Phylogeny and taxonomic revision of Microascaceae with emphasis on synnematous fungi.

The taxonomy of the synnematous genera Cephalotrichum, Doratomyces and Trichurus, and other related genera Gamsia, Wardomyces and Wardomycopsis, has been controversial and relies mainly on morphological criteria. These are microascaceous saprobic fungi mostly found in air and soil and with a worldwide distribution. In order to clarify their taxonomy and to delineate generic boundaries within the Microascaceae, we studied 57 isolates that include clinical, environmental and all the available ex-type strains of a large set of species by means of morphological, physiological and molecular phylogenetic analyses using DNA sequence data of four loci (the ITS region, and fragments of rDNA LSU, translation elongation factor 1α and ß-tubulin). The results demonstrate that Cephalotrichum, Doratomyces and Trichurus are congeneric and the genus Cephalotrichum is accepted here with Echinobotryum as a further synonym. The genera Acaulium and Fairmania, typified by A. albonigrescens and F. singularis, respectively, are distinct from Microascus and Scopulariopsis, Gamsia is distinct from Wardomyces, and Wardomycopsis is confirmed as a separate genus in the Microascaceae. Two new species of Cephalotrichum are described as C. brevistipitatum and C. hinnuleum. Nine new combinations are proposed, i.e. Acaulium acremonium, A. caviariforme, Cephalotrichum asperulum, C. columnare, C. cylindricum, C. dendrocephalum, C. gorgonifer, Gamsia columbina and Wardomyces giganteus. A neotype is designed for C. stemonitis. Lectotypes and epitypes are designated for A. acremonium, A. albonigrescens, C. gorgonifer, C. nanum and W. anomalus. Cephalotrichum cylindricum, C. microsporum, F. singularis and Gamsia columbina are also epitypified with new specimens. Descriptions of the phenotypic features and dichotomous keys for identification are provided for accepted species in the different genera.

Dermatomycosis caused by Paranannizziopsis australasiensis in five tuatara (Sphenodon punctatus) and a coastal bearded dragon (Pogona barbata) in a zoological collection in New Zealand.

CASE HISTORY: Health monitoring of tuatara (Sphenodon punctatus) at Auckland Zoo between 2001 and 2009 showed that 58/93 tuatara had been affected by dermatitis of unknown origin. From 2011 onwards, cases of suspected fungal dermatitis underwent extensive diagnostic investigations. CLINCAL FINDINGS: Six cases of dermatomycosis were attributed to Paranannizziopsis australasiensis, five in tuatara and one in a coastal bearded dragon (Pogona barbata). Cases presented typically as raised, yellow to brown encrustations on the skin. Severe cases progressed to necrotising ulcerative dermatitis, and in the bearded dragon to fatal systemic mycosis. Following topical and systemic treatments, lesions resolved in all five tuatara. LABORATORY FINDINGS: Histopathological examination of skin biopsy samples revealed dermatitis with intralesional septate branching hyphae. Fungal culture yielded isolates morphologically resembling Chrysosporium species, and isolates were submitted for molecular confirmation and sequencing of DNA. DIAGNOSIS: All six cases were confirmed as dermatitis due to infection with P. australasiensis, on the basis of fungal culture and DNA sequencing of isolates. CLINICAL RELEVANCE: These are the first reported cases of dermatomycosis associated with P. australasiensis infection in tuatara, and the first cases in which systemic therapeutic agents have been used in the treatment of such disease. Tuatara at the Auckland Zoo are now routinely examined every 3 months and tissue samples from any lesions sent for histopathology and fungal culture. Further work to elucidate the epidemiology and significance of P. australasiensis infections in reptiles in New Zealand is important for both welfare and conservation purposes.

Anti-C1q antibodies in systemic lupus erythematosus.

OBJECTIVE: Anti-C1q has been associated with systemic lupus erythematosus (SLE) and lupus nephritis in previous studies. We studied anti-C1q specificity for SLE (vs rheumatic disease controls) and the association with SLE manifestations in an international multicenter study. METHODS: Information and blood samples were obtained in a cross-sectional study from patients with SLE (n = 308) and other rheumatologic diseases (n = 389) from 25 clinical sites (84% female, 68% Caucasian, 17% African descent, 8% Asian, 7% other). IgG anti-C1q against the collagen-like region was measured by ELISA. RESULTS: Prevalence of anti-C1q was 28% (86/308) in patients with SLE and 13% (49/389) in controls (OR = 2.7, 95% CI: 1.8-4, p < 0.001). Anti-C1q was associated with proteinuria (OR = 3.0, 95% CI: 1.7-5.1, p < 0.001), red cell casts (OR = 2.6, 95% CI: 1.2-5.4, p = 0.015), anti-dsDNA (OR = 3.4, 95% CI: 1.9-6.1, p < 0.001) and anti-Smith (OR = 2.8, 95% CI: 1.5-5.0, p = 0.01). Anti-C1q was independently associated with renal involvement after adjustment for demographics, ANA, anti-dsDNA and low complement (OR = 2.3, 95% CI: 1.3-4.2, p < 0.01). Simultaneously positive anti-C1q, anti-dsDNA and low complement was strongly associated with renal involvement (OR = 14.9, 95% CI: 5.8-38.4, p < 0.01). CONCLUSIONS: Anti-C1q was more common in patients with SLE and those of Asian race/ethnicity. We confirmed a significant association of anti-C1q with renal involvement, independent of demographics and other serologies. Anti-C1q in combination with anti-dsDNA and low complement was the strongest serological association with renal involvement. These data support the usefulness of anti-C1q in SLE, especially in lupus nephritis.

Dermatitis and cellulitis in leopard geckos (Eublepharis macularius) caused by the Chrysosporium anamorph of Nannizziopsis vriesii.

An epizootic of ulcerative to nodular ventral dermatitis was observed in a large breeding colony of 8-month to 5-year-old leopard geckos (Eublepharis macularius) of both sexes. Two representative mature male geckos were euthanized for diagnostic necropsy. The Chrysosporium anamorph of Nannizziopsis vriesii (CANV) was isolated from the skin lesions, and identification was confirmed by sequencing of the internal transcribed spacer region of the rRNA gene. Histopathology revealed multifocal to coalescing dermal and subcutaneous heterophilic granulomas that contained septate fungal hyphae. There was also multifocal epidermal hyperplasia with hyperkeratosis, and similar hyphae were present within the stratum corneum, occasionally with terminal chains of arthroconidia consistent with the CANV. In one case, there was focal extension of granulomatous inflammation into the underlying masseter muscle. This is the first report of dermatitis and cellulitis due to the CANV in leopard geckos.

Deep fungal dermatitis caused by the Chrysosporium anamorph of Nannizziopsis vriesii in captive coastal bearded dragons (Pogona barbata).

Deep fungal dermatitis caused by the Chrysosporium anamorph of Nannizziopsis vriesii (CANV) was diagnosed in a group of coastal bearded dragons (Pogona barbata). The outbreak extended over a 6-month period, with four of six lizards from the same zoological outdoor enclosure succumbing to infection. A fifth case of dermatomycosis was identified in a pet lizard originally sourced from the wild. Diagnosis of infection with the CANV was based on similar clinical signs and histopathology in all animals and confirmed by culture and sequencing of the fungus from one animal. This is the first report of the CANV causing disease in a terrestrial reptile species in Australia and the first in the coastal bearded dragon.

Personal de salud como agente preventivo del tabaquismo en Santiago de Cuba / Health Personnel as Preventive Agents of Smoking in Santiago de Cuba Province

Objetivo: Identificar en el personal de salud capacidades esenciales contra el tabaquismo. Diseño: Estudio descriptivo, de tipo transversal. Método: Seevaluó una muestra de 129 trabajadores de salud ( 75 médicos (as), 54 enfermeras(os), de los diferentes municipios de la provincia Santiago de Cuba, a loscuales se le aplicaron técnicas cuantitativas y cualitativas en la secuencia siguiente: entrevistas en profundidad, encuestas, grupos focales y observación, eninstituciones educacionales: El tratamiento estadístico o la información obtenida incluyendo el cálculo de medidas de resumen y aplicación de χ2.Resultados: El 84 por ciento de trabajadores de salud no fumaban en su puesto, sólo el 7 por ciento consideraba como droga el tabaquismo, un 36 por ciento referían que nohabían carteles prohibitvos del hábito de fumar en su institución, el 69 por ciento recomienda habitualmente a los educadores no fumar delante de los niños. El 79 por cientodel personal de salud considera necesario que lo capaciten en tabaquismo, pues no se sienten preparados la mayoría confunde orientar e informar conaconsejar, en ninguna historia clínica de niños con problemas respiratorios, se reflejó la orientación antitabáquica hacia los padres. Conclusiones: Hayincompetencia en el personal de salud de estas instituciones que limitan su desempeño exitoso contra el tabaquismo por falta de formación académica, faltade exigencia y sostenibilidad en las instituciones educacionales para cumplir las disposiciones antitabáquicas vigentes, no hay diferencias entremédicos(as) y enfermeras(os) con relación a sus actitudes y competencias antitabáquicas(AU)

Objective: To identify essential abilities against smoking in health personnel. Design: Descriptive and cross-sectional study. Methods: We evaluated asample of 129 health workers (75 physicians and 54 nurses) from different Santiago de Cuba Province municipalities, in whom quantitative and qualitativetechniques were applied in the following sequence: in-depth interview; survey; focus group, and direct observation at childrens educational facilities.Statistical treatment or the obtained information including calculation of measured of summary, estimated by 95 percentil confidence interval reliability of eventsof-interest probabilities, and application of the χ2 test. Results: A total of 84 percentil of health workers did not smoke at their place of work, only 7 percent of workersconsidered smoking as a drug, 36.4 percent referred that there was visible ban such as posters against smoking at their workplace, and 69 percentil usually recommendsthat educators not smoke where they can be observed by the children. A total of 79 percent of health personnel consider it necessary to be offered courses onsmoking, because they do not feel prepared; the majority confuses the concepts of orienting and informing with that of counselling. No clinical file ofchildren with respiratory problems reflected anti-smoking orientation for their parents. Conclusions: Incompetence in the performance of health personnelat these facilities limits success in their work against smoking, due to lack of academic formation, and mainly lack of insistence and sustainability at theseeducational facilities in carrying out anti- smoking regulations. There is no difference between physicians and nurses regarding attitudes and anti-smokingcompetency(AU)

Pathogenicity of the Chrysosporium anamorph of Nannizziopsis vriesii for veiled chameleons (Chamaeleo calyptratus).

Veiled chameleons (Chamaeleo calyptratus) were experimentally challenged with the fungus Chrysosporium anamorph of Nannizziopsis vriesii (CANV). Chameleons were exposed to conidia in their captive environment, or were inoculated by direct application of a conidial suspension inoculum on intact and on abraded skin. The CANV induced lesions in all experimental groups and was recovered from infected animals, fulfilling Koch's postulates and confirming that it may act as a primary fungal pathogen in this species of reptile. A breach in cutaneous integrity, as simulated by mild scarification, increased the risk of infection but was not required for the CANV to express pathogenicity. Initial hyphae proliferation occurred in the outer epidermal stratum corneum, with subsequent invasion of the deeper epidermal strata and dermis. A spectrum of lesions was observed ranging from liquefactive necrosis of the epidermis to granulomatous inflammation in the dermis. CANV dermatomycosis appears to be contagious and can readily spread within a reptile collection, either directly through contact with infective arthroconidia or indirectly via fomites. Dense tufts of arthroconidiating hyphae were demonstrated histologically on the skin surface of many animals that developed dermatomycosis, and these arthroconidia may act as infective propagules involved in the transfer of disease between reptiles.

Disseminated Beauveria bassiana infection in a patient with acute lymphoblastic leukemia.

We describe a case of disseminated Beauveria bassiana infection in a patient with acute lymphoblastic leukemia. Her infection was successfully treated with amphotericin B and itraconazole. B. bassiana is rarely reported as a human pathogen. It is commonly found in soil and because of its pathogenicity to many insect species is incorporated into several pesticides.

Mycorrhizal and root endophytic fungi of containerized Picea glauca seedlings assessed by rDNA sequence analysis.

Fungi colonizing fine roots of containerized Picea glauca seedlings were assessed in four large conifer nurseries in northern Alberta. PCR amplification of fungal rDNA (internal transcribed spacer and a portion of the 5' end of the large subunit gene) from random samples of fine feeder roots gave between 1 and 4 amplicons per seedling. Amplicons were either separated by electrophoresis and sequenced directly, or cloned and sequenced. The resulting sequences were compared to sequences obtained from cultures established from seedling roots and from GenBank by maximum parsimony analysis. ITS sequences formed 11 distinct clades, each including at least one reference sequence. The ectomycorrhizal basidiomycetes Thelephora americana and Amphinema byssoides were dominant, whereas ascomycetes were less common. Fungi with sequences similar to members of the Heleotiales which form ericoid mycorrhizas were also present. Correspondence analysis revealed strong positive and negative associations among fungal taxa as well as an influence of applied fertilizer level on fungal diversity and species composition.

Chrysosporium anamorph of Nannizziopsis vriesii associated with fatal cutaneous mycoses in the salt-water crocodile (Crocodylus porosus).

The Chrysosporium anamorph of Nannizziopsis vriesii, recently identified as the cause of cutaneous infections in chameleons and brown tree snakes, was associated with skin infections and deaths in salt-water crocodile (Crocodylus porosus) hatchlings on two separate occasions 3 years apart. In all, 48 animals died from the infection. All hatchlings came from the same farm in northern Queensland, Australia.

Arachnomyces kanei (anamorph Onychocola kanei) sp. nov., from human nails.

Five isolates of a slow-growing cycloheximide resistant hyphomycetous fungus were obtained from nail specimens and investigated for their relationship to Onychocola canadensis (teleomorph Arachnomyces nodosetosus), a known agent of onychomycosis. In one patient diagnosed with superficial white onychomycosis, etiology was confirmed by a nail sample showing atypical filaments in direct microscopy, and by a follow-up specimen yielding cultures of the same fungus. A case of mixed infection with Aspergillus sydowii was also confirmed after examination of cultures grown from three successive microscopic-positive hallux nail specimens. For other isolates, etiological significance could not be confirmed by repeat sampling or results of direct microscopy were negative or unknown. Mating experiments yielded setose ascomata containing smooth oblate ascospores typical of Arachnomyces species. Phylogenetic analysis of ITS 2 region sequences support the conspecificity of the isolates and their placement within the genus. A. kanei sp. nov. (anamorph O. kanei sp. nov.) is described.

Aortocava fistula: experience with five patients.

Combined injuries of the aorta and inferior vena cava are rare. Mortality is over 70%, primarily from exsanguinating hemorrhage. Post-traumatic aortocava fistula can develop in survivors, who present in the postoperative period with manifestations of high output heart failure. This is a retrospective review of five male patients, age from 9 to 39 years, with aortocava fistulas that were referred with congestive heart failure, 2 days to 6 months after abdominal penetrating injuries. They had undergone surgery at another hospital and several organ injuries were treated. Retroperitoneal hematomas were not seen or were seen and left undisturbed. Four patients received a gunshot injury, had the fistula at the infrarenal level, and survived surgical repair. In one of the survivors, a left popliteal artery bullet embolism also occurred and was treated. Another patient sustained a thoracoabdominal stab injury and an aortocava fistula developed at the suprarenal level; he was in severe congestive heart failure and died during surgery. There are very few reports on this sequelae of vascular injuries at the abdominal level. Patients with aortic and cava injuries have a high mortality rate and arteriovenous fistula may develop with communicating pseudoaneurysms. If high output heart failure develops in a patient with a history of abdominal penetrating injury, an arteriovenous fistula must be suspected and arteriography will disclose the location of the fistula. Surgical treatment is necessary to prevent further heart damage. In the future endovascular procedures may have a role in the management of these difficult conditions.

High mortality in a large-scale zebrafish colony (Brachydanio rerio Hamilton & Buchanan, 1822) associated with Lecythophora mutabilis (van Beyma) W. Gams & McGinnis.

Zebrafish (Brachydanio rerio) have become an important model system for studying vertebrate embryonic development and gene function through manipulation of genotype and characterization of resultant phenotypes. An established research zebrafish colony without substantial disease problems for more than 7 years of operation began experiencing appreciable mortalities in November of 1997. Young fish (fry), from five to 24 days after hatching, spontaneously developed elongate strands of organic material protruding from the mouth, operculum, and anal pore, leading workers in the laboratory to describe the infected fish as "bearded." Unlike typical freshwater fish fungal infections, the skin surface did not have evidence of fungal colonization. The disease was associated with progressive lethargy, reduced feeding, and subsequent mortality. From 10 to 100% of the fry in a given tank were affected. Initial examination indicated that the biofilm around the head of affected fry consisted of bundles of septate fungal hyphae, large numbers of mixed bacterial populations, and protozoans. Environmental samples of air and water in the laboratory were obtained to ascertain the source of the infective agent and to isolate and identify the fungus. A fungus identified as Lecythophora mutabilis was isolated repeatedly from infected fish and water samples from infected fish tanks, and from the main laboratory water supply tanks, but not from laboratory air. Some biofilm beards on fish were found to consist of relatively pure bacterial populations, and beards on occasional fish examined in the later part of the study consisted of hyphae and spores of the oomycete genus Aphanomyces. Lecythophora mutabilis did not invade tissues; however, elimination of the epizootic correlated with reduction in the number of L. mutabilis conidia in the water following modification of the laboratory water system by use of new filtration and sterilization systems. We conclude that the dense hyphal strands of L. mutabilis composing the predominant biofilm type, along with mixed bacteria and protozoa, contributed to the die-off in young fry by occluding the oral cavity and/or gills, leading to starvation and/or asphyxiation.

Acrophialophora fusispora brain abscess in a child with acute lymphoblastic leukemia: review of cases and taxonomy.

A 12-year-old girl with acute lymphoblastic leukemia was referred to King Faisal Specialist Hospital and Research Center. The diagnosis without central nervous system (CNS) involvement was confirmed on admission, and chemotherapy was initiated according to the Children Cancer Group (CCG) 1882 protocol for high-risk-group leukemia. During neutropenia amphotericin B (AMB) (1 mg/kg of body weight/day) was initiated for presumed fungal infection when a computed tomography (CT) scan of the chest revealed multiple nodular densities. After 3 weeks of AMB therapy, a follow-up chest CT revealed progression of the pulmonary nodules. The patient subsequently suffered a seizure, and a CT scan of the brain was consistent with infarction or hemorrhage. Because of progression of pulmonary lesions while receiving AMB, antifungal therapy was changed to liposomal AMB (LAMB) (6 mg/kg/day). Despite 26 days of LAMB, the patient continued to have intermittent fever, and CT and magnetic resonance imaging of the brain demonstrated findings consistent with a brain abscess. Aspiration of brain abscess was performed and the Gomori methenamine silver stain was positive for hyphal elements. Culture of this material grew Acrophialophora fusispora. Lung biopsy showed necrotizing fungal pneumonia with negative culture. The dosage of LAMB was increased, and itraconazole (ITRA) was added; subsequently LAMB was discontinued and therapy was continued with ITRA alone. The patient demonstrated clinical and radiological improvement. In vitro, the isolate was susceptible to low concentrations of AMB and ITRA. A. fusispora is a thermotolerant, fast-growing fungus with neurotropic potential. We report the first case of human infection involving the CNS. Acrophialophora resembles Paecilomyces but differs in having colonies that become dark and in the development of phialides along the sides or at the tips of echinulate brown conidiophores. Conidia are borne in long chains and are smooth or ornamented with fine-to-coarse echinulations, sometimes in spiral bands. The taxonomy of the genus Acrophialophora is reviewed, and Acrophialophora nainiana and Acrophialophora levis are considered as synonyms of A. fusispora.

White grain mycetoma caused by a Cylindrocarpon sp. in India.

We describe a case of white grain eumycetoma of the foot of an Indian male caused by a slow-growing, poorly sporulating fungus that does not match any known agent of this infection. Histologic examination of a biopsy tissue specimen showed oval, lobular, white granules composed of hyaline, septate hyphae, and thick-walled chlamydospores. Culture of granules from a draining sinus yielded compact, very-slow-growing, poorly sporulating colonies producing a strong reddish brown pigment that diffused into the medium. The fungus was identified as a Cylindrocarpon sp. based on the development of rare cylindrical conidia borne from solitary phialides lacking collarettes, in addition to chlamydospores formed singly or in short chains.

Medical management of Beauveria bassiana keratitis.

PURPOSE: To describe a case of Beauveria bassiana keratitis and to discuss the management of this rare condition. METHODS: An 82-year-old woman underwent surgical repair of a graft wound dehiscence. Seven months later, shortly after the removal of sutures, the patient developed a fungal keratitis. B. bassiana was identified as the infecting organism. The patient was treated with topical natamycin and oral fluconazole. RESULTS: Following antifungal therapy, the corneal ulcer was eradicated, but the patient underwent repeat penetrating keratoplasty for decreased vision due to corneal edema. The graft remains clear and visual acuity is substantially improved. CONCLUSION: The medical management of B. bassiana keratitis has previously been unsuccessful. The use of topical natamycin combined with oral fluconazole in the management of this case is discussed.

Pulmonary infection caused by Gymnascella hyalinospora in a patient with acute myelogenous leukemia.

We report the first case of invasive pulmonary infection caused by the thermotolerant ascomycetous fungus Gymnascella hyalinospora in a 43-year-old female from the rural midwestern United States. The patient was diagnosed with acute myelogenous leukemia and treated with induction chemotherapy. She was discharged in stable condition with an absolute neutrophil count of 100 cells per microliter. Four days after discharge, she presented to the Cancer Clinic with fever and pancytopenia. A solitary pulmonary nodule was found in the right middle lobe which was resected by video-assisted thoracoscopy (VATHS). Histopathological examination revealed septate branching hyphae, suggesting a diagnosis of invasive aspergillosis; however, occasional yeast-like cells were also present. The culture grew a mold that appeared dull white with a slight brownish tint that failed to sporulate on standard media. The mold was found to be positive by the AccuProbe Blastomyces dermatitidis Culture ID Test (Gen-Probe Inc., San Diego, Calif.), but this result appeared to be incompatible with the morphology of the structures in tissue. The patient was removed from consideration for stem cell transplant and was treated for 6 weeks with amphotericin B (AmB), followed by itraconazole (Itr). A VATHS with biopsy performed 6 months later showed no evidence of mold infection. In vitro, the isolate appeared to be susceptible to AmB and resistant to fluconazole and 5-fluorocytosine. Results for Itr could not be obtained for the case isolate due to its failure to grow in polyethylene glycol used to solubilize the drug; however, MICs for a second isolate appeared to be elevated. The case isolate was subsequently identified as G. hyalinospora based on its formation of oblate, smooth-walled ascospores within yellow or yellow-green tufts of aerial hyphae on sporulation media. Repeat testing with the Blastomyces probe demonstrated false-positive results with the case isolate and a reference isolate of G. hyalinospora. This case demonstrates that both histopathologic and cultural features should be considered for the proper interpretation of this molecular test and extends the list of fungi recognized as a cause of human mycosis in immunocompromised patients.

Maxillary sinusitis caused by medusoid form of Schizophyllum commune.

We present a case of maxillary sinusitis in a diabetic female caused by the basidiomycete fungus Schizophyllum commune. Identification of the isolate was hampered by its atypical features. Subcultures formed sterile medusoid structures from nonclamped mycelia until spontaneous dikaryotization resulted in the development of characteristic fan-shaped fruiting bodies. Identification was confirmed by the presence of spicules formed on the hyphae and by vegetative compatibility with known isolates.

Fatal mycotic dermatitis in captive brown tree snakes (Boiga irregularis).

Cutaneous fungal infections occurred in four captive brown tree snakes (Boiga irregularis). The ventral scales were most commonly affected, and lesions began as areas of erythema and edema with vesicle formation, followed by development of caseous brown plaques. Lesions usually started where ventral scales overlapped and spread rapidly. All snakes died within 14 days after clinical signs were first noted. The deaths of three of the snakes were directly attributable to the cutaneous disease; the other snake died from renal failure and visceral gout, most likely induced by gentamicin therapy. Histologically, lesions consisted of epidermal hyperplasia and hyperkeratosis, with foci of epidermal necrosis, intraepidermal vesicle formation, and subacute inflammation of the underlying dermis. These lesions were associated with bacteria and numerous septate, branched fungal hyphae within the epidermis and overlying serocelluar crusts. Hyphae that penetrated through the superficial surface of the epidermis often formed terminal arthroconidia. The same species of fungus was isolated in pure culture from the skin of three snakes, but fungal cultures were not performed on samples from the fourth snake. The fungus has been identified as the Chrysosporium anamorph of Nannizziopsis vriesii based on its formation of solitary dermatophytelike aleurioconidia and alternate and fission arthroconidia. The source of the fungus in this outbreak was not determined; however, the warm, moist conditions under which the snakes were housed likely predisposed them to opportunistic cutaneous fungal infections.