Sumanas Bunyaratavej

Spectrum of Fusarium infections in tropical dermatology evidenced by multilocus sequencing typing diagnostics.

Fusarium species are emerging causative agents of superficial, cutaneous and systemic human infections. In a study of the prevalence and genetic diversity of 464 fungal isolates from a dermatological ward in Thailand, 44 strains (9.5%) proved to belong to the genus Fusarium. Species identification was based on sequencing a portion of translation elongation factor 1‐alpha (tef1‐α), rDNA internal transcribed spacer and RNA‐dependent polymerase subunit II (rpb2). Our results revealed that 37 isolates (84%) belonged to the Fusarium solani species complex (FSSC), one strain matched with Fusarium oxysporum (FOSC) complex 33, while six others belonged to the Fusarium incarnatum‐equiseti species complex. Within the FSSC two predominant clusters represented Fusarium falciforme and recently described F. keratoplasticum. No gender differences in susceptibility to Fusarium were noted, but infections on the right side of the body prevailed. Eighty‐nine per cent of the Fusarium isolates were involved in onychomycosis, while the remaining ones caused paronychia or severe tinea pedis. Comparing literature data, superficial infections by FSSC appear to be prevalent in Asia and Latin America, whereas FOSC is more common in Europe. The available data suggest that Fusarium is a common opportunistic human pathogens in tropical areas and has significant genetic variation worldwide.

Efficacy and safety of 1064-nm Nd:YAG laser in treatment of onychomycosis

Abstract Background: Onychomycosis is a common nail disease, especially in older patients. Various treatment options are currently available for onychomycosis; however, their limitations include high failure rates, time-consuming nature, high cost and high risk of drug interactions. Previous studies on the treatment of dermatophyte onychomycosis with a long-pulsed 1064-nm Nd:YAG laser demonstrated excellent outcomes without severe side effects. Objective: To evaluate the efficacy and side effects of onychomycosis treatment with a long-pulsed 1064-nm Nd:YAG laser. Methods: Sixty-four onychomycotic nails (35 patients) were evaluated. The first treatment cycle involved treatment with a long-pulsed 1064-nm Nd:YAG laser in four sessions at 1-week intervals. A potassium hydroxide examination and fungal culture were performed every week during this treatment course and then at a 1-month follow-up visit. If either test was positive for a pathogenic organism, a second treatment cycle was performed. If the two tests produced negative results, each affected nail was followed up at 3- and 6-month visits after completion of the second treatment protocol. In cases of resistance (positive for a pathogenic organism after completion of the second treatment cycle), the onychomycotic nails were excluded from the study and treated by standard methods. Results: Of all 64 nails evaluated, 59 completed the first cycle of treatment and 24 (40.7%) demonstrated mycological clearance at the 1-month follow up. Thirty-five of the 59 nails (59.3%) were positive for a pathogenic organism and underwent a second treatment cycle. Upon completion of the second treatment cycle, 28 nails remained enrolled in the study, and the mycological test results were negative in nine of these (31.2%). For all nails that completed the first or second treatment cycle, the overall cure rates at the 1-, 3- and 6-month follow-up visits were 63.5, 57.7 and 51.9%, respectively. Side effects were mild and limited to erythema and swelling after the laser procedure. Conclusions: Long-pulsed 1064-nm Nd:YAG laser therapy is safe and effective for the treatment of onychomycosis. However, a larger sample and longer follow-up period are needed to confirm our findings.

An unusual case of eumycetoma caused by Exophiala jeanselmei after a sea urchin injury

Penvadee Pattanaprichakul, Sumanas Bunyaratavej, Charussri Leeyaphan, Panitta Sitthinamsuwan, Montarop Sudhadham, Chanai Muanprasart, Peiying Feng, Hamid Badali and G. Sybren de Hoog Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok Thailand, Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, Department of Biology, Faculty of Science and Technology, Suansunandha Rajabhat University, Bangkok, Thailand, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China, Department of Medical Mycology and Parasitology ⁄ Invasive Fungi Research Centre (IFRC), School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran and CBS-KNAW Fungal Biodiversity Centre, Utrecht, The Netherlands

Distinct characteristics of Scytalidium dimidiatum and non‐dermatophyte onychomycosis as compared with dermatophyte onychomycosis

Studies of demographic data, predisposing factors and clinical manifestations of non‐dermatophyte mold (NDM) infection particularly in Scytalidium spp. have been limited. This study aimed to compare these data between dermatophytes (DMP) and NDM onychomycosis with statistical analysis. This was a retrospective chart review of outpatients with onychomycosis in the Nail Clinic of Department of Dermatology between January 2011 and December 2013. A total of 237 patients who had presented with onychomycosis were included. One hundred and eighty patients (75.9%) were infected with DMP: Trichophyton mentagrophytes, 46.8%; and Trichophyton rubrum, 28.3%. Of patients who had NDM onychomycosis, 17.3% were Scytalidium dimidiatum and 6.8% were Fusarium spp. Comparing the DMP and NDM groups, family history of superficial fungal infection was significantly demonstrated in the DMP group. Approximately 50% of patients in both groups had feet infections. However, no patients with NDM onychomycosis had fungal glabrous skin infection at other sites beyond the feet that was statistically different from cases with DMP onychomycosis. In conclusion, The distinct characteristic of patients with NDM onychomycosis was absence of fungal glabrous skin infection in areas other than the feet. This was statistically different from DMP.

Efficacy of 5% amorolfine nail lacquer in Neoscytalidium dimidiatum onychomycosis

Abstract Background: Amorolfine nail lacquer was mentioned as an effective treatment for non-dermatophyte nail infection. Onychomycosis that caused by Neoscytalidium dimidiatum is considered recalcitrant onychomycosis. Objective: This study aimed to demonstrate efficacy and treatment outcomes of amorolfine nail lacquer in N. dimidiatum onychomycosis, compared with topical urea treatment. Methods: This was a retrospective study of patients daiagnosed as N. dimidiatum onychomycosis at dermatologic clinic between April 2010 and August 2014. Clinical manifestations and laboratory results were collected. The evaluation included 50% improvement, which meant 50% decrease in subungual hyperkeratosis thickness from original untreated nails. Mycological cure is defined by negative result of both KOH and fungal culture. Moreover, complete cure means infected nails return to its normal condition as well as KOH and fungal culture yield negative results. Results: Among 53 outpatients of N. dimidiatum infection, 28 (52.8%) were treated by amorolfine nail lacquer and other 26 (47.2%) by conventional topical urea cream with occlusion. Comparison between amorolfine and topical urea groups, mycological cure rate was significantly shown in amorolfine group (89.3% vs. 32%; p < 0.0001). Moreover, 50% clinical improvement and complete cure rate of amorolfine group were significantly higher than those of topical urea group (85.7% vs. 48%; p = 0.003 and 50% vs. 20%; p = 0.023, respectively). Median time to mycological cure and complete cure in amorolfine group was significantly shorter than that of topical urea group (p = 0.001 and p = 0.013, respectively). Conclusion: This study supported that amorolfine nail lacquer provided promising efficacy in the treatment of Neoscytalidium onychomycosis as a novel monotherapy regimen which were superior to topical urea cream with occlusion in every aspect.

Cutaneous involvement by colonic extranodal NK/T-cell lymphoma mimicking mycosis fungoides: a case report*.

We report a 51‐year‐old woman with cutaneous involvement by extranodal NK/T‐cell lymphoma (TCL) of the colon that microscopically mimicked mycosis fungoides (MF). She had a history of fever of unknown origin for 2 months and then developed multiple erythematous papules on her trunk and extremities. A skin biopsy revealed superficial infiltration by atypical small to medium‐sized lymphocytes with epidermotropism and Pautrier collections. Immunohistochemical studies showed expression of CD3 and TIA‐1 with lack of expression (double negative) of CD4 and CD8. Initially, we reported the diagnosis as MF, cytotoxic variant. Thereafter, computerized tomography scan incidentally identified a colonic mass. A colonic biopsy revealed infiltration of atypical lymphoid cells with the same morphology and immunophenotype as those found in the skin. Additionally, CD56 and Epstein‐Barr virus‐encoded RNA in situ hybridization in both skin and colonic biopsies were diffusely positive. Thus, extranodal NK/TCL was diagnosed. Delta T‐cell receptor (TCR) gene rearrangement was documented in the skin biopsy by polyacrylamide gel electrophoresis and fluorescence capillary gel electrophoresis methods. There was no TCR gene rearrangement detected in the colonic biopsy. Unfortunately, the patient died within 2 months of diagnosis.

Prevalence and Clinical Correlation of Superficial Fungal Foot Infection in Thai Naval Rating Cadets

Background Superficial fungal foot infection is one of the most important dermatological diseases currently affecting military personnel. Many Thai naval rating cadets are found to suffer from superficial fungal foot infections and their sequels. Objective To investigate prevalence, potent risk factors, responding pathogens and clinical correlation of superficial fungal foot infection in Thai naval rating cadets training in Naval rating school, Sattahip, Thailand. Materials and Methods This cross-sectional study was performed in August 2015. Validated structured questionnaire was used regarding information about behaviors and clinical symptoms. Quality of life was assessed by Dermatology Quality of Life Index (DLQI) questionnaire and clinical presentation demonstrated by Athletes foot severity score (AFSS). Laboratory investigations including direct microscopic examination and fungal culture were performed and recorded. All of the participants were informed and asked for their consent. Results A total of 788 Thai naval rating cadets with a mean age of 19 yr were enrolled. There were 406 (51.5%) participants suspected of fungal skin infection from questionnaire screening. After clinical examination, 303 participants (38.5%) were found to have foot lesions (AFSS ≥1). Superficial fungal foot infection was diagnosed with microscopic examination and fungal culture in 57 participants, giving a point prevalence of 7.2%. Tinea pedis was diagnosed in 54 participants with the leading causative organism being Trichophyton mentagrophytes (52.8%). Other 3 participants were diagnosed as cutaneous candidiasis. Wearing combat shoes more than 8 h was found to be a predisposing factor (p = 0.029), taking a shower less than two times a day (p = 0.008), and wearing sandals during shower (p = 0.055) was found to be protective against infection. Most fungal feet infection cases noticed their feet abnormalities (p < 0.001) including scales (p < 0.001), vesicles (p = 0.003) and maceration at interdigital web spaces (p < 0.001). Mean DLQI in superficial fungal foot infection cases was 3.35. Participants who had foot lesions (AFSS ≥1) were concerned of their foots unpleasant odor demonstrated significantly higher mean DLQI than those without odor (4.2 vs. 2.28; p < 0.001). Conclusion Superficial fungal foot infection is found as 7.2% of naval rating cadets. Wearing combat shoes more than 8 h was found to be a predisposing factor. In addition to skin manifestations including scales, vesicles, and maceration, superficial fungal foot infection also exhibited an unpleasant foot odor which affected quality of life. Self-foot-examination and life style modification should be promoted to prevent fungal infection.

A cohort study of risk factors, clinical presentations and outcomes for dermatophyte, non-dermatophyte and mixed toenail infections

To the Editor: Mixed infections of dermatophyte and nondermatophyte mold (NDM) onychomycosis have increased, with prevalence ranging 20%-40%. This study investigated the clinical manifestations, risk factors, and treatment outcomes of mixed infection onychomycosis compared with dermatophyte onychomycosis and NDM onychomycosis. This cohort study comprised patients presenting at a Thai tertiary hospital with toenail onychomycosis during 2008-2016. To diagnose mixed infections, the dermatophytes needed to be detected in a fungal culture and the patients needed to meet all the criteria for NDM onychomycosis proposed by Gupta et al. The following oral antifungal regimens were assigned according to the patient’s health insurance for dermatophyte onychomycosis: pulsed itraconazole, continuous terbinafine, or fluconazole. Patients with mixed infections were treated with oral antifungals ( for dermatophytes) until mycologic cure and with topical amorolfine nail lacquer alone

Clinical and Laboratory Characteristics of a Tinea Capitis Outbreak Among Novice Buddhist Monks

Sixty novice Buddhist monks with tinea capitis confirmed according to clinical presentation and mycological laboratory finding were included in this study. Mixed‐type clinical presentation was observed in approximately half of all cases, together with scarring alopecia (95%) and superficial fungal skin infection at locations other than the scalp (43.3%). The major isolated organism was Trichophyton violaceum, and mixed‐organism infection was found in 27 cases (45%). Slow‐onset presentation and an extensive area of infection were significantly associated with mixed‐type clinical presentation.

Immune response in human chromoblastomycosis and eumycetoma - focusing on human interleukin-17A, interferon-gamma, tumour necrosis factor-alpha, interleukin-1 beta and human beta-defensin-2.

Knowledge regarding host immune response to chromoblastomycosis and eumycetoma is limited, particularly concerning cytokines and antimicrobial peptides production. This was a retrospective study of 12 paraffin‐embedded tissue samples from patients diagnosed with chromoblastomycosis or eumycetoma from histological findings and tissue culture. DNA extraction and polymerase chain reaction (PCR) from tissues were done to evaluate human interleukin‐17A (IL‐17A), interferon‐gamma (IFN‐γ), tumour necrosis factor‐alpha (TNF‐α), interleukin‐1 beta (IL‐1β) and human beta‐defensin‐2 (HBD‐2) expressions. Human beta‐actin primer was used for confirming DNA detection, and DNA extracted from psoriasis lesional skin samples was used as positive controls. The twelve paraffin‐embedded sections used in this study consisted of five chromoblastomycosis and seven eumycetoma tissues. All PCR reactions showed beta‐actin band at 51 bp in all clinical specimens, confirming adequate DNA levels in each reaction. As positive control, the psoriasis skin samples revealed bands for IL‐17A at 174 bp, IFN‐γ at 273 bp, TNF‐α at 360 bp, IL‐1β at 276 bp and HBD‐2 at 255 bp. For the chromoblastomycosis and eumycetoma tissues, PCR analyses showed IL‐17A band at 174 bp in two eumycetoma tissues and HBD‐2 band at 255 bp in a chromoblastomycosis tissue. This study demonstrated IL‐17A expression in human eumycetoma and HBD‐2 expression in human chromoblastomycosis for the first time. However, their role in immune response remains to be elucidated.