C. Gianni

Retrospective study of onychomycosis in Italy: 1985–2000

Cases of onychomycosis diagnosed by mycological examination in three mycology units (Florence, Siena and Milan) of central and northern Italy over the 15‐year period, 1985–2000, were studied retrospectively. The number of cases was 4046 (1952 women, 2094 men). Dermatophytes were isolated in 2859, yeasts in 655 and moulds in 532 cases. The most frequent dermatophyte was Trichophyton rubrum (87%), followed by T. mentagrophytes var. interdigitale (10%). Candida albicans (93.2%) was the prevalent yeast. Moulds were mainly Scopulariopsis brevicaulis (48.6%) and Aspergillus spp. (25.2%). Dermatophytes and moulds most commonly infected the toenails, yeasts the fingernails.

Non‐dermatophytic onychomycosis. An understimated entity? A study of 51 cases

The aim of our study was to evaluate the incidence, the clinic characteristics, the therapeutic antifungal response and the evaluation of side‐effects in 51 non‐dermatophytic onychomycosis cases which were observed in a case‐study of 1012 patients, affected by different types of onychopathy, attending the Mycology Ambulatory of San Paolo Hospital, Milan, Italy during the period 1994–97.

Usefulness of Histological Examination for the Diagnosis of Onychomycosis

Background: Direct microscopy and culture tests currently used in the diagnosis of nail mycosis can yield false-negative results, and confirmation of the pathogenic agent, especially in non-dermatophyte infections, is often a lengthy process. Objective: The aim of this study was to investigate the usefulness of the histological examination of nail clipping samples in supplementing the standard microscopic and culture techniques for the diagnosis of onychomycosis. Patients and Methods: One hundred and seventy-two subjects affected by nail alterations suggestive of onychomycosis were evaluated. Nail specimens were studied with 3 different techniques: direct microscopic examination of a 40% KOH clarified preparation, fungal culture and histological examination. Patients positive for fungal infection were re-evaluated with the same techniques after treatment with oral terbinafine, fluconazole or itraconazole and topical application of bifonazole or ciclopirox for 2 months. Results: Direct microscopy was positive in 102 (59.3%) nail specimens. The culture test was positive in 90 cases (52.9%), showing a dermatophyte in 45, a yeast in 23 and a mould in 22 samples. The histological examination was positive in 94 (54.6%) samples. In 4 cases, it was the only investigation confirming the clinical diagnosis of nail mycosis. In most of the cases, the morphological aspect of the hyphae and/or spores suggested also to which group of pathogens (dermatophytes, yeasts or moulds) the mycetes observed in the histological sections could be ascribed. The concurrent presence of a dermatophyte and a mould was evidenced in a few specimens. The control histological examination at the end of the treatment showed negative results or residual non-vital hyphae and/or spores. Conclusions: Results of the present study indicate that the histological examination of nail clipping specimens is a relatively inexpensive, rapid and easily performed procedure. It is useful to confirm or refute the results of routine microscopy and culture tests. Moreover, nail histopathological observation may help in ascribing a pathogenic role of non-dermatophyte isolates and evaluating the effectiveness of antifungal treatment.

Onychomycosis in children: a survey of 46 cases

This is a retrospective study of the agents, clinical aspects, sources of infection and therapy of onychomycosis in children. In the period 1989–2000, we observed 46 consecutive children, until 16 years of age with onychomycosis (29 boys, 17 girls, mean age 10.8 years). Dermatophytes were isolated in 30 cases (Trichophyton rubrum in 22 cases, Trichophyton mentagrophytes in five, Epidermophyton floccosum in two and Trichophyton violaceum in one) and Candida spp. in 16, associated with Trichophyton rubrum in two. Moulds were isolated in three children (Fusarium oxysporum in one, Scopulariopsis brevicaulis in another and Aspergillus fumigatus associated with Trichophyton rubrum in a third). The commonest features were distal and distolateral subungual hyperkeratosis in dermatophyte infections (93%) and onychodystrophy and paronychia in Candida infections (56% and 50% respectively). Forty patients achieved clinical and mycological recovery. It is appropriate to suspect onychomycosis in children, perform microbiological diagnosis and undertake early treatment. An approach of this kind may help to prevent nail dystrophy and the spread of infection.

Unusual clinical features of fingernail infection by Fusarium oxysporum

Summary. Four cases of invasion of fingernails caused by Fusarium oxysporum are described. The typical picture of onychomycosis by this non‐dermatophytic mould is a ‘white superficial onychomycosis’ which usually affects the great toenail. Only few cases of fingernail infections by this organism have been described in the literature and, to our knowledge, there are no reported cases on the pustulous and eczema‐like aspect of paronychia by Fusarium oxysporum. We report different and unusual clinical features of this infection successfully treated with systemic antifungals. Two patients were treated with terbinafine, 250 mg daily for 3 months, and two patients with itraconazole, 200 mg daily for 3 months.

Clinical and Histological Aspects of Toenail Onychomycosis Caused by Aspergillus spp.: 34 Cases Treated with Weekly Intermittent Terbinafine

Background: Non-dermatophytic onychomycoses represent 1.45–17.6% of all fungal nail infections. Epidemiological studies have shown that Aspergillus spp. are emerging fungal agents of toenail onychomycosis. Indeed, after Scopulariopsis spp. the genus Aspergillus is the second most common agent of non-dermatophytic onychomycosis. The diagnosis and treatment of toenail onychomycosis caused by non-dermatophyte moulds are not always straightforward. Objectives: The aims of this study were to describe the clinical appearance of toenail onychomycosis due to Aspergillus spp., to investigate the pathogenetic role of these agents and to evaluate the efficacy and safety of weekly intermittent terbinafine (500 mg/day for 1 week each month for 3 months) in the treatment of these patients. Patients and Methods: Mycological study of 2,154 patients with onychodystrophy revealed 1,228 onychomycoses (57%) including 71 cases due to non-dermatophytic fungi (5.6%). Non-dermatophytic onychomycosis caused by Aspergillus spp. represented 2.6% of all onychomycoses. The subjects were 34 patients (22 females, 12 males, age range 30–82 years) observed between September 1999 and December 2001, with toenail onychomycosis caused by Aspergillus spp. confirmed by standard techniques (microscopic examination and culture according to the criteria of English), histological examination of nail clippings and scanning electron microscope examination of the cultures whenever necessary. Results: The clinical features suggesting onychomycosis due to Aspergillus spp. are chalky deep white nail, rapid involvement of lamina and painful perionyxis without pus. Standard mycological tests (direct microscopy and fungal culture) and histological examination confirmed the pathogenetic role of Aspergillus spp. in onychomycoses. In particular, the histological examination was positive in 28 cases (82%) and useful in identifying typical aspects of Aspergillus spp. nail infections. At the follow-up, 12 months after the start of therapy with pulsed terbinafine, clinical and mycological recovery was confirmed in 30 of the 34 patients (88%). Conclusions: Treatment of non-dermatophytic onychomycosis with terbinafine usually requires at least 3 months of continuous systemic therapy. Our study of 34 patients confirms that terbinafine is particularly effective in the treatment of Aspergillus spp. nail infections and that a pulsed regimen is more economical and less demanding.

Skin infection due to Geomyces pannorum var. pannorum

Geomyces pannorum var. pannorum is an ubiquitous saprophytic fungus frequently isolated from the soil and from air samples. It has rarely been reported as an animal or plant pathogen and it is an occasional aetiological agent of superficial infection of skin and nails in humans. Here, we report a case of superficial infection of the skin due to this fungus in a healthy man. The patient was treated orally with terbinafine 250 mg daily and topic bifonazole with complete resolution in 2 months.

Tinea capitis in Infants less than 1 year of age

Tinea capitis is the most frequent manifestation of dermatophyte infection in children, but because it is rare in the first months of life it is often misdiagnosed. Here we report 15 cases of tinea capitis observed in Italy in infants less than 1 year of age. There were 10 boys and 5 girls (mean age 6 months). Diagnosis was confirmed by mycologic examination. Microsporum canis was isolated in nine cases and Trichophyton mentagrophytes in three. These 12 infants were Italian and animals were the source of infection. Trichophyton erinacei was isolated in one Italian infant, and the source was soil. In the other two cases, Trichophyton tonsurans and Trichophyton violaceum were isolated; these infants were from Central America and India, respectively, and had contracted the infection from humans. All achieved clinical and mycologic recovery after systemic and topical antimycotic therapy.

Tinea capitis in adults

Summary. Invasion of keratin of the hair by dermatophytes is a rare event after puberty. A study of 2200 patients affected by various mycotic cutaneous infections during 6 years of observation brought to our attention three cases of tinea capitis in adults. Confirming the studies of other authors. we also found that this disease mostly affected females. In all cases the isolated aetiological agent was Microsporum canis, the fungus species most frequently responsible for tinea capitis in Italy.

Case Reports. Six cases of infection due to Trichophyton verrucosum

Summary. Dermatophyte infections due to Trichophyton verrucosum are not frequent in Europe. Six cases observed in Italy in the period 1995–99 are reported. Two were cases of tinea barbae, two of tinea corporis and two of tinea capitis, one of which had been preceded by tinea faciei. In three cases the source of contagion was horses, in two it was cattle and in one case it was another person. The two cases of tinea barbae were initially interpreted and treated as bacterial infections, a diagnostic error reported with increasing frequency in the literature regarding dermatophytosis due to T. verrucosum.