Clara Romano

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.

Dermatophytes isolated from asymptomatic stray cats

Summary. Most human cases of dermato‐phytosis diagnosed in Siena, Italy, in the last 5 years have been caused by two zoophilic species: Microsporum canis and Trichophyton mentagrophytes. Since many patients had a history of contact with apparently healthy stray cats, we examined the fur of 173 stray cats for dermatophytes. The cats were captured in different parts of Siena and none of them had mycotic lesions. Microsporum canis was isolated in 82 cats, Trichophyton mentagrophytes in three and Microsporum gypseum in one. Trichophyton terrestre was isolated in two cats. No significant differences were found in terms of sex and race, however, healthy carriers were significantly more frequent in the 1‐year age group. The investigation showed that, in Siena, stray cats are a significant reservoir of Microsporum canis and source of infection for man.

Tinea incognito in Italy: a 15-year survey.

Tinea incognito or steroid modified tinea is a dermatophytic infection in which topical or systemic steroids, administered as a result of dermatological misdiagnosis or preexisting pathologies, have modified the clinical appearance of the fungal infection, transforming the typical ringworm and mimicking other skin diseases. This is a retrospective study of the agents, clinical aspects, sources of infection of 200 cases (98 males, 102 females, mean age 42 years) of tinea incognito, observed in Siena and Milan, Italy, in the period 1987–2002. In order of decreasing frequency, Trichophyton rubrum, Trichophyton mentagrophytes, Epidermophyton floccosum, Microsporum canis, Microsporum gypseum, Trichophyton violaceum and Trichophyton erinacei were isolated. The clinical appearance of the infection was lupus erythematosus discoid‐like, eczema‐like, rosacea‐like, especially on the face, impetigo‐like and eczema‐like on trunk and limbs. Less often the dermatophytosis resembled psoriasis, purpura, seborrhoic dermatitis and lichen planus. There was folliculitis in 9% of cases and dermatophytid in 3% of cases. Antimycotic therapy brought about clinical and mycological recovery in all patients except one, who had iatrogenic immunodepression.

Outcome of surgical release among diabetics with carpal tunnel syndrome.

OBJECTIVE To compare the results of surgical decompression of carpal tunnel syndrome (CTS) in patients with diabetes with those of patients with idiopathic CTS. DESIGN Prospective case series. SETTING Ambulatory care in Italy. PARTICIPANTS Twenty-four consecutive patients with diabetes type 1 or 2 and CTS (mean age, 66.7 y) were matched for age and sex with 72 patients (mean age, 66.2 y) with idiopathic CTS. INTERVENTIONS All patients underwent surgical release of CTS by the mini-incision of palm technique. MAIN OUTCOME MEASURES Clinical and electrophysiologic evaluation and patient self-administered Boston Questionnaire (BQ) for the assessment of severity of CTS symptoms and hand functional status before and 1 and 6 months after surgery. RESULTS After surgical release, almost all patients of both groups reported an absence of pain, disappearance or reduction of paresthesia, and improvement in hand function. One month after surgery, there was a significant improvement in clinical status, BQ scores, and distal conduction velocities of the median nerve. A further improvement was evident at 6-month follow-up. There were no differences between the 2 groups in the number of surgical complications, in clinical and electrophysiologic status, or in BQ scores before and after surgery. The improvement in distal conduction velocities of the median nerve, BQ scores, and clinical and electrophysiologic status were similar in the 2 groups after surgery. CONCLUSION Diabetes is not a risk factor for poor outcome of surgical decompression of CTS. Patients with diabetes have the same probability of positive surgical outcome as patients with idiopathic CTS.

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.

Tinea capitis in Siena, Italy. An 18-year survey.

In the period 1980–1998, 181 cases of tinea capitis out of a total of 1480 cases of dermatophytosis were observed in Siena, Italy; 176 cases were children (mean age 6 years, range 45 days to 14 years; 91 boys, 85 girls) and the other five cases were postmenopausal women. Diagnosis was made on the basis of culture which was positive in 179 cases, and direct microscopic observation which was positive in 155 of 179 cases. In two cases, positive direct microscopic results were not confirmed by the culture. The most frequently isolated mycete was Microsporum canis (162 cases, 90.5%) and the main source of infection was the cat, which was often a healthy carrier. The second most frequent mycete was Trychophyton mentagrophytes. Trichophyton violaceum, a dermatophyte practically absent from our province since the 1960s, was isolated in five patients. All patients were successfully treated. One adult was treated with oral ketoconazole and the other four with oral itraconazole. The children were all treated with griseofulvin and topical antimycotics. Two children, observed in 1997–1998, who did not respond to griseofulvin, achieved clinical and mycological recovery with oral itraconazole.

Zygomycosis in Italy: a Survey of FIMUA-ECMM (Federazione Italiana di Micopatologia Umana ed Animale and European Confederation of Medical Mycology)

Abstract The aims of the study were to analyze the clinical and epidemiological characteristics and treatments for patients who developed zygomycosis enrolled in italy during the european Confederation of medical mycology survey. This prospective multicenter study was performed between 2004 and 2007 at 49 italian Departments. 60 cases of zygomycosis were enrolled: the median age was 59.5 years (range 1-87), with a prevalence of males (70%). The majority of cases were immunocompromised patients (42 cases, 70%), mainly hematological malignancies (37). Among non-immunocompromised (18 cases, 30%), the main category was represented by patients with penetrating trauma (7/18, 39%). The most common sites of infection were sinus (35%) with/without CNS involvement, lung alone (25%), skin (20%), but in 11 cases (18%) dissemination was observed. According to EORTC criteria, the diagnosis of zygomycosis was proven in 46 patients (77%) and in most of them it was made in vivo (40/46 patients, 87%); in the remaining 14 cases (23%) the diagnosis was probable. 51 patients received antifungal therapy and in 30 of them surgical debridement was also performed. The most commonly used antifungal drug was liposomal amphotericin b (L- AmB), administered in 44 patients: 36 of these patients (82%) responded to therapy. Altogether an attributable mortality rate of 32% (19/60) was registered, which was reduced to 18% in patients treated with L-AmB (8/44). Zygomycosis is a rare and aggressive filamentous fungal infection, still associated with a high mortality rate. This study indicates an inversion of this trend, with a better prognosis and significantly lower mortality than that reported in the literature. It is possible that new extensive, aggressive diagnostic and therapeutic procedures, such as the use of L-AmB and surgery, have improved the prognosis of these patients.

Skin and nail infections due to Fusarium oxysporum in Tuscany, Italy

Summary. Nine cases of skin and nail infection due to Fusarium oxysporum, diagnosed in Tuscany in the period 1985‐97, are described. Two manifested as interdigital intertrigo of the feet and seven as onychomycosis. All were diagnosed on the basis of repeated mycological examination, direct microscope observation and culture, as well as histological examination of biopsy specimens in two cases of intertrigo. Fragments of the fungal colonies were examined by scanning electron microscopy (SEM) for more detailed observation of fungal morphology. All patients had normal immune status and a history of the infection extending several years. Four of the patients with onychomycosis were treated with oral itraconazole, and clinical and mycological recovery was achieved in three cases. Two others were treated with cyclopyrox nail lacquer, successfully in one case. One patient with intertrigo was treated with oral itraconazole and one with oral terbinafine; both were also treated and with topical drugs, however clinical recovery was not confirmed by the mycological results.

Prevalence of dermatophytic skin and nail infections in diabetic patients.

Summary. To determine whether there is a higher frequency of mycotic infections due to dermatophytes in diabetics, 171 diabetic outpatients and 276 controls were recruited in the period 1997–98. Patients with suspicious lesions underwent mycological examination which was positive in seven diabetics and 17 controls. In diabetics the most frequent infection was tinea pedis, followed by distal subungual onychomycosis; the most frequently isolated fungus was Trichophyton mentagrophytes. The results of the study did not show a prevalence of dermatophyte infections in diabetics. No correlation was found between dermatophytosis and duration or type of diabetes and its complications, blood sugar levels or levels of glycosylated haemoglobin. None of the diabetic patients with dermatophytosis had complications related to diabetes and basal blood sugar and glycosylated haemoglobin levels indicated good metabolic control.

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.