[Scabies-Renaissance of an ectoparasite infection : Diagnosis and therapy-How to proceed in practice]. / Skabies ­ Renaissance einer Ektoparasitose : Diagnostik und Therapie ­ Vorgehen in der Praxis.

Scabies or mange is currently a common dermatosis in Germany and other countries, and should be more important in health policy. It affects a cross-section of society, including all age groups, from infants to the aged. Locals and people with a migration background both suffer from this highly contagious ectoparasite infection with excessive, predominately nocturnal itching. Clinical diagnosis represents a challenge for the experienced dermatologist due to the variety of dermatosis to be considered in the differential diagnosis. It is still unclear whether treatment failure or the recurrences observed everywhere are due to in vitro and in vivo resistance of the pathogen agent Sarcoptes scabiei against permethrin or ivermectin. Therapeutic errors seem to play a role as often not all direct contact persons are recorded and treated with antiscabious treatment. They form the reservoir for reinfections. In the event of repeated nonresponse to topical (permethrin) and/or oral antiscabious treatment, alternative topical preparations-benzyl benzoate or crotamiton-should be used. Combination with ivermectin is mandatory.

Spread of Terbinafine-Resistant Trichophyton mentagrophytes Type VIII (India) in Germany-"The Tip of the Iceberg?"

Chronic recalcitrant dermatophytoses, due to Trichophyton (T.) mentagrophytes Type VIII are on the rise in India and are noteworthy for their predominance. It would not be wrong to assume that travel and migration would be responsible for the spread of T. mentagrophytes Type VIII from India, with many strains resistant to terbinafine, to other parts of the world. From September 2016 until March 2020, a total of 29 strains of T. mentagrophytes Type VIII (India) were isolated. All patients were residents of Germany: 12 females, 15 males and the gender of the remaining two was not assignable. Patients originated from India (11), Pakistan (two), Bangladesh (one), Iraq (two), Bahrain (one), Libya (one) and other unspecified countries (10). At least two patients were German-born residents. Most samples (21) were collected in 2019 and 2020. All 29 T. mentagrophytes isolates were sequenced (internal transcribed spacer (ITS) and translation elongation factor 1-α gene (TEF1-α)). All were identified as genotype VIII (India) of T. mentagrophytes. In vitro resistance testing revealed 13/29 strains (45%) to be terbinafine-resistant with minimum inhibitory concentration (MIC) breakpoints ≥0.2 µg/mL. The remaining 16 strains (55%) were terbinafine-sensitive. Point mutation analysis revealed that 10/13 resistant strains exhibited Phe397Leu amino acid substitution of squalene epoxidase (SQLE), indicative for in vitro resistance to terbinafine. Two resistant strains showed combined Phe397Leu and Ala448Thr amino acid substitutions, and one strain a single Leu393Phe amino acid substitution. Out of 16 terbinafine-sensitive strains, in eight Ala448Thr, and in one Ala448Thr +, new Val444 Ile amino acid substitutions were detected. Resistance to both itraconazole and voriconazole was observed in three out of 13 analyzed strains. Treatment included topical ciclopirox olamine plus topical miconazole or sertaconazole. Oral itraconazole 200 mg twice daily for four to eight weeks was found to be adequate. Terbinafine-resistant T. mentagrophytes Type VIII are being increasingly isolated. In Germany, transmission of T. mentagrophytes Type VIII from the Indian subcontinent to Europe should be viewed as a significant public health issue.

[Extensive tinea corporis due to a terbinafine-resistant Trichophyton mentagrophytes isolate of the Indian genotype in a young infant from Bahrain in Germany]. / Ausgeprägte Tinea corporis durch ein Terbinafin-resistentes Trichophyton-mentagrophytes-Isolat vom indischen Genotyp bei einem Säugling aus Bahrain in Deutschland.

A 6 month-old-female infant from Bahrain visiting Germany with her family for a holiday was seen by us for extensive dermatophytosis of the back, buttocks, chest and groins. Topical treatment by terbinafine for over 2 months was not successful. Other family members including adults and children were treated in Bahrain with topical antifungals and oral voriconazole which was not helpful. Mycological examination performed in Germany revealed the detection of the zoophilic dermatophyte Trichophyton (T.) mentagrophytes. The newly described genotype VIII within the species T. mentagrophytes was identified by sequencing of the "internal transcribed spacer" (ITS) region of the fungal rDNA. This genotype of T. mentagrophytes is the main causative agent of the current epidemic of chronic recalcitrant dermatophytoses in India. Transmission of this Indian genotype of T. mentagrophytes to other countries due to globalization is a serious issue to be considered. Moreover, a significant percentage of these Indian T. mentagrophytes strains are resistant to terbinafine both in vitro and by the way of genetic point mutations in the squalene epoxidase (SQLE) gene. Some are also found to be partially resistant against itraconazole and voriconazole. The point mutation TTC/TTA was found by SQLE mutation analysis in this particular T. mentagrophyte isolate from Bahrain. This point mutation is closely associated with F397L amino acid substitution of the enzyme indicative of in vitro resistance of the dermatophyte against terbinafine. The girl was successfully treated by topical miconazole and later by ciclopirox olamine. This is the first report on an infection due to a terbinafine-resistant T. mentagrophytes strain of the ITS genotype VIII from India in Germany.

[Anaphylactic reaction to soy drink in three patients with birch pollen allergy]. / Anaphylaktische Reaktion auf ein Sojagetränk bei drei Patienten mit Birkenpollenallergie.

Three patients presented with anaphylactic reactions to soy drink. Cross-reactivity of soy protein with birch pollen allergens was identified as the cause for their severe reactions. Because of the rising popularity of soy products and the large number of birch pollen allergic patients, allergologists will be increasingly confronted with these reactions in future. Patients with birch pollen allergy should avoid the intake of soy protein.