Amado Saúl

Treating chromoblastomycosis with systemic antifungals

Chromoblastomycosis is a subcutaneous mycosis for which there is no treatment of choice but rather, several treatment options, with low cure rates and many relapses. The choice of treatment should consider several conditions, such as the causal agent (the most common one being Fonsecaea pedrosoi), extension of the lesions, clinical topography and health status of the patient. Most oral and systemic antifungals have been used; the best results have been obtained with itraconazole and terbinafine at high doses, for a mean of 6 – 12 months. In extensive and refractory cases, chemotherapy with oral antifungals may be associated with thermotherapy (local heat and/or cryosurgery). Limited or early cases may be managed with surgical methods, always associated with oral antifungal agents. It is important to determine the in vitro sensitivity of the major causal agents to the various drugs, by estimating the minimum inhibitory concentration, as well as drug tolerability and drug interactions.

Polymorphous light eruption: Treatment with thalidomide.

Epidemiological, clinical, aetiological and therapeutic aspects of polymorphous light eruption, a very common disease in Mexico, are reviewed. Twenty‐five patients with this disease were treated with thalidomide over a period of 45 to 150 days with a dose depending on age: 100 to 200 mg a day. The results were satisfactory in 88% of the cases without any important side‐effect. The teratogenic action of the drug is stressed and the authors think that although the action mechanism of the drug remains unknown, it may shed new light on the understanding and treatment of this disease.

Mycetoma: Experience of 482 Cases in a Single Center in Mexico

Mycetoma is a chronic granulomatous disease. It is classified into eumycetoma caused by fungi and actinomycetoma due to filamentous actinomycetes. Mycetoma can be found in geographic areas in close proximity to the Tropic of Cancer. Mexico is one of the countries in which this disease is highly endemic. In this retrospective study we report epidemiologic, clinical and microbiologic data of mycetoma observed in the General Hospital of Mexico in a 33 year-period (1980 to 2013). A total of 482 cases were included which were clinical and microbiology confirmed. Four hundred and forty four cases (92.11%) were actinomycetomas and 38 cases (7.88%) were eumycetomas. Most patients were agricultural workers; there was a male predominance with a sex ratio of 3∶1. The mean age was 34.5 years old (most ranged from 21 to 40 years). The main affected localization was lower and upper limbs (70.74% and 14.52% respectively). Most of the patients came from humid tropical areas (Morelos, Guerrero and Hidalgo were the regions commonly reported). The main clinical presentation was as tumor-like soft tissue swelling with draining sinuses (97.1%). Grains were observed in all the cases. The principal causative agents for actinomycetoma were: Nocardia brasiliensis (78.21%) and Actinomadura madurae (8.7%); meanwhile, for eumycetomas: Madurella mycetomatis and Scedosporium boydii (synonym: Pseudallescheria boydii) were identified. This is a single-center, with long-follow up, cross-sectional study that allows determining the prevalence and characteristics of mycetoma in different regions of Mexico.

AMOXICILLIN AND CLAVULANIC ACID IN THE TREATMENT OF ACTINOMYCETOMA

Background. Mycetoma is a relatively frequent disease in tropical countries. Drugs commonly used need a long period of treatment, and some cases are resistant to these drugs, especially those with bone or visceral involvement. The combination of amoxicillin‐clavulanic acid has shown effectiveness against strains of Nocardia brasiliensis in vitro.

Mycetoma in Children: Experience With 15 Cases

Background: Mycetoma is a chronic infection caused by aerobic actinomycetes and filamentous fungi. It is an occupational disease frequent in tropical countries and is uncommon in children. Methods: A retrospective (25 years) report of mycetomas was conducted in children less than 15 years of age. Each of the cases was studied clinically and proven with microbiologic tests: direct examinations (to identify and classify the grains), cultures and identification based on morphology and biochemical tests. The therapeutic experience of the cases was also reviewed. Results: In a 25-year period, a total of 334 mycetomas were seen at our institution, 15 of which (4.5%) were in patients 15 years of age and younger (mean age: 11.2 years, age range: 6–15 years). Twelve cases were males and 3 females. The main clinical location was the foot in 10 of 15 (66.6%). Etiologies included 13 actinomycetomas and 2 eumycetomas. Etiologic agents were Nocardia brasiliensis in 12 cases, Nocardia asteroides in one and Madurella mycetomatis in 2. Eleven of the13 cases of actinomycetomas treated with trimethoprim–sulfamethoxazole plus diaminodiphenylsulfone were cured. The 2 failures were successfully treated with amoxicillin/clavulanate. One of the eumycetomas was cured with itraconazole therapy, whereas the other failed various treatments eventuating in surgical amputation. Conclusions: Mycetomas are exceptional in children; in our setting, actinomycetomas are more frequent than eumycetomas. The clinical and microbiologic diagnosis is simple. Overall, treatment response is better for actinomycetomas than for eumycetomas.

Successful Treatment of AIDS-Related Disseminated Cutaneous Sporotrichosis with Itraconazole

Sporotrichosis is a chronic granulomatous mycosis caused by a dimorphic fungus, Sporothrix schenckii. The most common manifestations of infection are lymphocutaneous and fixed-cutaneous types. In the case of immunosuppressed patients, and particularly in patients with acquired immune deficiency syndrome (AIDS), it occurs as disseminated cutaneous disease. This is a report of a 28-year-old male patient who presented with disseminated cutaneous and hematogenous sporotrichosis involving multiple ulcerative, nodular lesions in various body areas. Treatment consisted of 300 mg/d of itraconazole, which resulted in clinical and mycological cure.

Tinea barbae (Tinea sycosis): Experience with nine cases

Tinea barbae is a rare dermatophytosis that affects the hair and hair follicles of the beard and mustache. This paper presents 9 cases of tinea barbae observed over an 18‐year period of time and classified as follows: 1 was superficial and 8 were deep (6 folliculitis‐like and 2 kerion‐like). Most of the cases ( 4 ) were associated with topical steroid therapy, others with pet contact (3 cases) and one with diabetes. The causal agents isolated were: Trichophyton rubrum in 3; Microsporum canis in 3; Trichophyton mentagrophytes in 2; and Trichophyton tonsurans in one. The involvement of the hair was observed and classified in all cases. The trichophytin skin reaction was positive in all 9 patients. All the patients were treated with systemic antimycotics, 3 cases with griseofulvin, 1 with ketoconazole, 3 with itraconazole, and 2 with terbinafine. Clinical and mycologic cures were achieved at 6 to 8 weeks of treatment at the usual doses.

Mycetoma Due to Nocardia Caviae

ABSTRACT: Mycetoma is the most frequent deep mycosis in Mexico and is caused by Nocardia brasiliensis in 86% of the cases. Two cases of mycetoma due to Nocardia caviae, the first in Mexico, are reported. The strains were identified by their biochemical properties according to the criteria of Gordon and Mihm (1962). Few cases of mycetoma caused by this ac‐tinomycete have been reported In the world. One of our cases was unusual: occurring on the trunk as a tumor and diagnosed by finding the “grains” on histohgic examination.

Utility of helical computed tomography to evaluate the invasion of actinomycetoma; a report of 21 cases

Background  Actinomycetoma is a chronic infection caused by several aerobic actinomycetes; it is a relatively frequent condition in tropical countries like Mexico. It is important to be aware of the extension and depth of the disease (bone and visceral) to make the prognosis and select treatment.

Primary cutaneous coccidioidomycosis treated with itraconazole

The patient was a 27-year-old man from Oaxaca (South of Mexico), a resident of Mexico City, D.F., who previously lived in Fresno, California (USA) for 2 years. He presented with dermatosis localized on his right leg, extending to the sole of the fifth toe, maceration and abundant exudation of pus (Fig. 1). The condition had progressed over 6 months. The patient explained that the condition began as a wart which he traumatized with various objects, such as wood splinters, needles, etc. The symptoms consisted of discreet pruritus and some pain on palpation. He had received the following treatments, topical miconazole nitrate and systemic ketoeonazole, irregularly administered. The presumptive clinical diagnosis was an impetiginized plantar wart for which the patient received local treatment with baths of copper sulfate and 800,000 IU of penicillin for 10 days. But the exudate persisted and topical Garamycin was administered. A biopsy was taken 20 days later and the presumptive diagnosis of spinocellular carcinoma was made. The histopathology report indicated that the epidermis showed hyperkeratosis foci of parakeratosis, and marked irregular acanthosis; at a superficial level of the dermis, a dense lymphohistiocytic infiltrate was observed with plasma cells and abundant multinuclear giant cells; round spherules with a double contour were found in the stroma, some of them with endospores for which the diagnosis of coccidioidomycosis was made (Fig. 2). Once the diagnosis was made through histopathology, the following studies were commenced. Mycology studies: Direct examination revealed many double-contoured spherules and abundant endospores (Fig. 3). Cultures were obtained with Sabouraud media and with antibiotics, confirming Coccidioides immitis by microscopy showing the classic artroconidiae with intercalate joints. Immunology tests: Testing with skin antigens showed the following results: coccidioidin 1.5 x 1.3 cm induration and erythema, negative PPD, and candidine 1.0 x 1.2 cm. Complement fixation test (CFT) titer was 1:64, and titer of precipitin in capillary tube (PCT) was 1:32. Blood tests and urine and liver function tests were all within normal limits. A roentgenogram of the thorax was normal. Radiologic examination of the foot (lateral and anteroposterior views) showed a slight diminution of bone den-