Multilocus microsatellite analysis of European and African Candida glabrata isolates.

This study aimed to elucidate the genetic relatedness and epidemiology of 127 clinical and environmental Candida glabrata isolates from Europe and Africa using multilocus microsatellite analysis. Each isolate was first identified using phenotypic and molecular methods and subsequently, six unlinked microsatellite loci were analyzed using automated fluorescent genotyping. Genetic relationships were estimated using the minimum-spanning tree (MStree) method. Microsatellite analyses revealed the existence of 47 different genotypes. The fungal population showed an irregular distribution owing to the over-representation of genetically different infectious haplotypes. The most common genotype was MG-9, which was frequently found in both European and African isolates. In conclusion, the data reported here emphasize the role of specific C. glabrata genotypes in human infections for at least some decades and highlight the widespread distribution of some isolates, which seem to be more able to cause disease than others.

[Onychomycosis : a crown jewel of dermatology]. / Onychomykose : Ein Kronjuwel der Dermatologie.

Onychomycosis is a curable infection disease. It is widespread, but not easy to treat. Because fungal pathogens never induce immunity, the relapse rate of mycoses is generally high. The main causes are residual fungal spores in the nail and the individual susceptibility of the patient, which can hardly be influenced. Crucial for long-term therapeutic success is a sporicidal topical therapy. In severe cases ones also needs long-term, well-tolerated systemic therapy, based on accurate microbiological diagnosis of the causative agent. Presented is a three-step therapeutic approach that is easy to perform, well- tolerated and produces sustained results.

[Candida glabrata : pathogenicity and therapy update]. / Candida glabrata : Pathogenität und Stand der Therapie.

Chronic recurrent vulvovaginal candidiasis caused by Candida glabrata is still rare in comparison to C. albicans infection, but therapy remains more difficult. Standard agents as fluconazole or itraconazole often fail, as well as the newer systemic triazoles like voriconazole or posaconazole. Micafungin is a new echinocandin drug with a wide antifungal spectrum including rare Candida species. No clinical trials with micafungin in chronic recurrent vulvovaginal candidiasis have been undertaken. We present the initial results employing a new therapy regimen consisting of micafungin in combination with topical ciclopirox olamine. All 14 patients with chronic recurrent vulvovaginal candidiasis caused by C. glabrata were treated successfully.

[Fungal nail infections--an update: Part 1--Prevalence, epidemiology, predisposing conditions, and differential diagnosis]. / Onychomykose--ein Update: Teil 1--Prävalenz, Epidemiologie, disponierende Faktoren und Differenzialdiagnose.

Onychomycosis describes a chronic fungal infection of the nails most frequently caused by dermatophytes, primarily Trichophyton rubrum. In addition, yeasts (e. g. Candida parapsilosis), more rarely molds (Scopulariopsis brevicaulis), play a role as causative agents of onychomycosis. However, in every case it has to be decided if these yeasts and molds are contaminants, or if they are growing secondarily on pathological altered nails. The point prevalence of onychomycosis in Germany is 12.4%, as demonstrated within the "Foot-Check-Study", which was a part of the European Achilles project. Although, onychomycosis is rarely diagnosed in children and teens, now an increase of fungal nail infections has been observed in childhood. More and more, diabetes mellitus becomes important as significant disposing factor both for tinea pedis and onychomycosis. By implication, the onychomycosis represents an independent and important predictor for development of diabetic foot syndrome and foot ulcer. When considering onychomycosis, a number of infectious and non-infectious nail changes must be excluded. While psoriasis of the nails does not represent a specific risk factor for onychomycosis, yeasts and molds are increasing isolated from patients with psoriatic nail involvement. In most cases this represents secondary growth of fungi on psoriatic nails. Recently, stigmatization and impairment of quality of life due to the onychomycosis has been proven.

[Fungal nail infections - an update. Part 2 - From the causative agent to diagnosis - conventional and molecular procedures]. / Onychomykose - ein Update. Teil 2 - Vom Erreger zur Diagnose - konventionelle und molekularbiologische mykologische Diagnostik.

Trichophyton (T.) rubrum is the most frequently isolated dermatophyte in onychomycosis, both in Germany and worldwide. T. interdigitale (formerly T. mentagrophytes var. interdigitale) follows in second place. A further however rarely isolated dermatophyte in onychomycosis is Epidermophyton floccosum. Candida parapsilosis, Candida guilliermondii, and Candida albicans, followed by Trichosporon spp. are the most important yeasts which are found in onychomycosis. The molds most often responsible include Scopulariopsis brevicaulis, and several Aspergillus species, e. g. Aspergillus versicolor, and Fusarium spp. These so called non-dermatophyte molds (NDM) are increasingly isolated as emerging pathogens in onychomycosis. The diagnosis of onychomycosis should be verified in the mycology laboratory. Conventional diagnostic methods include the direct examination, ideally using fluorescence staining with Calcofluor® or Blancophor®, and culture. However, new molecular biological methods primarily employing the polymerase chain reaction (PCR) for direct detection of dermatophyte DNA in skin scrapings and nail samples have been introduced into routine mycological diagnostics. The diagnostic sensitivity is higher when both conventional and molecular procedures are combined.

[A 25-year-old patient with corneal infiltration]. / 25-jähriger Patient mit Hornhautinfiltrat.

Filamentous fungal keratitis represents a serious infection of the eye. When corneal infiltrates appear, particularly in those who wear contact lenses, mycological assessment should already be performed initially so that filamentous fungal keratitis can be recognized early and treated. Keratitis caused by Fusarium responds well in most cases to topical therapy with ketoconazole or other antimycotic agents so that surgical intervention is only necessary in advanced or treatment-refractory cases.

Differential stripping: introduction of a method to show the penetration of topically applied antifungal substances into the hair follicles.

Investigations concerning the penetration of topically applied drugs are the subject of a multiplicity of research, as the exact knowledge of these mechanisms is the prerequisite for the optimization of such substances. As the hair follicles represent a good long-term reservoir for topically applied substances, it can be assumed that they also represent a reservoir for microorganisms residing on and in the skin. Therefore, the hair follicles must be seen as one main site of action for antimicrobial substances and a simple non-invasive in vivo method for the determination of penetration of antimicrobial substances into the hair follicles. The aim of the present study was to show that differential stripping, by removing the hair follicle content selectively, represents a suitable method to demonstrate the penetration of antifungal substances into the hair follicles. The follicular casts, removed from skin areas of human volunteers, which were partially pre-treated with brilliant green (well-known antifungal properties), were applied on agar plates inoculated with Candida albicans. The results showed inhibited growth of C. albicans, if the follicular casts were removed from skin areas pre-treated with brilliant green. This indicates clear evidence that brilliant green had penetrated into the hair follicles. Therefore, differential stripping represents a suitable method to determine the penetration of antifungal substances into the hair follicles, which is of clinical importance for the optimization of topical antifungal therapeutics.

Onychomycosis.

The guideline on onychomycosis, as passed by the responsible German medical societies, is presented in the present study.

Tinea capitis: ringworm of the scalp.

The guideline tinea capitis, as passed by three German medical societies, is presented in the present study.

[Modern mycologic diagnosis. Problems in the daily practice]. / Moderne mykologische Diagnostik. Fallstricke der täglichen Praxis.

Mycological diagnosis is an integral part of dermatology. Modern aspect include not only the identification of causative agents but also sensitivity testing against topical and systemic antimycotic agents and more detailed molecular biological diagnosis using fingerprinting and PCR. In routine practice, the essential question is if a fungal infection is present or not. A positive culture identification should precede use of systemic antimycotic agents especially when dealing with advanced onychomycosis, tinea capitis and chronic candidosis. Determination of resistance is important when dealing with recurrent infections with special candidal species. PCR is most useful in diagnosing otherwise difficult to identify causative agents and in analyzing the chain of infection.

Antifungal effect of 5-aminolevulinic acid PDT in Trichophyton rubrum.

In the present investigation, we have shown for the first time that the onychomycosis-inducing dermatophyte Trichophyton rubrum was able to metabolize 5-aminolevulinic acid (ALA) to protoporphyrin IX (PpIX) in liquid culture medium. We have established and optimized the culture conditions and could show the typical PpIX-induced red fluorescence which was evaluated qualitatively by Wood's light examination and fluorescent microscopic analysis. The optimum concentration of ALA was in the range of 1-10 mmol l(-1). If used in higher concentrations, ALA leads to a significantly reduced growth rate and absence of PpIX formation due to highly acidic conditions. The first observation of red fluorescence was detected between 10 and 14 days poststimulation with ALA, increasing thereafter. Fluorescent microscopic examinations demonstrated that formation of PpIX was restricted to selected parts of the fungal mycelium. Repeated application of ALA in order to achieve the highest formation of PpIX in T. rubrum failed, probably due to the sustained low pH values. ALA treatment and irradiation of T. rubrum clearly demonstrated the growth-inhibiting effect of ALA PDT, either leading to reduced numbers of colonies or reduced diameters of single fungal colonies. Summarizing our results, ALA PDT might be a promising approach in the reduction of T. rubrum colonization in onychomycosis.

Case reports: tinea corporis in a 13-year-old German girl due to Trichophyton schoenleinii.

We report the first case of a tinea corporis with partly profound lesions in a 13-year-old girl on her arms, legs and trunk due to Trichophyton schoenleinii but without any lesion on scalp and hair. Moreover, this is the first case of an infection with Trichophyton schoenleinii in Germany since more than 40 years. The diagnosis was confirmed by microscopy of mycological specimens. Other causes of the skin symptoms could be excluded (atopic dermatitis, bacterial or other fungal infection). Clinical and epidemiological aspects of this anthropophile dermatophyte are briefly reviewed.

Lethal otogenic Candida meningitis.

History revealed a chronic obstructive pulmonary condition which had been treated with prednisolone for a long time. There was a raised temperature with further signs of an acute inflammatory underlying disease and internal hydrocephalus. After performing trepanation, the symptoms of raised intercerebral pressure ceased. Candida albicans could be detected microbiologically in the cerebrospinal fluid. There was no pneumonia at the time of admission. Despite instituting immediate intensive care with administration of antibiotics and antimycotics, the patient died 11 days after inpatient admission. Autopsy revealed a C. albicans mycosis originating from the right middle ear with extensive suppurative meningitis, which was the immediate cause of death. Confluent bronchopneumonia had developed in both lower lung lobes at the time of death, but did not show any signs of mycosis and had contributed indirectly to the death of the patient.

Incidence of systemic mycoses in autopsy material.

The incidence of systemic mycoses was investigated in the autopsy material of the Institute of Pathology of the Humaine Hospital in Bad Saarow, Germany. This hospital provides qualified standard care in east Brandenburg with a wide spectrum of medical disciplines caring for patients with acute medical conditions as well as oncological cases (660 beds). Between 1973 and 2001, 47 systemic mycoses were diagnosed in 4813 autopsies of deceased adults, corresponding to 0.98%. During the period of investigation, both the care provided by the hospital and the organization of the health service changed. The autopsy frequency fell from about 80% (1973-1991) to about 28% (1992-2001). This is thus still far higher than the average of about 3% assumed for the Federal Republic of Germany. Although the incidence of systemic mycoses increased during the entire 29-year period of investigation, the number of cases in whom this was the immediate cause of death decreased. Whereas candidoses predominated from 1973 to 1991, a shift in favor of aspergilloses was noticed in the period from 1992 to 2001. Systemic mycosis was diagnosed intravitally in only three of 47 cases. The present study therefore underscores the significance of clinical autopsy as a diagnostic method and means of medical quality control.

Generalized fungal infection in a patient with AIDS appearing as skin papules.

Human immunodeficiency virus infection (HIV) is unique among cutaneous fungal infections caused by defects of the cell-mediated immune system. Infections with Candida albicans occur with increased frequency and severity among HIV-infected individuals. Oral candidiasis is the most common manifestation, superficial cutaneous infections of the dermis are rarely seen. We report a HIV-positive man from Cameroon presenting with generalized cutaneous papules and nodes, oral candidiasis, and soor esophagitis, who was successfully treated with fluconazole monotherapy.

[Therapy problems in chronic recurrent vaginal mycosis]. / Therapieproblem chronisch rezidivierende Vaginalmykose.

Vulvovaginal candidiasis is one of the most frequent infectious diseases. The mainly acute forms occur sporadically, have an uncomplicated course and can mostly be treated effectively with topical antimycotics. However, chronic infections are almost always a therapeutic problem. In most cases, systemic therapy is indicated. Since some mycoses cannot be treated effectively with fluconazole and itraconazole, prior identification of the causative agent is obligatory. Treatment of chronic vulvovaginal candidiasis also comprises identification and clearance of existing endogenous (oral cavity, intestine) and exogenous (sex partner) sources of reinfection. The following three-ponged treatment is suggested: (1) depending on the colonization status, selective orointestinal fungal decontamination with a polyene antimycotic, (2) depending on the kind of fungal pathogen systemic treatment with fluconazole or itraconazole, (3) topical treatment using ciclopiroxolamine as a synergistic combination partner.

First isolation of Trichophyton raubitschekii (syn. T. rubrum) in Europe.

Trichophyton raubitschekii is a rare dermatophyte which belongs to the Trichophyton rubrum species complex. Since 1981, only a few cases of dermatophytosis due to this anthropophilic causative agent were published. In this paper the authors report the first cases of Tinea corporis caused by Trichophyton raubitschekii (syn. T. rubrum) in Europe. The patients, one immigrant from Ghana and three from Cameroon, had typical lesions of tinea corporis. Four strains were isolated and characterized by conventional and molecular methods. On morphological and physiological grounds the isolates were identified as T. raubitschekii by the following phenotypical features: (1) velvety colony texture; (2) brown pigment; (3) abundant macroconidia and (4) positive urease activity. Molecular diagnostics were performed by single strand conformation polymorphism (SSCP) and sequence analysis of the ATPase9 intron of the mitochondrial (mt) DNA and the internal transcribed spacer (ITS) region of the rDNA, respectively. The ITS sequences and SSCP patterns of the ATPase9 intron were found to be identical among the four strains and also when compared to reference strains of T. rubrum. As shown in the present paper, T. raubitschekii is genetically identical to T. rubrum but differs in some phenotypical characteristics. Since misidentification with other dark-coloured dermatophyte variants is possible, medical mycologists should bear in mind the special morphological characteristics of T. raubitschekii (syn. T. rubrum) for future identifications.

One week terbinafine 1% cream (Lamisil) once daily is effective in the treatment of interdigital tinea pedis: a vehicle controlled study. LAS-INT-06 Study Group.

Duration of therapy is an important factor determining patients' compliance in dermatomycosis clinical practice. We undertook a prospective, randomised, double-blind, parallel group study to investigate the efficacy and tolerability of once daily treatment with terbinafine 1% cream for 1 week, compared to its vehicle, in adult patients with interdigital tinea pedis. Efficacy was assessed in terms of mycological cure, total clinical signs and symptoms scores, and clinical response, 1 day and 1, 5 and 7 weeks after end of treatment. Terbinafine 1% cream was significantly more effective than its vehicle in achieving and maintaining mycological cure for 7 weeks: 91.4% vs. 37.1%, P < 0.001. Terbinafine was also significantly more effective than its vehicle in reducing total clinical signs and symptoms scores, and in achieving clinical response. We conclude that terbinafine 1% cream, applied once daily for 7 days, is an effective and well-tolerated treatment for interdigital tinea pedis in nonimmunocompromised patients. The short duration of treatment needed to achieve mycological cure has important implications for patient compliance and for control of infection within the community.