A randomized trial of amorolfine 5% solution nail lacquer combined with oral terbinafine compared with terbinafine alone in the treatment of dermatophytic toenail onychomycoses affecting the matrix region.

In view of recent advances in the development of antifungal agents, this study examined the possible synergy of two new antifungal agents, terbinafine and amorolfine. The study compared two different courses of terbinafine treatment combined with amorolfine 5% solution nail lacquer. Terbinafine was given orally for 6 (AT6 group) or 12 weeks (AT12 group) and amorolfine nail lacquer applied weekly for 15 months. A control group received terbinafine alone for 12 weeks. This was a randomized, prospective, open study of severe dermatophyte toenail onychomycosis with matrix region involvement. Nail samples were taken before the start of the study, at inclusion and at the visits at 6 weeks, 3, 9, 15 and 18 months. To assess the value of such combined therapy we chose an early parameter as the principal outcome variable, which was the result of mycological examination, including direct microscopy and culture, at 3 months (allowing a margin of 15 days). The secondary parameters of success were the mycological results at the later visits, clinical evaluation and a combined mycological-clinical response. Safety and tolerance were also assessed. Adverse events were recorded and liver function tests were performed monthly during the terbinafine treatment. Of the 147 patients included in the trial, 121 attended the 3-month visit, within a time limit of 15 days of 3 months after the beginning of treatment: 40 in the AT6 group, 40 in the AT12 group and 41 in the control group. In all, 32 of 121 patients (26. 4%) had negative mycological results on direct microscopy and culture: 14 of 40 (35.0%) in the AT6 group, 11 of 40 (27.5%) in the AT12 group and seven of 41 (17.1%) in the control group. The cure rate for the global (mycological and clinical cure) response measured at 18 months in 145 patients was 44.0% (22 patients) in the AT6 group, 72.3% (34 patients) in the AT12 group and 37.5% (18 patients) in the terbinafine group. These results suggest that the combination of amorolfine and terbinafine may be of value in the treatment of severe onychomycosis. At the same time a pilot pharmacoeconomic analysis was performed demonstrating a better cost per cure ratio for the patients receiving combination treatment.

Dermatophytosis in northern Greece during the decade 1981-1990.

Dermatophytic infections are very common in Greece. In the Mycological Laboratory of the Venereal and Skin Diseases Hospital in Thessaloniki, 6572 isolates of different dermatophytes were obtained from 17,120 patients examined. It is suggested that 5% of the people who present with skin problems in Greece suffer from dermatophyte infections. They are frequent causative agents of tinea pedis, tinea cruris, tinea corporis, tinea capitis and tinea unguium. In this paper, the species, the number and the prevalence of the dermatophytes were studied according to location and sex of the patients. The contribution of dermatophyte infections to the overall incidence of superficial fungal infection over 10 years was also studied.

Dermatophytosis due to Trichophyton rubrum in northern Greece during the decade 1981-1990.

During the years 1981-1990 Trichophyton rubrum was the most frequent causative agent of dermatophytic infections in Northern Greece, especially in cases of tinea pedis, cruris, corporis, and unguium, as well as dermatophytosis of the hands. Between sexes there was a prevalence in women in tinea pedis and toenail infections. Men were particularly infected in the groin, the hands and the face. The chronic follicular dermatophytosis in the lower legs was also presented in women, but tinea corporis and fingernail infections showed no significant differences between the sexes. Also studied were the age of the patients, the inflammatory component of the lesions and the morphotypes of T. rubrum isolated.

[Mycotic infection in immunosuppressed patients. An anatomopathologic study]. / Les infections mycosiques chez les immunodéprimés. Etude anatomo-pathologique.

Mycotic infections are a frequent and often severe complication in the immunosuppressed patient. A review of autopsy findings in 54 cases with gross, histologic and mycologic studies was undertaken among immunocompromised patients after chemotherapy or allogenic bone marrow transplantation: fungal infections were either localized especially in lungs and gastrointestinal tract, or disseminated. Fungi were various: principally Candida and Aspergillus, but also Fusarium, Torulopsis and Trichosporon. In acquired immunodeficiency syndrome (11 autopsy cases), mycotic infections appeared different. Oral and esophageal candidiasis could be found, but cryptococcosis and histoplasmosis were the major generalized mycosis. This study suggests that fungal infections are not the same in patients treated by chemotherapy or bone marrow transplantation, and in acquired immunodeficiency syndrome.

Interferon inhibits Aspergillus fumigatus growth in mice: an activity against an extracellular infection.

Prophylactic treatment of mice with interferon (IFN) or polyinosinic-polycytidylic acid [poly(I:C)], an IFN inducer, provided significant protection against an extracellular infection by Aspergillus fumigatus in both Swiss and Swiss athymic nude mice. Tunicamycin (TM) treatment inhibits the antifungal activity of IFN and poly(I:C) in these mice. Anti-asialo GM1 or TM [both inhibitors of natural killer (NK) cell function] treatment enhance the severity of A. fumigatus infection. These results suggest that NK cells may play a role in A. fumigatus infection and in the antifungal activity of IFN.

[Dermatophytes and immigration]. / Dermatophytes et immigration.

An epidemiological study of dermatophytes was achieved during the years 1983-1984 in the Mycology Laboratory of Saint-Louis' Hospital. Immigrants represent an important part of the people who came to consult us: 28 per cent in 1983. The two most important immigrant peoples show different features: Black African people, who were mass contaminated by tinea agents (Trichophyton soudanense and Microsporum langeronii), were not much contaminated by epidermophytic agents (Trichophyton rubrum, Trichophyton interdigitale, Epidermophyton floccosum). Conversely, in people from the Maghreb, if tinea (Trichophyton violaceum) were not numerous, epidermophyties were found in the same proportion than in native people. The transmission of various dermatophytes from one population to another seems quite easy to detect for tinea agents: Trichophyton soudanense, Microsporum langeronii and Trichophyton violaceum can contaminate native people. Microsporum canis often contaminates the children from the Maghreb, and rarely Black African children. But the transmission of epidermophytes is much more difficult to study, due to a lack of documents in the African countries involved. The Scytalidium and Hendersonula pathology recently discovered in France is almost exclusively restricted to Black immigrants from the West Indies and Africa.

[Cutaneous localizations of disseminated Histoplasma capsulatum histoplasmosis in a case of acquired immunodeficiency]. / Localisations cutanées d'une histoplasmose disséminée à Histoplasma capsulatum au cours d'un cas d'immunodéficience acquise.

A widespread maculo-papular cutaneous rash appeared on a HIV-positive young bisexual Cambodian man. He was treated for Mycobacterium tuberculosis and Pneumocystis carinii infections. He had been residing in France for seven years. Histology showed, within the dermis, abundant extracellular and intramacrophagic yeast-like organisms suggestive of histoplasmosis. Cultured specimens produced a growth of colonies after three weeks on Sabouraud 4 p. 100 dextrose agar at 25 degrees C. Numerous macroconidia were found which made the species diagnosis of Histoplasma capsulatum possible. Despite initiation of therapy with amphotericin B the patient died. Cutaneous involvement with or without specific features is uncommon in disseminated histoplasmosis. The specific cutaneous lesions are protean. They rarely are the presenting sign of initial infection. Disseminated histoplasmosis has a poor prognosis in acquired immunodeficiency syndrome: amphotericin B is not curative. Maintenance suppressive therapy with ketoconazole has been recommended following amphotericin B completion, although break-through has been reported.

[Role of invasive candidiasis in hospital pathology]. / Place des candidoses invasives en pathologie hospitalière.

The frequency, mode of occurrence, diagnostic criteria and main features of systemic and visceral candidiasis have been evaluated in a retrospective study of all cases managed in St Louis Hospital, Paris, during the [June 1, 1985-May 31, 1986] period. During this one year period 23 patients suffered from systemic or visceral candidiasis and Candida spp. accounted for 9.6% of all positive blood cultures, fourth in number after Enterobacteriaceae, Staphylococcus and Pseudomonas. Abnormal underlying condition was present in all patients, mainly haematologic malignancies, serious abdominal surgery and AIDS. In patients with haematologic malignancies C. tropicalis was the main species involved in contrast with surgical patients in whom the dominant responsible species was C. albicans. No Candida oesophagus was common. Therapeutic regimens included amphotericin B in all patients with systemic disease. We conclude that in an institution mainly oriented toward management of cancer and surgical patients, systemic and visceral candidiasis are common and represent a serious problem.

Existence of ornamentations on macroconidia and hyphae of Epidermophyton floccosum.

The surface features of cell walls of several recent clinical isolates of Epidermophyton floccosum were examined by scanning electron microscopy. Macroconidia from each of our isolates displayed excrescences on the wall which were similar in their location and in their substructural appearance. We believe these irregularities sufficiently developed to regard them as true wall ornamentations. Comparisons were made with wall features of the macroconidia of Microsporum persicolor. In some cases, our Epidermophyton isolates possessed warty as well as secondary smooth spiral hyphae. The demonstration of these structures in recent isolates might imply that some sexual activity persists so that discovery of a teleomorph(s) for the genus Epidermophyton may yet be forthcoming.

Scanning electron microscopy on Microsporum audouini complex.

Several strains of Microsporum audouini, M. langeroni and M. rivalieri were observed by light and scanning electron microscopies. The macroaleuriospore shape and ornamentation were illustrated and compared for the 3 species as the pectinate hyphae for M. langeroni and M. rivalieri and the chlamydospores and particular hyphae for M. audouini and M. langeroni. The 3 species are morphologically very close but they are distinguishable from each other on the basis of morphology, geographic distribution and pathogenicity.

[Severe candidiasis in heroin addicts]. / Candidoses graves des héroïnomanes.

Seven cases of severe candida infection in heroin addicts are reported. The principal features of this condition which arose in 1980, apparently due to a particular quality of heroin, are described, Candida albicans was the only pathogenic agent isolated from mainly scalp nodular and pustular lesions. These cutaneous lesions were associated in half the cases with ocular lesions, which sometimes had a poor prognosis despite active therapy. Osteo-articular complications were less common. Ketoconazole therapy alone gave good results in this series. The precise reasons for this dissemination of Candida albicans and for these localisations are still not clearly understood.