[Mycetoma with black granules: first case in a native of Israel]. / Myzetom mit schwarzen Granula: erstmals bei einem gebürtigen Israeli.

We present a case of black grain mycetoma caused by Madurella mycetomatis. The diagnosis was made on the basis of conventional light microscopy and mycological studies. After 12 months of oral therapy with ketoconazole, the patient showed partial response. This is the first native Israeli case of black grain mycetoma.

Mycetoma of the forearm due to Actinomadura madurae.

A case of mycetoma, with abscess-like lesions which appeared on the right forearm of a 43-year-old male, is briefly reported. A few whitish granules were detected in the oily-like discharge, the same as in the histologic examination. No bone involvement was discovered in X-ray examination. Actinomadura was identified in the culture. A daily dose of 4 g bactrin brought significant improvement to the patients continuing the treatment.

15-year survey of tinea faciei in the adult.

In a series of 100 adults with tinea faciei various dermatologic manifestations were mimicked, viz.: discoid lupus erythematosus in 52 patients, lymphocytic infiltration in 15, seborrheic dermatitis in 11, rosacea in 8, contacts dermatitis in 7, polymorphous light eruption in 4 and granuloma faciale in 3. Trichophyton rubrum was isolated in 78% of the respective cases, other isolated organisms being Microsporum canis (13 cases), Trichophyton violaceum in 6, Trichophyton mentagrophytes (asteroides) in 2 and Epidermophyton floccosum in 1 case. In 85% of these patients the nails were also involved by the same agent found in the lesions of the face. On the basis of these observations it is recommended that all adult patients with tinea faciei should undergo a comprehensive mycological investigation to find the primary focus, which may be an infected nail.

Two years of follow-up of oral ketoconazole therapy in 60 cases of pityriasis versicolor.

In a series of 60 patients (42 males, 18 females) with widespread lesions of pityriasis versicolor, 200 mg of oral ketoconazole was administered daily for a period of 24 days. Routine laboratory examinations, including microscopic and Wood's light examinations, were performed prior to initiation of treatment and twice during the treatment period as well as 3 and 6 months, and 1 and 2 years after completion of treatment. In 95% of the patients the clinical cure was maintained after 3 months but after 6 months it was still present in only 80% and after one year in only 57%. At the end of two years 60% showed relapse of the disorder. In 75% hypopigmented macules persisted after 6 months but without microscopic evidence of the fungus. No side effects were reported. It is evident that oral ketoconazole is effective in maintaining a clinical cure mainly during the first 3 months after treatment. The question as to whether side effects might appear with a more prolonged course of the drug should be given serious consideration before continuation of treatment is contemplated.

Rapid response of transient acantholytic dermatosis to selenium sulfide treatment for pityriasis versicolor.

The observation of a 51-year-old male patient with transient acantholytic dermatosis (TAD) is briefly reported. The discrete eruption, composed of erythematous escoriated papules and papulovesicles, moderately itching, was located on the back and chest, more permanent during the summer season. The biopsy revealed suprabasal acantholysis and Darier-like elements. Lesions of pityriasis versicolor, confirmed by microscopic examination and fluorescence in Wood's light, were intermingled with TAD in the same patient. A topical treatment with selenium sulfide brought TAD lesions to the disappearance in 1 week. Comments are made in relation with the possibility of Malassezia furfur to induce acantholytic phenomena.

The increasing role of Microsporum canis in the variety of dermatophytic manifestations reported from Israel.

During a period of 8 years 300 cases of dermatophytoses involving both hairy areas and the glabrous skin were found to be caused by M. canis. There was scalp involvement in 60%, including 8 infants and 27 adults; most of the adults presented Kerion-like lesions and presented various clinical aspects such as seborrhea capitis, folliculitis and discoid lupus erythematosus. In the 21 patients showing invasion of the beard the clinical manifestations included superficial erythemato-squamous patches with hyperemic slightly elevated margins, folliculitis or abscess-like lesions and Kerion-like lesions. Among the lesions found on the glabrous skin there were unusual aspects of tinea faciei in 19 adults, mimicking lymphocytic infiltration, granuloma faciale or discoid lupus erythematosus. Some of the cases of tinea corporis found in 70 patients also had lesions simulating various other dermatological entities, including erythema multiforme, psoriasiform eruption, pityriasis rosea and seborrheic dermatitis. The hands were invaded in 5 adults patients, with involvement of the finger nails in one. Repeated mycologic examinations were necessary to establish the true etiology in many of these cases.

The incidence of skin manifestations by dermatophytes in patients with psoriasis.

Thirty-four psoriatic patients (23 males, 11 females) were found to have skin manifestations of dermatophyte infection. Tinea pedis was observed in 20 cases, tinea cruris in 6 and tinea manuum in 2. T. rubrum was the causative agent in all of these with the exception of 2 cases caused by E. floccosum. Lesions of tinea corporis were found intermingled with psoriatic plaques in various areas of the body skin in 6 patients (4 males, 2 females); T. rubrum was isolated from 5 of these and M. canis from one. Twenty-one of these psoriatic patients also had lesions caused by C. albicans in the toe-webs and interdigital aspects of the fingers, the latter being associated with paronychia in 9 cases. These findings indicate that we should remain aware of the possibility of fungus manifestations in patients with psoriasis, which would not appear to be an exceptional occurrence.

The second case of mycetoma due to Nocardia caviae in Israel.

A second case of actinomycetoma due to Nocardia caviae contracted in Israel is reported. A 39-year-old female of Yemenite origin, resident in Israel for more than 15 years, presented with a sclerotic tumor mass on the dorsum of the right foot which discharged an oily purulent fluid containing minute yellowish granules. Seen in the microscopic examination of smears were thin Gram-positive filaments and bacillary elements. Culture of the crushed granules yielded small pale colonies identified as Nocardia caviae. In vitro testing of the isolate to various antibiotics, isoniaside and sulphonamides showed the organism to be more sensitive to isoniaside and tetracycline. Isoniaside was administered for one year with marked improvement and was then replaced by tetracycline due to side effects, this treatment still being continued.

Tinea capitis among children of Ethiopian immigrants.

The incidence, clinical appearance and causative agent of tinea capitis among children of Ethiopian immigrants, was studied. Out of 124 children examined, 36 had scalp lesions and 32 cases were confirmed as scalp-ringworm on direct microscopy. Culture showed the dermatophyte to be Trichophyton violaceum. The clinical presentation, resembling seborrheic dermatitis, without clinically apparent hair invasion, was atypical.

Tinea capitis due to Microsporum canis in infants.

Three cases of scalp involvement by M. canis in infants are briefly reported. The first was a 2-month-old female with a few erythematous spots on the scalp, the second an 8-month-old male with lesions resembling seborrhoeic dermatitis and the third an 11-month-old male having areas of folliculitis of a kerion type. The father of the second case was found to have a tinea barbae infection due to the same fungus. Stray kittens were the most probable source of infection in all these cases.

Unusual aspects of granulomatous dermatophytosis.

Described are three male patients showing bizarre manifestations of granulomatous dermatophytosis, all in the hand region. One had a small infiltrated nodular lesion near the thumb which was mistaken for a common insect bite. The second had a violaceous-yellowish plaque, also on the thumb, composed of 2-3 small subcutaneous nodules. The third case had five reddish intracutaneous nodules on the dorsum of the hand. Puncture of these nodules revealed the presence of fungal elements and culture yielded T. rubrum in all cases. Each patient was also found to have a fingernail affected by the same agent. Histologic sections in each case showed granulation tissue in the dermis and hypodermis, mainly in the vicinity of hair fragments with spores. These lesions appeared to be variants of Majocchi's granuloma trichophyticum.

New data on the epidemiology of Tinea cruris in Israel.

Among 250 patients with tinea cruris (160 males, 90 females) lesions of both tinea pedis and tinea unguium were found in 221 and lesions of only tinea pedis in another 25. The four children were free of associated dermatophytic lesions. The predominant causative agent was T. rubrum, which was also found to be responsible for the hairy area invasion of the beard and pubis in 12 patients and for the widespread lesions of tinea corporis in 10 patients with lymphoma. None of these patients had noticed the discrete nail and foot involvement. It is therefore recommended that all patients with tinea cruris be subjected to careful examination of all possible mycotic foci, particularly the feet and nails.

Widespread cutaneous candidiasis and tinea infection masking mycosis fungoides.

A 71-year-old female with a widespread double mycotic infection caused by C. Albicans and T. rubrum was discovered to be suffering from mycosis fungoides. Clinically she was found to have large, polycyclic erythematous plaques with scaly, slightly infiltrated borders, covering almost all areas of the glabrous skin, and also involving the scalp (with no hair penetration), the soles and palms, toe-webs, finger and toe nails; there was also perleche and oral thrush. Cultures yielded C. albicans from most of the skin lesions, from the scalp, mouth, finger nails and urine and stool specimens, and T. rubrum from intermingled skin specimens, from the palms and soles and toe-nails. Blood culture was negative as were intracutaneous tests with fungal antigens and tuberculin. Histological examination confirmed the fungal invasion of the horny layer and at the same time revealed an underlying pathologic picture of mycosis fungoides, the lesions having been masked by the mycotic eruption. Intensive cytostatic and antifungal therapy led to a transient improvement but shortly thereafter there was a relapse of the fungal and lymphoproliferative manifestations and the patient died in septic shock.

The high incidence of Tinea pedis and unguium in patients with Kaposi's sarcoma.

Forty patients suffering from Kaposi's sarcoma (31 males, a females aged from 18 to 80 years) were examined for the presence of mycotic invasion of the toe-webs, toe-nails and soles. Fungi were found without exception in all patients. In 35 patients all three sites were invaded; the remaining 5 showed no involvement of the toe-nails. The causative agent was T. rubrum in 31 patients. T. mentagrophytes in 7, E. floccosum in 2. Four subjects with T. rubrum infection also showed a super-imposed C. albicans infection in the toe-webs. The skin tests with Trichophytin and Candidin yielded a mildly positive response to the former antigen in 4 cases and to the latter in 8 cases. The strikingly high percentage of affected cases in this group of patients with Kaposi's sarcoma is discussed.

Atypical cases of Microsporum canis infection in the adult.

Eleven adult patients (7 males, 4 females) were found to be infected with Microsporum canis. There was involvement of the scalp in three patients: in one male and one female there were kerion-like lesions and in one male the lesions resembled seborrheic dermatitis. There were three cases of tinea barbae, males aged 28, 65 and 82 years, in the first resembling an infected single lesion of granuloma annulare, the second with a kerion-like lesion and the third with an abscess-like tumor. There were five patients with lesions in glabrous areas: one male with a lesion of the palm resembling erythema multiforme and one with an infection of the auricular lobe resembling a seborrheic dermatitis or otitis externa; of three females with tinea faciei one had a lesion simulating granuloma faciale, one simulating lymphocytic infiltration and one simulating discoid lupus erythematosus. A cat was the source of infection in three cases; in the remainder it could not be determined with certainty. It is of note that a continuous increase in infection with M. canis has been observed in Israel during the past five years.

An unusual case report: tinea capitis, verrucae vulgares and other infections in a girl with T and B cell disturbances.

Hereby described is a case of a young girl suffering from widespread dermatophytosis caused by Trichophyton violaceum which proved intractable to accepted methods of therapy throughout a number of years. The girl was also found to have a history or recurrent respiratory tract infection and pyoderma in addition to verrucae vulgares, and Giardia lamblia in the gastrointestinal tract. Investigation revealed a marked immunological deficit seen in both the cellular and humoral system. It is suggested that in similar cases resistant to therapy it may be helpful to carry out a comprehensive investigation of the immunological system.