Difficulties in diagnosing Malassezia furfur bloodstream infection and possibility of spontaneous resolution in a patient undergoing chemotherapy for neuroblastoma: A case report.

Malassezia furfur is a lipophilic, yeast-like fungus that forms part of the normal human skin microflora and is associated with a wide range of infections, such as pityriasis versicolor, folliculitis, and systemic infections in immunocompromised patients. Although matrix-assisted laser desorption/ionization time-of-flight mass spectrometry has enabled rapid identification of Malassezia species, it is still a challenge to diagnose systemic infections because Malassezia fungemia can often be missed by automated blood culture systems. We report a case in which M. furfur in blood was detected by the presence of yeast-like fungi in blood smears. Yeast-like organisms were observed in the blood smears of a 3-year-old boy, taken over 2 weeks without any symptoms. He had undergone several courses of chemotherapy for neuroblastoma via an indwelling central venous catheter (CVC) that was placed in his right anterior chest for 11 months. Although the blood cultures obtained from an automated blood culture system were negative, M. furfur growth was detected in the subcultured blood taken from the CVC. The CVC was removed, and the scheduled chemotherapy was postponed. No systemic M. furfur bloodstream infection occurred; the infection resolved spontaneously without any specific treatment; only prophylactic fluconazole was administered. M. furfur fungemia may not be diagnosable by an automated blood culture system. Further, M. furfur may not cause infections in humans even when administered intravenously. This report may lead to the discovery of factors related to human infectivity of this disease in the future.

A case of anti- pityriasis versicolor therapy that preserves healthy mycobiome.

BACKGROUND: The impact of Malassezia yeasts on skin mycobiome and health has received considerable attention recently. Pityriasis versicolor (PV), a common dermatosis caused by Malassezia genus worldwide, is a manifestation of dysbiosis. PV can be associated with hyper- and/or hypopigmented skin lesions. This disease entity is characterized by high percentage of relapses, which demands a proper antifungal therapy that is based on unambiguous species identification and drug susceptibility testing. CASE PRESENTATION: Comprehensive analysis of PV case in man presenting simultaneously hyper- and hypopigmented skin lesions was performed. Conventional and molecular diagnostic procedures revealed Malassezia furfur and Malassezia sympodialis, respectively as etiological agents of skin lesions observed. Susceptibility tests showed significantly lowered sensitivity of M. furfur cells to fluconazole. Based on susceptibility profiles local antifungal therapy with drugs characterized by entirely different mechanism of action was included. CONCLUSIONS: Our study indicates that cases of PV represented by two types of skin lesions in one patient may be associated with distinct Malassezia species. Moreover, as observed in this case, each of the isolated etiological agents of PV may differ significantly in susceptibility to antifungals. This can significantly complicate the treatment of dermatosis, which by definition is associated with a significant percentage of relapses. In the presented case localized topical treatment was sufficient and successful while allowing maintaining the physiological mycobiome.

Acquired disorders with hypopigmentation: A clinical approach to diagnosis and treatment.

Acquired hypopigmented skin changes are commonly encountered by dermatologists. Although hypopigmentation is often asymptomatic and benign, occasional serious and disabling conditions present with cutaneous hypopigmentation. A thorough history and physical examination, centered on disease distribution and morphologic findings, can aid in delineating the causes of acquired hypopigmented disorders. The second article in this 2-part continuing medical education series focuses on conditions with a hypopigmented phenotype. Early diagnosis and appropriate management of these disorders can improve a patient's quality of life, halt disease progression, and prevent irreversible disability.

Presentations, Signs of Activity, and Differential Diagnosis of Vitiligo.

Vitiligo has a variety of presentations, including focal, acrofacial, segmental, and generalized forms. Thorough knowledge of these presentations is important to make the correct diagnosis. Signs of activity are important to recognize so that treatment is optimized. Clinical findings of confettilike depigmentation, trichrome and inflammatory vitiligo, and the Koebner phenomenon should alert the clinician that a patient's disease is likely to worsen. These patients may require systemic treatment to stabilize their disease. Many other skin disorders present with hypopigmentation or depigmentation and must be distinguished to determine the right diagnosis, advise the patient on prognosis, and prescribe the correct treatment.

Folliculocentric tinea versicolor.

Tinea versicolor (TV) is typically an asymptomatic fungal infection of the stratum corneum owing to Malassezia overgrowth. It presents as hypo or hyperpigmented macules with fine scale that coalesce into patches on the trunk, neck, and/or arms. Presented in this report is a 34-year-old man with an interesting case of folliculocentric tinea versicolor manifesting as perifollicular hypopigmented macules on the lower back.

Atrophic pityriasis versicolor occurring in a patient with Sjögren's syndrome.

Pityriasis versicolor is one of the most frequent epidermal mycotic infections in the world, but its atrophic variant is rarely described. The aetiology of the atrophy is still unknown, and two main hypotheses have been formulated, one suggesting a correlation with long-term use of topical steroids and the other a delayed type hypersensitivity to epicutaneous antigens derived from components of the fungus. Atrophic pityriasis versicolor is a benign disease, but needs to be distinguished from other more severe skin diseases manifesting with cutaneous atrophy. The diagnosis can be easily confirmed by direct microscopic observation of the scales soaked in 15% potassium hydroxide, which reveals the typical 'spaghetti and meatball' appearance, or by a skin biopsy in doubtful cases. Here, we describe a case of extensive atrophic pityriasis versicolor occurring in a woman affected by Sjögren's syndrome which completely resolved after topical antifungal treatment.

Fungemia and interstitial lung compromise caused by Malassezia sympodialis in a pediatric patient.

A case of fungemia with interstitial lung compromise caused by Malassezia sympodialis is reported in an obese pediatric patient on long-term treatment with inhaled corticosteroids for asthma. The patient was hospitalized due to a post-surgical complication of appendicitis. The patient was treated with amphotericin B for 3 weeks, with good clinical evolution and subsequent negative cultures.

Hair loss in pityriasis versicolor lesions: a descriptive clinicopathological study.

BACKGROUND: We have observed that hair thinning and/or loss occur at times as a presenting symptom or sign in patients with pityriasis versicolor (PV). OBJECTIVE: Our objective was to verify and explore this clinical observation and depict its underlying pathology. METHODS: A total of 39 patients with PV were examined during a period of 11 months and skin biopsy specimens were taken from lesional and nonlesional skin. Hematoxylin-eosin- and periodic acid-Schiff-stained sections were examined and described. Results were statistically analyzed. RESULTS: Hair loss and/or thinning within PV lesions was shown in 61.5% of patients (P value < .0005), appearing most commonly on forearms, abdomen, and neck as well as the beard area (only in male participants). Histopathologically, in addition to the classically described features of PV, basal hydropic degeneration, follicular degeneration, miniaturization, atrophy, plugging, and/or hair shaft absence occurred in 46% of lesional versus 20.5% of nonlesional biopsy specimens (P value < .05); these changes appeared to be directly or indirectly related to the presence of Malassezia organisms in hair follicles and/or stratum corneum. LIMITATIONS: Some patients with PV lesions on the face did not approve facial biopsy. CONCLUSION: This study provides clinical and histopathological evidence that PV lesions may be associated with hair thinning and/or loss.

Interesting effect of Malassezia spp. infection on dermatoses of other origins.

BACKGROUND: Tinea versicolor (TV) is a superficial fungal infection affecting as many as 40% of the population in the tropics. We noticed an unusual affect of TV on dermatoses of other origins. METHODS: In this prospective clinical study, we examined patients attending our dermatology outpatient department over a period of one year for coexistence of TV with any unrelated dermatoses. We confirmed the diagnosis of TV by microscopy of skin scrapings. Skin biopsy was performed when necessary to confirm the diagnosis of associated dermatoses. RESULTS: We describe four cases in which unrelated dermatoses (viral exanthem, acute generalized exanthematous pustulosis, polymorphous light eruption, and irritant contact dermatitis) specifically spared sites affected with TV. CONCLUSIONS: Recent research has elucidated the immunomodulatory properties of Malassezia spp. in vitro. Our cases serve as possible in vivo models illustrating such properties. Further studies based on these reports could lead to the isolation of molecules from Malassezia, which may have potential use in anti-inflammatory drug formulations.

Hypopigmented macules: leprosy, atopy or pityriasis versicolor?

Lepromatous leprosy (LL) represents the highest infective and multibacillary form of leprosy. Clinical manifestations are consequent to the haematogenous spread of bacilli and include macules, plaques and nodules in a symmetric distribution or a diffuse infiltration of the skin. LL may mimic many different inflammatory and neoplastic skin diseases and in a small percentage of patients, skin manifestation may be atypical. This article reports the case of a South American child with LL presenting with symmetrically distributed hypopigmented macules previously misdiagnosed as pytiriasis alba, atopic dermatitis and pityriasis versicolor. Atopy and pityriasis versicolor are common skin conditions that can be also observed in leprosy patients and that can masquerade the diagnosis of LL, especially if occurring in dark skin. Dermatologists in Europe should be aware of this unusual form of presentation of leprosy and must take in mind Hansen disease in the differential diagnosis in patients coming from endemic areas.

Etanercept e infecciones / Etanercept and infections

Los tratamientos biológicos para la psoriasis, principalmente los inhibidores del factor de necrosis tumoral alfa (TNF-α), han demostrado su eficacia y seguridad desde los ensayos clínicos hasta su posterior comercialización. Sin embargo, los estudios de farmacovigilancia han detectado un ligero incremento de las infecciones. El manejo del riesgo infeccioso en los pacientes con psoriasis en tratamiento con etanercept u otros medicamentos anti-TNF pasa por valorar la idoneidad de su uso en aquellos pacientes con infecciones por los virus de la hepatitis C, B y de la inmunodeficiencia humana, con infecciones activas localizadas o generalizadas, con riesgo de sepsis (portadores de catéteres endovenosos y sondas urinarias permanentes) o con trastornos subyacentes que pudieran predisponer a sufrir infecciones (diabetes, hemodiálisis). En caso de que un paciente en tratamiento con etanercept presente una infección, si ésta es grave debe suspenderse el tratamiento y si es leve deberá seguirse estrechamente al paciente, y la interrupción del tratamiento se decidirá en función de su evolución. La larga experiencia de uso de etanercept en diferentes enfermedades permite afirmar que tiene un buen perfil de seguridad en lo que se refiere a las infecciones, si se toman las precauciones referentes a la tuberculosis y a la concomitancia de otras infecciones activas durante el tratamiento (AU)

The biological treatments for psoriasis, mainly the tumor necrosis factor-alpha inhibitors (TNF-α), have demonstrated their efficacy and safety beginning with the clinical trials up to their subsequent marketing. However, pharmacovigilance studies have detected a mild increase in infections. For the management of infectious risk in patients with psoriasis being treated with etanercept or other anti-TNF medications, an evaluation should be made of the adequacy of its use in patients infected by HCV, HBV, HIV, with localized or generalized infections, with risk of sepsis (carriers of intravenous catheter and indwelling urinary catheter) or with underlying disorders that could predispose them to infections (diabetes, hemodialysis). If a patient under treatment with etanercept presents an infection, if the infection is serious, treatment should be discontinued and if it is mild, the patient should be closely monitored and treatment interrupted if decided based on the evolution. Long experience on the use of etanercept in different diseases has made it possible to state that it has a good safety profile in regards to infections, if precautions are taken in regards to tuberculosis and the concomitance of other active infections during the treatment (AU)

Anxiety and depression in patients with pityriasis rosea compared to patients with tinea versicolor.

BACKGROUND: Few researchers have specifically evaluated how the quality of life of patients with pityriasis rosea (PR) and tinea versicolor (TV) are affected. There are even less studies exploring the psychological status of these patients. The objective of this study was to investigate and compare quality of life and psychological status of patients with PR and TV. METHOD: Thirty-six patients with pityriasis rosea and 43 patients with tinea versicolor (N = 79) were selected for the study. All patients were required to complete Dermatology Life Quality Index (DLQI) and Hospital Anxiety and Depression (HAD), Hospital Anxiety and Depression-Depression (HAD-D), and Hospital Anxiety and Depression-Anxiety (HAD-A) scales. RESULTS: Both groups did not differ from each other with regard to DLQI, HAD-D, HAD-A, and total HAD scores (p > 0.05). With regard to cutoff points of HAD-A, 11 patients in the PR group and 15 patients in the TV group had anxiety. The number of patients with depression in pityriasis rosea and tinea versicolor groups were 11 and 13 respectively. Depression and anxiety scores were highly correlated with DLQI scores in both patients with PR and TV. CONCLUSIONS: Results of the present study indicate that patients with PR and TV are at risk for psychopathology. Uncertainties about the etiology and length of recovery period in PR and location of disease to visible parts and recurrent nature of the disease in TV groups might have affected the patients' psychological status.

La pitiriasis versicolor y las levaduras del género Malassezia / Pityriasys versicolor and the yeasts of genus Malassezia

Aunque la pitiriasis versicolor (PV) es la única enfermedad humana en la que el rol etiológico de las levaduras Malassezia está plenamente establecido, permanece como objeto de controversia cuál (o cuáles) es la especie implicada. La mayoría de los estudios llevados a cabo en estos últimos años apoyan nuestra hipótesis, expuesta ya en 1999, indicando que M. globosa es la especie predominante en las lesiones de PV, al menos en los climas templados. La confirmación de esta hipótesis podría ayudar a comprender las condiciones, todavía poco claras, que inducen la transformación de esta levadura de su forma saprofita presente en la piel sana, a la parasitaria, caracterizada por la formación de pseudomicelio, y ayudarían también a establecer las mejores medidas terapéuticas. Por otro lado, el aislamiento de otra especie, M. furfur, que parece predominar en regiones tropicales, podría plantear la posibilidad de un segundo agente etiológico confinado a ciertas áreas geográficas, como acontece en algunas otras micosis humanas (AU)

Although pityriasis versicolor is the only human disease for which Malassezia yeasts have been fully established as pathogens, it is still not clear which species are implicated. Most studies carried out in recent years support our hypothesis —proposed in 1999— that Malassezia globos a is the predominant species in pityriasis versicolor lesions, at least in temperate climates. Confirmation of this hypothesis could help us understand the conditions, as yet unclear, that induce transformation of this yeast from the saprophytic form present in healthy skin to the parasitic form, characterized by the formation of pseudomycelium, and could also guide therapy. In addition, isolation of another species, Malassezia furfur, which seems to be predominant in the tropics, raises the possibility of a second etiologic agent confined to certain areas, as occurs with some other human mycoses (AU)