Commonly affected body sites in 92 Japanese combat sports participants with Trichophyton tonsurans infection.

Outbreaks of Trichophyton tonsurans infection constitute one of the serious problems among combat sports practitioners in Japan. To facilitate the diagnosis of individuals at risk, we undertook a study to determine which body sites are most commonly infected. We reviewed medical data, hairbrush culture results and questionnaire information from patients with T. tonsurans infection who were admitted to the dermatology clinic of Juntendo University hospital from 2000 to 2004. The study included 92 patients (87 males), aged 6-38 years (mean age: 18.4 years old). Eighty-nine patients were judo practitioners and three were wrestlers. Twenty-eight patients (30.4%) were asymptomatic carriers. In 64 patients, 51 patients (55.4%) with tinea corporis, 27 patients (29.3%) with tinea capitis, and/or one patient (1.1%) with tinea manuum were seen. Tinea corporis was observed on the forehead, auricles, nape of the neck, bilateral shoulders, left side of the upper chest, both elbows, back of the left hand to the wrist and both knees. Tinea capitis was most common in the occipitonuchal region at the hairline and in the temporal and frontal regions, at both auricles. Initial screening of these sites might facilitate the identification of the infection especially in judo practitioners.

[Results of questionnaire survey of Trichophyton tonsurans infection in judo clubs registered under the All Japan Judo Federation].

UNLABELLED: It has been seven years since an outbreak of Trichophyton tonsurans infection occurred in Japan. We have examined the state of T. tonsurans infection by a hairbrush test of athletes and a questionnaire survey of doctors' experience in its treatment, but have not completely grasped the actual state of infection at the sites of judo matches and its treatment or application of preventive measures. SUBJECTS AND METHODS: The questionnaire was distributed to the leaders of all judo clubs (10,077 clubs) registered under the All Japan Judo Federation, and responses recovered from 1,199 clubs (11.9%) were analyzed. These leaders were asked about (1) members of the club, (2) recognition of the infection, (3) experience of the breakout of infection at present and in the past, (4) present state of preventive measures, and (5) their opinions and requests. RESULTS: A higher percentage of the leaders of junior high school physical education judo clubs and primary school judo clubs responded they "did not know" about the infection, as compared with leaders of the other age groups. The answer regarding the "experience of the outbreak of infection" was "yes" in responses from 371 clubs (30.9%) , with a significantly higher percentage of leaders of senior high school judo clubs replying in the affirmative. Concerning preventive measures such as providing shower rooms, 540 clubs (45.1%) answered "no measures taken", which was more frequent in junior high school and primary school judo clubs. Since T. tonsurans infection is expected to spread to younger age groups in the future, a nationwide campaign by the All Japan Judo Federation for the education of risk of infection is urgently needed.

Candida albicans abrogates the expression of interferon-gamma-inducible protein-10 in human keratinocytes.

Candida albicans is the predominant causative agent of human cutaneous candidiasis. Epidermal keratinocytes play an important role in the cutaneous immune response through the production of cytokines and chemokines, including IFN-gamma-inducible protein 10 (IP-10). Here, we investigated the influence of C. albicans infection on IP-10 production by normal human epidermal keratinocytes (NHEK) in vitro. Our results showed that IFN-gamma-stimulated NHEK showed enhanced IP-10 mRNA and protein expression; this expression was downregulated by C. albicans infection. Candida tropicalis also impaired IFN-gamma-induced IP-10 expression, but Candida glabrata did not. Heat-killed C. albicans did not impair IFN-gamma-induced IP-10 expression. We found that coincubation of NHEK with live C. albicans without cell-to-fungi contact impaired IFN-gamma-induced IP-10 mRNA and protein expression in NHEK, suggesting the role of soluble factors derived from live C. albicans in this impairment. Enzyme-linked immunosorbent assay analysis revealed that C. albicans and C. tropicalis could produce marked levels of prostaglandin (PG) E(2), while C. glabrata produced low levels of this prostaglandin. Treatment with E-series prostaglandin receptor antagonists, AH6809 and AH23848, restored IFN-gamma-induced IP-10 expression in C. albicans-infected NHEK. Thus, Candida-derived PGE(2) may impair IFN-gamma-induced IP-10 expression in human keratinocytes and may play a role in the pathogenesis of cutaneous candidiasis.

Management and follow-up survey of Trichophyton tonsurans infection in a university judo club.

The prevalence of Trichophyton tonsurans infection of the scalp in members of a university judo club (combat sport) was investigated over a 3.5-year period using a questionnaire survey and an assay based on fungal culture by the hairbrush method. In November 2002, 11 (35%) of 31 athletes were found to be positive for T. tonsurans infection by the hairbrush method and provided treatment with oral and topical antifungal agents according to a prescribed protocol. All the infected subjects became culture-negative following this treatment. We continued to conduct screening examinations every year in the month of April, when new university enrolment occurs. During three-and-a-half years of follow-up, there have been no outbreaks of the infection among the members of the university judo club. There were some positive culture results among the newly enrolled students, but these cases also became culture-negative with treatment. No re-infection has been noted after graduation among the club members who had been educated about and treated for the infection. Our findings indicate that the spread of T. tonsurans infection in sports clubs can be controlled by regular mass screening examination, therapy and measures at regular intervals to prevent the infection.

Assessment of the treatment protocol described in the guidelines for Trichophyton tonsurans infection.

BACKGROUND: Infection with the anthropophilic fungus Trichophyton tonsurans has spread among members of combat sports clubs and has become a serious public health problem in Japan and other countries. Infection usually provokes only a weak inflammatory response, and treatment compliance tends to be poor. OBJECTIVE: To evaluate the hairbrush method and the treatment protocol described in the guidelines for T. tonsurans infection. METHOD: The study subjects were 69 individuals with positive hairbrush culture from among 327 members of 12 judo clubs participating in the survey. (a) Subjects with no more than 4 colonies by the hairbrush method were treated with miconazole nitrate shampoo. (b) Subjects with 5 or more colonies were treated with (1) itraconazole at a dose of 100 mg/day for 6 weeks or at a dose of 400 mg/day for 1 week, or (2) terbinafine at a dose of 125 mg/day for 6 weeks or at a dose of 500 mg/day for 1 week. Treatment efficacy was monitored by the hairbrush method at 1.5 and 3 months after treatment. RESULTS: Of the 46 subjects with 5 or more colonies isolated by the hairbrush method, 32 (69.6%) took itraconazole or terbinafine in compliance with their treatment schedules and were negative for T. tonsurans after treatment. Of the 23 subjects with 4 or fewer colonies, 15 (65.2%) were negative for T. tonsurans after treatment with miconazole nitrate shampoo. CONCLUSION: The treatment protocol seems promising, but poor compliance is a problem with the oral treatment regimens. The shampoo therapy is only partially effective, with 35% of subjects remaining positive for T. tonsurans after this therapy. In order to eradicate this disease, we have renewed the guidelines for T. tonsurans infection.

Combination of pulse therapy with terbinafine tablets and topical terbinafine cream for the treatment of dermatophyte onychomycosis: a pilot study.

We performed a pilot study to assess the safety and efficacy of pulse therapy with terbinafine tablets in 66 patients with dermatophyte onychomycosis. One pulse consisted of oral terbinafine tablets (500 mg/day) given for 1 week followed by a 3-week interval. Topical 1% terbinafine cream was applied daily. The number of pulses was determined by the extent of improvement in the affected nails and by the patient's requests, up to a maximum of six pulses. Efficacy was assessed based on both clinical and mycological examinations 1 year after treatment initiation. We observed a complete cure in 51 patients (77.3%), marked improvement in five patients (7.6%), improvement in five patients (7.6%) and slight improvement in one patient (1.5%). Four patients (6.0%) showed no change. In the patients who were completely cured, the average number of pulses used was 3.7 +/- 1.4 pulses and the treatment duration was 3.3 +/- 1.6 months. Nine patients experienced adverse effects, consisting of gastrointestinal disturbance (eight patients) and drug-induced eruption (one patient). There were no abnormal findings in the laboratory tests, including liver function tests. In summary, terbinafine pulse therapy in combination with topical application of terbinafine cream appeared safe and effective in this pilot study.

[Trichophyton tonsurans infection among judo practitioners who attended the National Junior High School Judo Tournament in Japan (2005): incidence and therapeutic response].

The spread of Trichophyton tonsurans infection among high school students and university undergraduates who practice Judo is an emerging problem in Japan and other countries. However, the extent of infection among Judo practitioners in junior high school in Japan is unknown. We conducted an epidemiological study of T. tonsurans infection among students who participated in the national junior high school Judo tournament in 2005. Of the 1,039 tournament participants invited to undergo screening, 496 (218 boys and 278 girls) consented, and 45 participants (9.1%) were found to be positive by hairbrush culture. We found the following to be relative risk factors for T. tonsurans infection: 1) male gender, 2) frequent judo practice in groups at either a high school or a dojo, 3) presence of tinea corporis in practice partners, 4) history of tinea corporis, 5) classification in lower-weight categories. 45 culture positive subjects were offered treatment and re-examined by hairbrush culture 3 months later. All twelve of them had negative cultures after miconazole shampoo treatment. A half of 12 subjects who had systemic antifungal therapy with itraconazole had positive culture. These observations suggest that T. tonsurans infection is rapidly spreading among junior high school Judo players in Japan. We speculate that the outbreak is caused, at least in part, by ignorance of the disease among Judo students, coaches and officials due to the high incidence of carriers and the mild or asymptomatic form of disease seen in infected individuals. Appropriate measures should be taken immediately to prevent more severe outbreak of this disease.

Cytokine secretion profiles of human keratinocytes during Trichophyton tonsurans and Arthroderma benhamiae infections.

Dermatophytes cause intractable superficial infections in humans. Arthroderma benhamiae, a zoophilic dermatophyte, triggers severe inflammatory responses in humans, while Trichophyton tonsurans, an anthropophilic dermatophyte, triggers minimal ones. Cytokines and other factors derived from keratinocytes play important roles in inflammatory and immune responses in the skin. The authors performed an in vitro investigation to determine the human keratinocyte cytokine profiles during dermatophyte infection. The human keratinocyte cell line PHK16-0b was infected with A. benhamiae or T. tonsurans for 24 h, and the cytokines secreted were analysed using a human cytokine antibody array. Marked differences were observed in the cytokine profiles of the cells infected with the two dermatophytes. A. benhamiae infection resulted in the secretion of a broad spectrum of cytokines, including proinflammatory cytokines, chemokines, and immunomodulatory cytokines. In contrast, T. tonsurans-infected keratinocytes secreted only limited cytokines, including eotaxin-2, interleukin (IL)-8 and IL-16. cDNA microarray analysis confirmed that A. benhamiae infection upregulated genes encoding IL-1beta, IL-2, IL-4, IL-6, IL-10, IL-13, IL-15, IL-16, IL-17 and interferon (IFN)-gamma, while T. tonsurans infection upregulated only a few genes, such as those encoding IL-1beta and IL-16. RT-PCR demonstrated that infection by both dermatophytes enhanced IL-8 mRNA expression in keratinocytes. These results suggest that A. benhamiae-induced secretion of several cytokines from keratinocytes may be involved in a severe inflammatory response, and that the limited cytokine secretion from keratinocytes in response to T. tonsurans infection may result in a minimal inflammatory response in the skin. These cytokine profiles may aid in proving the clinical features of dermatophytosis.

A case of tinea corporis caused by Arthroderma benhamiae (teleomorph of Tinea mentagrophytes) in a pet shop employee.

We describe herein a case of tinea corporis caused by Arthroderma benhamiae that presented with atypical clinical symptoms. We suggest that this infection has already spread widely in Japan.

A case of lymphangitic sporotrichosis occurring on both forearms with a published work review of cases of bilateral sporotrichosis in Japan.

The patient, 56-year-old man who was working as a clerk and a farmer, presented with nodules that had appeared on the dorsa of both his hands 3 months earlier. At the first examination, there were multiple dark-red nodules scattered on the fingers, dorsa and wrists of both hands. The nodules were up to 3 cm in diameter and had crusts in the incenters. The patient was suspected to suffer from prurigo and was subsequently treated with topical steroid, but the nodules did not respond. Therefore, a skin biopsy and fungal culture were performed, and the patient was finally diagnosed as having bilateral multiple sporotrichosis. He was then successfully treated with local thermotherapy and oral potassium iodide. Bilaterally-distributed lymphangitic sporotrichosis is very rare and often difficult to diagnose. Careful attention is required to avoid misdiagnosis.

A Chinese-Japanese boy with black dot ringworm due to Trichophyton violaceum.

A 4-year and 8-month-old Chinese-Japanese boy, who had been visiting Dalian, China frequently, developed multiple alopecia lesions 1 year previously. At his initial visit to our department, multiple patchy alopecia with black dots was observed in the parietal scalp area. Multiple erythematous macules were also seen on the face, nape and right dorsum of the hand. A diagnosis of tinea capitis and tinea corporis was obtained on the basis of potassium hydroxide (KOH) microscopic examination of hair and scales from the lesions. Colonies grown on Sabouraud cycloheximide-chloramphenicol agar culture were examined using Fungi-Tape and MycoPerm-blue, and numerous microconidia and a small number of macroconidia were observed. Trichophyton violaceum was identified as the causative organism on the basis of colony morphology, microscopic morphology and molecular biology technique. As T. violaceum infection is not often seen in Japan, we suspected that the patient was infected by T. violaceum during his stay in Dalian. Conidia formation is rarely observed with T. violaceum, and only five cases with T. violaceum macroconidia formation have been reported in Japan (including this case). We also report the method for visualizing conidia formation of T. violaceum using Fungi-tape and MycoPerm-blue.

A nationwide survey of Trichophyton tonsurans infection among combat sport club members in Japan using a questionnaire form and the hairbrush method.

BACKGROUND: The emerging outbreak of Trichophyton tonsurans infection among members of combat sports clubs in Japan during the last 4 years has become a serious public health problem. To overcome this outbreak, a survey for T. tonsurans infection in Japan may be essential. OBJECTIVES: We sought to clarify the prevalence of T. tonsurans infection among members of combat sports clubs in Japan. METHODS: We conducted a survey of members of participating combat sports clubs using a standardized questionnaire to assess background factors and using the hairbrush method to identify T. tonsurans infection. Statistical significance of the correlation between data from the questionnaire and the hairbrush culture results was determined. RESULTS: We surveyed 1000 people (826 male) from 49 institutions and found 115 (11.5%) were positive for T. tonsurans infection revealed by the hairbrush method. Demographic factors associated with high positive rates (> or =20%) of the infection were familial T. tonsurans infection (20.0%), history of tinea corporis (24.2%), increased dandruff (32.1%), and concomitant tinea corporis (31.6%). Those with positive hairbrush culture results without current or previous tinea were considered asymptomatic carriers. LIMITATIONS: The study population was limited to members of judo clubs all over Japan; they were asked to participate in this survey via the All Japan Judo Federation. CONCLUSION: Infection of T. tonsurans appears to have spread widely among members of combat sports club in Japan. The questionnaire used in this study is a simple and useful tool to estimate epidemiology of this infection.

Genotype analysis of the variable internal repeat region in the rRNA gene of Trichophyton tonsurans isolated from Japanese Judo practitioners.

Tinea capitis due to Trichophyton tonsurans is currently epidemic among Japanese Judo practitioners. T. tonsurans has seven genotypes in a variable internal repeat (VIR) region of the rRNA gene. All 101 isolates obtained from Japanese Judo practitioners had the identical genotype. This suggests that a specific genotype strain occurs throughout Japan.

[Questionnaire investigation of incidence of Trichophyton tonsurans infection in dermatology clinics in the Kanto area].

We conducted a questionnaire investigation to learn the incidence of T. tonsurans infection. Subjects of this investigation were 1,060 dermatologists in 1,060 dermatology clinics in the Kanto area to whom questionnaires were mailed. We asked each dermatologist whether he/she had experienced T. tonsurans infection cases (including suspected cases) and if so, we further asked; a. time of onset, b. number of cases, c. sexuality of the patient, d. club that the subject had joined (judo club, wrestling club or other), e. age of the subject, and f. number of cases suspected of having familial infection, the response rate was 47.5% (504 of the 1060 doctors), and 25.8% (130 of the 504) had handled T. tonsurans infection cases. The total number of patients was 707 (657 males and 50 females), with 400 (56.6%) of those in the 18 high-ranking clinics. The number of cases had increased rapidly from around 2002; 72.9% of the patients were students in high schools and universities and in 8 cases familial infection was suspected. 96.5% of the patients were in a judo or wrestling club. Our investigation revealed that this infectious disease had spread more than we had expected. It is important to develop more reliable infection control measures and to determine the actual conditions of this infection using mycological examinations.

[An investigation of Trichophyton tonsurans infection in university students participating in sports clubs].

BACKGROUND: The prevalence of the infectious disease Trichophyton tonsurans is rapidly increasing in Japan, particularly in athletes of these sports such as judo. Recognition of the current prevalence of this disease not only in athletes of these sports but also in other athletes is important to prevent its further spread. SUBJECTS AND METHODS: In November, 2002 we used a questionnaire survey and hairbrush culture to identify hair dermatophyte carriers among 31 members of a university judo club. The dermatophyte carriers received antimycotic therapy, and all participants were taught infection prevention. Repeat screenings of the judo club members were performed 9 times over the following 18-month period. In addition, from November, 2003 to February, 2004 we screened 466 students of other university sports clubs for hair dermatophytes using the questionnaire survey and hairbrush culture technique. RESULTS: (1) Initially, we identified 11 (35%) of 31 members of the judo club as dermatophyte-positive by hairbrush culture. These dermatophyte carriers received antimycotic therapy, and implementation of infection prevention measures by all club members was initiated. Members continued to participate in matches and group judo practices under daily instructions for infection prevention. Tests performed on 9 occasions over a 1.5-year period following the initial testing showed all members of the judo club to be dermatophyte-negative and with no signs of tinea corporis. (2) Using a questionnaire and the hairbrush culture technique, we screened 466 members of other sports clubs, including 138 students who had weekly judo lessons and 185 students who were living in a dormitory. All were dermatophyte-negative by hairbrush culture, and no participant acknowledged any history or presence of eruptions suggestive of tinea. CONCLUSIONS: Our investigation suggests that the current spread of T. tonsurans infection in Japan is occurring mainly in athletes of high-contact sports such as judo. The successful control of this disease by the judo club in our university suggests that spread of the infection can be prevented without requiring that training be discontinued in a group fully informed about the disease.

Combination therapy of once-weekly fluconazole (100, 150, or 300 mg) with topical application of ketoconazole cream in the treatment of onychomycosis.

In order to assess the safety and efficacy of once-weekly fluconazole orally (100, 150, or 300 mg) with once-a-day topical application of 1% ketoconazole cream in the treatment of onychomycosis in Japan, 121 patients were assigned to one of three fluconazole dosages (100, 150, or 300 mg) and took fluconazole orally, once weekly, for 12 months or until a complete cure was achieved. In addition, once-a-day topical ketoconazole cream was applied. At each weekly visit, adverse events were investigated and the length of the diseased nails was measured. Treatment efficacy was assessed 12 months after discontinuation of fluconazole using the following scale: cured, markedly improved, improved, slightly improved, no change. Mycological cure was assessed using KOH wet mount and fungus culture. The results showed that the numbers of patients achieving marked improvement or better were 38/68 (55%), 13/22 (60%), and 21/31 (67%) for the 100 mg, 150 mg, and 300 mg groups, respectively. There was no significant difference between any two groups. The duration of fluconazole therapy was the longest for patients in the 100 mg group. None of the patients reported adverse effects. These findings led to the conclusion that once-weekly fluconazole with once-a-day application of topical ketoconazole cream appears safe and effective for treating onychomycosis. The dosage of 150 mg once weekly for 6 months was recommended, considering both effectiveness and economy.

Successful high-titer immunoglobulin therapy for persistent parvovirus B19 infection in a lymphoma patient treated with rituximab-combined chemotherapy.

A 40-year-old female diagnosed with follicular lymphoma was treated with rituximab-combined chemotherapy. Although she achieved complete remission, she developed progressive anemia and reticulocytopenia. Bone marrow examination revealed features of pure red cell aplasia and hemophagocytosis. In addition, the appearance of large pronormoblasts suggested that she was infected with parvovirus B19. Excess viral DNA in her bone marrow confirmed that her illness was caused by persistent parvovirus B19 infection. Serum immunoglobulin levels decreased beyond the lower normal limit, which indicated that her humoral immunity was impaired after rituximab-combined chemotherapy. Although she had been infected with parvovirus B19, she was re-infected and failed to control the viral expansion. High-titer immunoglobulin against parvovirus B19 was intravenously administrated and resulted in remarkable reticulocytosis and improvement of anemia. High-titer immunoglobulin, which contained a sufficient amount of neutralizing antibodies against parvovirus B19, likely inactivated most viruses in vivo. We successfully eradicated the virus after 2 courses of high-dose therapy at 0.5 g/kg/day every week followed by 8 courses of maintenance therapy at 0.1 g/kg/day every other week. It is important to consider that parvovirus B19 infection is a possible cause of progressive anemia in B-cell lymphoma patients treated with rituximab-combined chemotherapy. We propose that the use of high-titer immunoglobulin against parvovirus B19 may enable such immunocompromised patients to eradicate the virus before sufficient immune system reconstruction.

[Screening Examination and Management of Dermatophytosis by Trichophyton tonsurans in the Judo Club of a University].

Thirty-one members of the Judo Club of a certain university (age: 18~23) underwent a screening examination for dermatophytosis by Trichophyton tonsurans. Test items were: age, sex, height, weight, living mode, exercise duration, number of judo contestants, presence of foreign contestants, occurrence, if any, of dermatophytosis past or present according to a subject's answers to a questionnaire, medical examinations and mycological examinations (KOH, cellophane tape culture, and hairbrush culture). Twenty-four subjects (77%) replied that they had suffered from dermatophytosis in the past, and 8 subjects (26%) had had head eruption in the past. Eleven subjects (35%) had suspicious dermatophytosis at the time of screening; 3 of them were found positive by direct microscopy, 2 of them were positive by cellophane tape culture. Eleven subjects (35%) were found positive by the hairbrush culture, but only 2 had eruption-like folliculitis. The remaining 9 subjects were free from clinical symptoms and were judged to be asymptomatic carriers. As countermeasures, we recommended cleaning and the use of shampoo containing miconazole nitrate. Subjects with suspicious tinea corporis were treated with antimycotic ointment. The 7 subjects who showed more than 5 colonies by the hairbrush culture were treated with 1-week pulse therapy of 400 mg itraconazole, and 3 of these who took a total dose of a pulse became negative through one pulse therapy.