of the study clearly demonstrate the importance of diagnosing and proper treatment of mycotic scalp infection in the Europe. If not diagnosed and treated properly, its prevalence might reach epidemic proportions in the near future. Therefore, an increased level of surveillance (screening in schools), and a highly effective interdisciplinary cooperation among general practitioners, mycologists, veterinarians and dermatologists are strongly recommended.

[Clinical study of 57 cases of infection with Trichophyton tonsurans examined at a dermatology clinic in Saga Prefecture, Japan]

This paper is a clinical study of 57 cases of infection with Trichophyton tonsurans (T. tonsurans) examined in our clinic between January 2004 and July 2006. The patients were 31 high school students, 19 junior high school students, 2 primary school students, 1 kindergartener, and 4 sports instructors. The male:female ratio was 51:6. Most patients were male Judo practitioners. Patients were clinically categorized as follows: 13 cases of tinea capitis {10 containing black dot ringworms (BDR), 2 scaled, and 1 with inflammation}, 41 cases of tinea corporis, 1 case of tinea manum, and 7 carriers. Five patients displayed both tinea capitis and tinea corporis. Among tinea corporis patients, 21 displayed annular erythemas, whereas 19 displayed small circular eythemas characterized by a lightly inflamed non-typical rush. In 3 tinea corporis cases, we sampled T. tonsurans from hair grown inside the skin rash. Eleven of the tinea corporis patients displayed multiple lesions. Compared to patients with singular lesions, these 11 cases had a larger degree of comorbidity with BDR or HB positivity. A 6-8 week treatment with griseofulvin was efficient in 90% of the tinea capitis cases. Tinea corporis patients were healed following a 4-9 week treatment with topical antifungals and griseofulvin. When examining T. tonsurans infections, patients with BDR or lightly inflamed tinea corporis as well as asymptomatic carriers can be easily overlooked or misdiagnosed. Therefore, we suggest that mycological examination, including careful observation of the rash and KOH mount, is essential in these cases.

Microsporum canis: Report of a primary school outbreak

Microsporum canis is the causative organism in less than 10% of all tinea capitis infections in the UK. Transmission is generally via contact with an infected family pet and there are only rare reports of case clustering. This article describes an outbreak of M. canis in a primary school classroom demonstrating human-to-human spread from an index case who was presumed to have acquired the infection prior to arriving in the UK. There was no suggestion of clinical improvement following 4 weeks of oral terbinafine 125 mg daily and treatment was changed to griseofulvin. The Health Protection team screened class members and confirmed cases (either clinically or mycologically) were also treated with griseofulvin 10-20 mg/kg/day for 10 weeks. Classmates and siblings of classmates were recommended to use selenium sulphide or ketoconazole-containing shampoo twice weekly.

A nationwide survey of Trichophyton tonsurans infection among combat sport club members in Japan using a questionnaire form and the hairbrush method

BACKGROUND

The emerging outbreak of Trichophyton tonsurans infection among members of combat sports clubs in Japan during the last 4 years has become a serious public health problem. To overcome this outbreak, a survey for T. tonsurans infection in Japan may be essential.

OBJECTIVES

We sought to clarify the prevalence of T. tonsurans infection among members of combat sports clubs in Japan.

METHODS

We conducted a survey of members of participating combat sports clubs using a standardized questionnaire to assess background factors and using the hairbrush method to identify T. tonsurans infection. Statistical significance of the correlation between data from the questionnaire and the hairbrush culture results was determined.

RESULTS

We surveyed 1000 people (826 male) from 49 institutions and found 115 (11.5%) were positive for T. tonsurans infection revealed by the hairbrush method. Demographic factors associated with high positive rates (> or =20%) of the infection were familial T. tonsurans infection (20.0%), history of tinea corporis (24.2%), increased dandruff (32.1%), and concomitant tinea corporis (31.6%). Those with positive hairbrush culture results without current or previous tinea were considered asymptomatic carriers.

LIMITATIONS

The study population was limited to members of judo clubs all over Japan; they were asked to participate in this survey via the All Japan Judo Federation.

CONCLUSION

Infection of T. tonsurans appears to have spread widely among members of combat sports club in Japan. The questionnaire used in this study is a simple and useful tool to estimate epidemiology of this infection.

[Trichophyton violaceum infection occurring in a nursing home]

Six cases of Trichophyton (T.) violaceum infection seen in a nursing home are reported. A 66-year-old female (case 1) was found with tinea corporis on her face, chest and shoulder, associated with black dot ringworm. A KOH examination of hair showed endothrix parasitism. Reddish purple colonies were isolated from the patient on Sabouraud's dextrose agar, and intercalary and terminal chlamydospores were observed on slide culture. PCR-RFLP analysis of the microorganism showed a pattern of T. violaceum type. Therefore, the isolated fungus was identified as T. violaceum, a typical anthropophilic dermatophyte which had spread among residents and staffs easily. Using a mycological method, we examined 59 persons (21 residents and 38 staff members) who had had contact with case 1. The results were as follows. An 85-year-old female (case 2) and an 83-year-old female (case 3) were carriers of T. violaceum. A 23-year-old male (case 4) had tinea corporis on his right forearm due to T. violaceum. A 24-year-old male (case 5) probably had tinea corporis on his right forearm due to T. violaceum. One year after case 1's first visit to our clinic, we observed an 88-year-old female (case 6) of tinea capitis by T. violaceum. It seems that the organism was preserved in surroundings and members of the nursing home. The contagion in our cases could either have been caused by directly touching the person or by sharing their comb. PCR-RFLP analysis was performed within a short time, so that we managed effectively to select a way of treatment and to prevent the infection from spreading.

Current topics of tinea capitis in China

Tinea capitis is one type of superficial fungal infection which is found all over the world. The major etiologic agent of tinea capitis varies in different areas. Tinea capitis in China has unique characteristics. The epidemiology, transmission and therapy of child and adult tinea capitis in China are reviewed in this paper.

[Identification of geophilic and zoophilic dermatophytes in siblings with tinea capitis. A pathogenic factor or contamination?]

Two siblings of African origin presented with multiple scaling patches and alopecia on the scalp four weeks after returning from a vacation in Eritrea. Direct KOH examination revealed fungal elements; Trichophyton mentagrophytes and Trichophyton terrestre were identified in the fungal culture. We discuss the putative pathogenic role of both microorganisms in causing disease. Although infection with Microsporum canis currently accounts for almost fifty percent of all cases of tinea capitis in Germany, other fungi have gained importance due to tourism and increasing migration.

An outbreak of tinea capitis in a child care centre

We describe an outbreak of tinea capitis in a kindergarten. Individuals with relation to the institution were examined clinically and mycologically (n-98), Microsporum audouinii was cultured from 12 people, out of whom eight patients had tinea capitis, four patients had tinea corporis, and three patients had both. The problems with spread of anthropophilic infections and the difficulties with treatment of Microsporum dermatophytes are discussed.

[An outbreak of tinea capitis in a child care center]

We describe an outbreak of tinea capitis in a kindergarten. Individuals with relation to the institution were examined clinically and mycologically (n = 98). Microsporum audouinii was cultured from 12 people, out of whom eight patients had tinea capitis and seven patients had tinea corporis. Three patients had both tinea capitis and tinea corporis. The problems with spread of anthropophilic infections and the difficulties with treatment of Microsporum dermatophytes are discussed.

Tinea capitis: focus on African American women

Tinea capitis is a common cutaneous fungal infection in US school children, but adults may be carriers of tinea pathogens in the scalp. However, few cases of actual tinea capitis in adults have been reported in the literature. A retrospective analysis of all adult patients with positive scalp fungal cultures from June 1997 to March 2000 were reviewed. Seventy-nine cases of tinea capitis were identified. Nine (11.4%) were adults, 7 of whom were African American women, who were an average of 46 years old (range, 25 to 64 years). Three of these patients had prior exposure to a child with tinea capitis. These results suggest that tinea capitis affects adult African Americans, particularly women. Widespread scalp culture is indicated for papulosquamous disease and alopecia in this segment of the population.

Tinea capitis in infants less than 1 year of age

Tinea capitis is the most frequent manifestation of dermatophyte infection in children, but because it is rare in the first months of life it is often misdiagnosed. Here we report 15 cases of tinea capitis observed in Italy in infants less than 1 year of age. There were 10 boys and 5 girls (mean age 6 months). Diagnosis was confirmed by mycologic examination. Microsporum canis was isolated in nine cases and Trichophyton mentagrophytes in three. These 12 infants were Italian and animals were the source of infection. Trichophyton erinacei was isolated in one Italian infant, and the source was soil. In the other two cases, Trichophyton tonsurans and Trichophyton violaceum were isolated; these infants were from Central America and India, respectively, and had contracted the infection from humans. All achieved clinical and mycologic recovery after systemic and topical antimycotic therapy.

[Tinea capitis: sample surveys among school doctors and dermatologists in the Paris suburbs]

BACKGROUND

Subsequent to detection of several cases of anthropophilic tinea capitis, we wanted to know whether the legal decree requiring eviction from school and an epidemiology survey in the children community or the family is implemented properly.

METHODS

Two sample surveys were carried out among 50 school doctors from the Hauts-de-Seine department and 110 dermatologists working the Paris suburbs.

RESULTS

Eviction from school was rare and not based on the type of dermatophytes (anthropophilic or zoophilic agent). Likewise, epidemiology survey was neglected, often being solely clinical for other family members. Systematic sampling in the children community or in the family was very exceptional.

DISCUSSION

Despite the rise in the number of cases of anthropophilic tinea capitis in Paris suburbs, the decree is not often implemented. Dermatologists would appear to be responsible for this situation, especially in case of M. langeronii, which is very contagious in nursery school.

Tinea capitis in two elderly women: transmission at the hairdresser

Tinea capitis is rare in the elderly. We report cases of two elderly women who presented to our dermatology clinic within 8 weeks of each other, with scalp scaling and alopecia. In both cases, Microsporum canis grew on fungal culture of their hair, and required prolonged treatment with terbinafine. Neither of them gave a history of contact with young children or any animals. Both were fairly fit and not systemically immunocompromised. However, both had been regularly visiting the same hairdresser, during the presumed period of infectivity, making this the most likely source of infection.

[Epidemiology of tinea capitis]

PREDOMINANT IN CHILDREN: Tinea capitis is the most frequent fungal infection in children under the age of puberty. It occurs only rarely in men but is observed in adult women. Human-to-human, animal-to-human and soil-to-human transmission can be involved.

HISTORICAL BACKGROUND

The spectrum of fungal species known to cause tinea capitis has steadily grown for more than a century, varying with the local urban or rural environment. Since the beginning of the 20th century and up to the advent of griseofulvin in the sixties, M. audouinii, an anthropophilic species, caused major epidemics in France, England and the USA. In the sixties to eighties, M. canis was the cause of most cases observed throughout the world. Over the last 20 years, anthropophilic species have again become the leading cause of tinea capitis epidemics, particularly in large cities, in relationship with immigration: T. tonsuransi in the USA and England and T. soudanense and M. langeronii in France.

HYGIENE AND EDUCATION

Despite the benign curable nature of the disease, interhuman transmission of tinea capitis is nevertheless a considerable public health problem due to the increasing number of children affected and the risk of contagion in schools. The considerations resulting from recent studies point out the fact that transmission occurs more often in the family than the school setting, particularly indirectly by common use of grooming instruments. This would explain the high percentage of tinea capitis in large immigrant families where hair combing habits favor transmission. In France, these observations should lead to a revision of the current regulations concerning expulsion from school of children affected by tinea capitis. Better education would be a more appropriate response to the problem.

Tinea capitis: study of asymptomatic carriers and sick adolescents, adults and elderly who live with children with the disease

Tinea capitis is a dermatophyte infection that occurs mainly in childhood; there are few reports, in Brazil, in adolescents and adults. The detection of asymptomatic carriers is of great importance in the disease control. From February 1998 to February 1999, a study was performed at the outpatient Dermatologic Unit of Instituto de Puericultura e Pediatria Martagão Gesteira (Universidade Federal do Rio de Janeiro, Brasil) to verify the frequency of asymptomatic carriers and tinea capitis between 79 adolescents, adults and elderly who lived in the same household of 56 children (0-12 years) with tinea capitis. Of these, one female and one male adults (2.5%) were asymptomatic carriers and the cultures revealed Trichophyton tonsurans and Microsporum canis respectively. One female adolescent and two female adults (3.8%) had tinea capitis and all cultures revealed Trichophyton tonsurans. The study has shown that adolescents and adults who live in the same household of children with tinea capitis may be sick or asymptomatic carriers.

Trichophyton tonsurans tinea capitis and tinea corporis: treatment and follow-up of four affected family members

We report a Caucasian family of two veterinary practitioners and their two children, ages 2 years and 6 months, simultaneously infected with the dermatophyte Trichophyton tonsurans, causing tinea capitis and tinea corporis in the children and tinea corporis in the parents. The parents and older child were successfully treated with oral terbinafine. The infant clinically responded to treatment with topical terbinafine and ketoconazole shampoo but presented with recurrent tinea capitis 12 months later, from which T. tonsurans was cultured. At this time, scalpbrush samples from the other family members failed to culture any fungi, and neither were fungi isolated from the family hairbrushes. The infant then received oral terbinafine, resulting in clinical and mycologic cure. After a further 12 months follow-up, there has been no mycologic evidence of recurrence in any family member.

Tinea capitis: a current perspective

During the past 50 years, the predominant etiologic agent of tinea capitis in the United States and in Western Europe has changed from Microsporum audouinii to Trichophyton tonsurans. This is thought to be due in part to the sensitivity of M audouinii to griseofulvin treatment and, in part, due to the importing of T tonsurans by people emigrating from geographic areas where that vector had been the prominent cause of tinea capitis. With these changes, prospects for newer therapies with the novel antimycotic agents itraconazole, fluconazole, and terbinafine are reviewed. (J Am Acad Dermatol 2000;42:1-20.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the history, epidemiology, and current knowledge of tinea capitis, as well as the newer antifungal agents (ie, itraconazole, fluconazole, and terbinafine) to treat this infection.

Asymptomatic dermatophyte carriers in the households of children with tinea capitis

OBJECTIVES

To determine the prevalence of the carrier state in household contacts in children with tinea capitis, the duration of the carrier state, factors associated with carriage, and the proportion of carriers who develop clinical disease.

DESIGN

Cross-sectional, cohort, prevalence study.

SETTING

General pediatric clinic serving an indigent, inner-city, African American population.

PATIENTS

Household contacts in children with tinea capitis. Index cases and carriers (no clinical evidence of infection) were identified by culture. Carriers were monitored until the results of their culture became negative, they developed clinical disease, or a 6-month period had elapsed.

RESULTS

Fifty-six index cases and 114 contacts (50 adults and 64 children) were evaluated. Ninety-eight percent of the dermatophytes identified in index cases and 100% in carriers were Trichophyton tonsurans. At the initial visit, 18 (16%) of 114 (95% confidence interval [95% CI], 10-24) of contacts were carriers and 14 (32%) of 44 of the families studied had at least 1 carrier. At the 2-, 4-, and 6-month visits, the carrier state persisted in 7 (41%) of 17 (95% CI, 19-67), 3 (20%) of 15 (95% CI, 4-48), and 2 (13%) of 15 (95% CI, 2-40), respectively. Three of the carriers were lost to follow-up. Of the carriers, 1 (7%) of 15 (95% CI, 0.2-32) developed tinea capitis. Univariate and multivariate analysis showed no association of carrier state to age, sex, comb sharing, or cosleeping. However, cosleeping and comb sharing were common among the contacts, occurring 75% and 78% of the time, respectively, making statistical correlation difficult with our sample size.

CONCLUSIONS

Initial prevalence of asymptomatic carriage of dermatophytes among household contacts of a child with tinea capitis was 16%, with 41% of carriers persisting up to 2 months. Thirty-two percent of families had at least 1 member who was a carrier. Seven percent of the carriers developed an active infection. Treatment of carriers with sporicidal shampoo should be considered since they may act as a reservoir for infection or develop active disease. The high prevalence of cosleeping and comb sharing may be important factors in the spread of the disease.

[Epidemiology of Microsporum langeronii tinea capitis in the Paris suburban area. Results of 2 school and familial surveys]

INTRODUCTION

One epidemiologic survey was carried out in two children communities, following detection of several cases of Microsporum langeronii tinea capitis.

PATIENTS AND METHODS

In one case, 3 year-old children from a day-nursery were contaminated by a child originating from France, who had been previously infected by contact with a friend originating from Ivory Coast. In the second case, lesions were diagnosed in a nursery-school in African children born in France. These were treated before epidemic progression into the school.

RESULTS

Our study confirms data from the literature concerning the risk of contamination by Microsporum langeronii, with a familial contamination being more frequent than scholar one.

DISCUSSION

The interest of our study was the rapid starting of the epidemiologic survey after first case diagnosis (one to two months) and the treatment of all the patients without scholar eviction. Treatment of all affected patients as well as "asymptomatic carriers" leaded to the arrest to the epidemy. No case of relapse was noted during the following year.

Tinea capitis in a newborn caused by two organisms

Tinea capitis is a common infection of childhood. There have been several reports of tinea capitis in newborns. Our patient presented at 19 days of age to the emergency room with a scalp lesion of 5 days duration. The fungal culture grew both Trichophyton rubrum and Trichophyton mentagrophytes. The patient was successfully treated with oral griseofulvin.

Semiquantitative study of tinea capitis and the asymptomatic carrier state in inner-city school children

OBJECTIVE

To quantify and characterize the asymptomatic carrier state of tinea capitis in school children from the inner city.

METHODS

All students attending a parochial school (kindergarten through seventh grade) in the city of Philadelphia were cultured for tinea capitis periodically over 16 months (1404 hemi-scalp cultures from 224 children).

RESULTS

Our initial prevalence study of this all-black population (ages 5 to 13 years) found a 3% rate of index cases (symptomatic) and a 14% rate of asymptomatic carriers (without black-dot lesions, obvious hair loss, scaling, crusts, pustules, or erythema). Trichophyton tonsurans was the predominant dermatophyte (96% of 125 positive cultures; Microsporum canis was the only other isolate). Fifty percent of all positive cultures came from children in kindergarten and first grade; first grade had the highest rate of index cases. The overall prevalence of asymptomatic carriers was not higher in the classes containing index cases. Fifty-nine percent of asymptomatic carriers had a 1+ spore load (1 to 10 colonies isolated per scalp), while 74% of index cases had a 4+ spore load (> 150 total colonies). Forty-five untreated asymptomatic carriers were followed for 2 to 5 months: 19 (42%) became culture-negative; of these, 17 (90%) had a 1+ spore load.

CONCLUSIONS

We found that inner-city black school children who are asymptomatic carriers of T tonsurans had lower spore loads than index cases. Index cases did not appear to be the primary mode of transmission within a classroom. More than half of untreated asymptomatic carriers remained culture-positive after 2 months and probably play a role in the transmission of tinea capitis within this population.

Tinea capitis: new perspectives on an old disease

Tinea capitis caused by Trichophyton tonsurans is a common infection in children, and has become a significant public health problem in the United States. Epidemics of tinea capitis occur both in families and in institutions such as schools and day care centers. Infection is often difficult to eradicate. Fomites and asymptomatic carriers likely contribute to the spread of the disease and to re-infection of treated patients. The morphology of tinea capitis is diverse, from seborrhea-like scaling to tender, inflammed nodules on the scalp. Because a lengthy course of systemic griseofulvin is required to treat this infection, management of tinea capitis can be challenging. As newer antifungal agents are developed, more effective and convenient therapy for tinea capitis may become available.

Human Trichophyton equinum infection treated with terbinafine

A case of tinea capitis caused by Trichophyton equinum is described. This responded to a 6-week course of treatment with the allyl amine antifungal agent, terbinafine.

Dermatophytosis of the scalp: incidence, immune response, and epidemiology

Tinea capitis remains a common infection among the pediatric population of North America. The 'gray patch' Microsporum audouinii infections of the 1950's have been supplanted by the 'black dot' ringworm of Trichophyton tonsurans. The clinical presentation of T. tonsurans infection is quite variable and may be related to specific host T-lymphocyte response. This dermatophytosis is most frequently incurred from contact with an infected child either directly or via a variety of fomites. Current studies indicate that an asymptomatic adult carrier state may also exist which could contribute to the morbidity of this mycosis.

Evaluation of the adult carrier state in juvenile tinea capitis caused by Trichophyton tonsurans

The anthropophilic dermatophyte Trichophyton tonsurans is an occasional cause of scalp ringworm in adults. An asymptomatic adult carrier state also has been described. In this study the parents and/or grandparents of 50 children with proved T. tonsurans tinea capitis were evaluated. Cultures were obtained from the scalps of 46 asymptomatic adults; 14 of the cultures grew T. tonsurans. This population may provide a source for continued reinfection in children.

Studies on the prevalence of tinea capitis infection in Ile-Ife, Nigeria

Investigations were carried out into the prevalence of tinea capitis infection among school children in Ile-Ife, Nigeria. The prevalence rate of clinical infection was found to be 14.02%. The infection was found to be more frequent among pupils between ages 5 and 10 years, and more prevalent among the poor than the rich (p less than 0.005). Families having between 1 and 4 children had lower prevalence than families having minimum of five children (p less than 0.10). Approximately one-third of the clinically infected children were not receiving any treatment while about two-thirds of the remaining two-thirds were using local native remedies, some of which had resulted in deaths of some children. The most common causative agent isolated from the lesions was Microsporum audouinii.

Microsporum canis infection: first epidemic in Israel

We report here on the first epidemic of Microsporum canis infection in Israel. All 78 cases were diagnosed in the port city of Eilat between August, 1975 and May 1976. The epidemic has apparently been controlled with Griseofulvin therapy and public health measures.