Epidemiology of onychomycosis in Serbia: a laboratory-based survey and risk factor identification.

Onychomycosis is a fungal infection of the fingernails and/or toenails caused by dermatophytes, yeasts and non-dermatophyte moulds. The epidemiology of onychomycosis in Serbia is yet to be fully established. This epidemiological study was aimed at evaluating the epidemiology of onychomycosis in a sample of the Serbian patients at risk of onychomycosis, to determine the fungal aetiological agents and to identify the possible risk factors. The study population included 374 patients from six centres in Serbia with suspected onychomycosis. Demographic data, data about comorbidities, lifestyle, clinical aspects of onychomycosis, trauma, excessive perspiration and personal and family history of previous onychomycosis were studied. Laboratory confirmation of diagnosis was done by direct microscopy, fungal culture and PCR. Diagnosis of onychomycosis was confirmed in 50.8% of patients, who tested positive to at least one laboratory test (direct microscopy, fungal culture or PCR). Trichophyton rubrum was predominant both on toenails (85.98%) and on fingernails (38.46%). Independent risk factors for onychomycosis were: old age (OR = 2.285; P < 0.001), family history of previous onychomycosis and/or tinea pedis (OR = 2.452; P = 0.005), excessive perspiration (OR = 2.165; P = 0.002) and higher degree of hyperkeratosis (OR = 1.755; P = 0.020). This is a first epidemiological study of onychomycosis from Serbia.

Levels of Selected Aqueous Humor Mediators (IL-10, IL-17, CCL2, VEGF, FasL) in Diabetic Cataract.

PURPOSE: To compare levels of selected mediators in serums and aqueous humor (AH) of type 2 diabetes mellitus cataract patients with senile cataract patients, and to determine their association with postoperative corneal edema (CE). METHODS: Patients (32 senile and 29 diabetic cataract) undergoing standardized phacoemulsification combined with intraocular lens implantation were recruited. CE was assessed using an ordinal scale (grade 0 to 3). IL-10, CCL2, IL-17, FasL, and VEGF were measured by ELISA. RESULTS: Diabetic patients had higher AH levels of VEGF (p = .042) and IL-10 (p = .021), lower AH levels of FasL (p = .048), and higher serum levels of CCL2 (p = .002). AH levels of CCL2 were higher in diabetic patients with more severe CE at the first postoperative day (p = .012). CONCLUSIONS: We found disturbed AH microenvironment in diabetic cataract, with significant changes for VEGF, IL-10, and FasL. Higher CCL2 was associated with the development of early postoperative CE in diabetic patients.

[Antimycotics susceptibility testing of dermatophytes].

Dermatophytes are moulds that produce infections of the skin, hair and nails of humans and animals. The most common forms among these infections are onychomycosis and tinea pedis affecting 20% of world population. These infections are usually chronic. The treatment of dermatophytoses tends to be prolonged partly because available treatments are not very effective. Antifungal drug consumption and public health expenditure are high worldwide, as well as in Serbia. For adequate therapy, it is necessary to prove infection by isolation of dermatophytes and to test the antifungal susceptibility of isolates. Susceptibility testing is important for the resistance monitoring, epidemiological research and to compare in vitro activities of new antifungal agents. The diffusion and dilution methods of susceptibility tests are used, and technical issues of importance for the proper performance and interpretation of test results are published in the document E.DEF 9.1 (EUCAST) and M38-A2 (CLSI). The aim of our paper is to promptly inform the public about technical achievements in this area, as well as the new organization of laboratory for medical mycology in our country. The formation of laboratory networks coordinated by the National Reference Laboratory for the cause of mycosis need to enable interlaboratory studies and further standardization of methods for antifungal susceptibility testing of dermatophytes, reproducibility of tests and clinical correlation monitoring (MIK values and clinical outcome of dermatophytosis). The importance of the new organization is expected efficient improvement in the dermatophytosis therapy at home, better quality of patient's life and the reduction of the cost of treatment.

[Antifungal drug resistance: mechanisms of resistance, freqeuncy, prevention and control of resistance].

Fungi are important causes of human infections, especially systemic mycoses. Pathogenic fungi have many complex mechanisms of resistance to antifungal drugs. In this article, information about the cellular, genetic and clinical factors contributing to antifungal-drug resistance, and their diagnostic and epidemiologic characteristics are reviewed. Understanding the mechanisms of resistance should assist in developing better detection and preventive strategies. The emergence of acquired antifungal resistance, especially in immunocompromised hosts, has necessitated routine antifungal susceptibility testing. Initial antifungal screening of clinical isolates by the disk-diffusion method would be followed by confirmation of resistant strains by the broth dilution method. Also, strategies to avoid and suppress the antifungal resistance are discussed. There are several strategies to overcome antifungal resistance, including increased antifungal-dose intensity, immunomodulation, combined antifungal therapy and new antifungals.

[IgG serum antibody responses in suspected liver cystic echinococcosis patients].

INTRODUCTION: Cystic echinococcosis is a parasitic zoonosis caused by a tapeworm Echinococcus granulosus. Liver infection is the most common form of human echinococcosis. Diagnosis of liver echinococcosis could be made by different methods. It is very important to have good anamnesis and epidemiological evaluation, clinical status and clinical investigations such as X-ray examination, ultrasonography, nuclear magnetic resonance, computerized tomography, laboratory analysis and serology. Different serologic tests could be used for diagnosis of echinococcosis: complement fixation test, immunoelectrophoresis, indirect haemagglutination, latex agglutination, indirect fluorescence test and enzyme immunoassays sush as ELISA test. OBJECTIVE: The aim of this study was to investigate anti-E granulosus antibodies by ELISA test as a complementary laboratory method in the diagnosis of human echinococcosis. METHOD: In this study, we investigated 212 patients of suspected liver cystic echinococcosis. ELISA test was used for detection of whole anti-E granulosus IgG antibodies specific for AgB. RESULTS: Out of 212 patients, in 26 (12.26%) patients echinococcosis was confirmed by ELISA test. In 7/26 patients who had data about the ultrasonographic morphological type of cyst according to Gharbi, high values of seropositivity were found. Borderline values were found in 15/212 (7.08%) patients. In three patients with borderline values, second sera samples were examined after 18-22 days. In one patient, the test showed the same value, in the second patient echinococcosis was confirmed while in the third, the test showed a negative value. In 171 (80.66%) patients, anti-Echinococcus antibodies were not found by ELISA test. CONCLUSION: It has already been known that serological investigation has some limitations, but detection of specific antibodies remains an indispensable mark in evaluation of suspected liver cystic echinococcosis patients.

Ultraviolet light and pterygium.

The purpose of this study was to evaluate the contribution of ultraviolet light (UV) as a causal factor of primary and pterygium recurrence. A conjuctival autograft transplantation was a surgical method of pterygium treatment. In the first group (38 eyes) were patients with primary and recurrent pterygium exposed to sun (worked outdoors), evaluating geodemographic status, and in the second group (20 eyes) were patients who were not. During 6-12 months of follow up recurrence rate after surgical removal was 27% in the first group and 10% in the second one. UV light seems to have an important role in cause of primary and recurrent pterygium.

Diagnosis of Trichomonas vaginalis infection: The sensitivities and specificities of microscopy, culture and PCR assay.

OBJECTIVES: The aim of this study was to compare wet mount-, Giemsa stain-, acridine orange fluorescent stain-, cultivation- and polymerase chain reaction (PCR)-based approaches to establish which method or combination of methods was most effective in the laboratory diagnosis of trichomoniasis. STUDY DESIGN: Out of 200 investigated patients with various gynecological complaints, Trichomonas vaginalis infection was detected in 27 (13.5%) by any of methods investigated. Among women with trichomonads, a typical clinical finding was presented in only nine. For analysis of sensitivity and specificity of the methods used, the receiver operating characteristic (ROC) curve concept with culture as a gold standard was applied. RESULTS: Infection was diagnosed by wet mount in 14 (7.0%) women, by Giemsa stain in 11 (5.5%) and by acridine orange stain in 16 (8.0%) women. In 21 (10.5%) women, it was diagnosed by culture in Diamond's medium, and in 22 (11.0%) by PCR. For the initial diagnosis of trichomoniasis, wet preparation is the test that is widely available in most STD clinics, but its sensitivity is poor (66.67%). Giemsa stain shows a low sensitivity of 52.38%. Acridine orange shows reasonable sensitivity and specificity of 71.43% and 99.44%, respectively. The sensitivity and specificity of PCR (80.95% and 97.21%) did not exceed that of culture. CONCLUSION: With regard to the fact that trichomoniasis can have an atypical or even asymptomatic course, in order to accurately diagnose this disease, microbiological investigation is necessary. Comparison of different methods showed that at least two techniques, such as culture and acridine orange staining, have the potential for better diagnosis of T. vaginalis infection. PCR detection of infection has been demonstrated to be highly specific and sensitive, but its availability and cost effectiveness are in question. PCR could provide an alternative for laboratory diagnosis of trichomoniasis by culture.

[The role of parasites and fungi in secondary infertility]. / Uloga parazita i gljiva u nastanku sekundarnog steriliteta.

INTRODUCTION: Parasite-host relationships can cause diminished or absent ability to conceive, ectopic pregnancy or pregnancy with undesired course. LITERATURE REVIEW: There are reports that some protozoa, helminths and fungi may impair women's reproductive capacity, causing deformities of genital tract, so that conception is impossible, or, if it does occur, normal implantation and development of placenta are impossible. Schistosoma haematobium may cause vulvar papule, swelling, tumors, irregular vaginal hemorrhage, tubular infertility and ectopic pregnancies. Patients with cirrhosis caused by schistosomas have gonadal dysfunction and schistosomiasis itself can lead to tubular infertility. Some authors found microfilaria of Mansonella perstans in follicular aspirates in patients with tubular adhesions. Chronic Entamoeba histolytica infection can cause pelvic pain and dyspareunia in some patients. Although Trichomonas vaginalis is a common cause of tubal inflammation, this protozoa affects semen quality and leads to secondary infertility. Soluble parasite extract of T. vaginalis can lead to impaired motility of 50% spermatozoa in vitro and affects semen quality by increased viscosity and amount of debris, or damage spermatozoid membrane. In enterobiosis, presence of adult worms and eggs in fallopian tube, can be followed by chronic salpingitis and tubal occlusion. Also in ascariosis, presence of adult forms and eggs can lead to acute colpitis. chronic endometritis, salpingitis or ovarian abscess. The consequence of fungal infections, such as colpitis and endometritis, caused by Candida albicans, may be infertility. Also, according to some reports, C. albicans leads to decreased spermatozoan motility. CONCLUSION: Hence parasites and fungi can cause infertility, we recommend examination of both partners in treatment of infertility.

[Human babesiosis--recent discoveries]. / Humana babezioza--nova saznanja.

INTRODUCTION: Babesiosis is caused by intraerythrocytic parasites of the genus Babesia, which is a common animal infection worldwide. This protozoa requires both a competent vertebrate and a nonvertebrate host (Ixodes sp. etc.) to maintain the transmission cycle. HUMAN BABESIOSIS: Human babesiosis is predominantly caused by Babesia microti (rodent-borne piroplasm, an emerging zoonosis in humans in North America) and by Babesia divergens (bovine pathogen, in Europe). Occasionally, infection in America is caused also by a newly recognized species, so-called WA1 piroplasm. The spectrum of human babesiosis in the USA is broad, and ranges from an apparently silent infection to a fulminant. In Europe, babesiosis is considerably rarer, but more lethal (42% mortality rate in Europe and 5% in the USA, for clinically apparent infections) and mostly in splenectomized patients. Various determinants are involved in the severity of infection, such as age, immunocompetence and coinfection with other pathogens (Borrelia burgdorferi). B. microti antigens can trigger specific activation of T-cells and the infection can be effectively controlled by a Th1-dominant CD4+ T-cell response. The diagnosis of babesiosis should include examination of blood smears stained by Giemsa, as well as serologic evaluation with indirect immunofluorescent antibody tests and possibly PCR. The treatment of babesiosis depends on severity of cases; if it is mild it resolves spontaneously, whereas very severe cases with B. divergens require prompt treatment that includes erythrocyte exchange transfuision along with intravenous clindamycin and oral quinine to arrest hemolysis and prevent renalfailure. This paper offers an overview of recent developments in the investigation of Babesia sp. and babesiosis.

Correlation between clinical symptoms and diagnosis of trichomoniasis in women.

The aim of this study was to investigate correlation between clinical symptoms and diagnosis of trichomoniasis in women. 200 women were included in the study. Swabs were taken from all patients from the posterior vaginal fornix. Each sample was examined using the following five methods: wet mount, Giemsa stain, acridine orange fluorescence stain, cultivation in Diamond medium and PCR method. Trichomoniasis was diagnosed in 27 women using any of the applied methods and 33.3% presented with typical frothy yellow-green discharge, characteristic for tichomoniasis and yellowish discharge characteristic for the third group of vaginal discharge. White discharge, characteristic for Candida infection, was found in 18.5% of patients with diagnosed trichomoniasis. Finally, 14.8% of positive patients had a normal discharge. Based on the results of our study we came to the conclusion that microbiological investigations are necessary for accurate diagnosis of trichomoniasis, as well as for revealing asymptomatic infections, in order to prevent spreading of this relatively common disease.

[First case of Malassezia globosa isolation in Serbia]. / Prvi slucaj isolacije Malassezia globosa kod nas.

Today is known that genus Malassezia includes seven species: M. furfur, M. sympodialis, M. obtusa, M. globosa, M. restricta, M. sloofflae and M. pachydermatis, but role of each of the species in the pathogenesis of disease has not been elucidated yet, so further laboratory isolation and identification are necessary. We report the first case of isolation of Malassezia globosa in Serbia (Belgrade), in a patient suffering from Pityriasis versicolor. Identification of M. globosa was based on macroscopic, microscopic and biochemical characteristics. Isolation was done on Leeming and Notman medium and on mDixona agar, at 350C, during 7 days in aerobic conditions. Also the yeast's biochemical phenotype was determined as catalase (+), lipase (+), esculin degradation (-), Tween (20, 40, 60 and 80) assimilation (-). M. globosa is a lipophilic yeast of the genus Malassezia and the common member of the skin flora. In concordance with some predisponing factors M. globosa is implicated in the pathogenesis of several skin diseases (pityriasis versicolor, malassezia foliculitis, seborheic dermatitis and some forms of atopic dermatitis). In immunocompromised patients and neonates this yeast can even cause fatal systemic infections. Because the role of Malassezia spp. In pathogenesis of skin disease is not still determined, we suggest laboratory diagnosis and identification of these species as a routine diagnostic procedure.

[Characteristics of the immune response in protozoan infections]. / Karakteristike imunskog odgovora u toku infekcije protozoama.

INTRODUCTION: When protozoa enter the blood stream or tissues they can often survive and replicate because they adapt to the resisting natural host defenses. The interaction of immune system with infectious organisms is a dynamic interplay of host mechanisms aimed at eliminating infections and microbial strategies designed to permit survival in the face of powerful effector mechanisms. Protozoa cause chronic and persistent infections, because natural immunity against them is weak and because protozoa have evolved multiple mechanisms for evading and resisting specific immunity. NATURAL AND SPECIFIC IMMUNE RESPONSE TO PROTOZOA: Different protozoa vary greatly in their structural and biochemical properties and stimulate distinct patterns of immune responses and have evolved unique mechanisms for evading specific immunity. Protozoa activate quite distinct specific immune responses, which are different from the responses to fungi, bacteria and viruses. Protozoa may be phagocytozed by macrophages, but many are resistant to phagocytic killing and may even replicate within macrophages. T. brucei gambiense is the best example of protozoa which can induce humoral immune response because of its extra-cellular location. In Leishmania sp. infections, cellular defense mechanisms depend upon CD4+ T-lymphocytes and activate macrophages as effector cells that are regulated by cytokines of Th1 subset. Plasmodium sp. is a protozoa which show the diversity of defence mechanisms which can be cellular or humoral, depending on Ag and protozoa's location. IMMUNE EVASION MECHANISMS OF PROTOZOA: Different protozoa have developed remarkably effective ways of resisting specific immunity: a) anatomic sequestration is commonly observed with protozoa Plasmodium and T. gondii; b) some protozoa can become resistant to immune effector mechanisms: Trypanosoma, Leishmania and T. gondii; c) some protozoa have developed effective mechanisms for varying their surface antigens: Plasmodium and Trypanosoma; d) some protozoa shed their antigen coats, either spontaneously or after binding with specific antibodies: E. histolytica; e) some protozoa alter host immune response by nonspecific and generalized immunosuppression (abnormalities in cytokine production, deficient T cell activation): Trypanosoma, Leishmania, Toxoplasma, Entamoeba. CONCLUSION: Protozoa activate numerous, different immune mechanisms in human body. Evolution, progression and outcome of diseases depend upon these mechanisms. Resent progresses in research have defined and selected Ag as candidates for new vaccines. Better definitions regarding the role of cytokines in protozoan infections will facilitate rational development of cytokines and cytokine antagonists and their use as immunotherapeutic agents.