Yan-Ping Yang

Molecular identification and antifungal susceptibility of 186 Candida isolates from vulvovaginal candidiasis in southern China.

There is limited information regarding the molecular epidemiology and antifungal susceptibilities of Candida isolates using the Neo-Sensitabs method in patients with vulvovaginal candidiasis (VVC). From August 2012 to March 2013, 301 non-pregnant patients aged 18-50 years with suspected VVC were prospectively screened at a teaching hospital in southern China. The vaginal isolates were identified by DNA sequencing of internal transcribed spacer and the D1/D2 domain. Antifungal susceptibility testing of seven antifungal agents was performed using the Neo-Sensitabs tablet diffusion method. Candida species were isolated from 186 cases (61.79 %). The most common pathogen was Candida albicans (91.4 %), followed by Candida glabrata (4.3 %), Candida tropicalis (3.2 %) and Candida parapsilosis (1.1 %). The susceptibility rates to C. albicans were higher for caspofungin, voriconazole and fluconazole than those for itraconazole, miconazole, ketoconazole and terbinafine (P<0.01). The resistance rates to C. albicans were 4.7, 6.5, 7.1, 7.6, 12.3, 27.7 and 74.7 % for caspofungin, miconazole, itraconazole, voriconazole, fluconazole, ketoconazole and terbinafine, respectively. No drugs tested apart from fluconazole exhibited differences in resistance between C. albicans and non-albicans Candida isolates. The results demonstrate that, using DNA sequencing, C. albicans is the most common isolate from Chinese patients with VVC. Caspofungin, voriconazole and fluconazole may be preferable to other azoles and terbinafine in the treatment of VVC.

Bier spots: Six case reports

To the Editor: Bier spots are characterized by multiple pale, irregularly shaped patches of histologically normal appearing skin in which the pharmacologic response to certain mediators may be aberrant. Although Bier first reported the reproducible experimental vascular phenomenon in 1898, Bier spots have been used to describe similar lesions occurring in the clinical setting. To date, these white lesions have been given several names, including Bier spots, speckled mottling of the limbs, exaggerated physiologic speckled mottling of the skin, constitutive speckled vascular mottling of the skin, physiologic anemic macules, nevus anemicus, and angiospastic macules. The prevalence of this skin disorder is uncertain, but it may be not uncommon. We report herein six cases of Bier spots. Six patients (5 men and 1 woman, all between 18 and 32 years of age) with multiple asymptomatic white macules presented to our dermatology clinic between 2005 and 2008. They had no other complaints suggesting vascular disease, and denied a family history of similar lesions. In five cases, the physical examination revealed multiple pale, irregularly shaped macules, 3 to 10 mm in diameter, that were scattered over the extensor surface of the upper and lower extremities, especially on the forearms, legs, and the dorsal aspect of the hands (Fig 1, A). The intervening skin was normal or mildly erythrocyanotic. The white spots on the arms became almost invisible on blanching the surrounding skin or elevation of the arms (Fig 1, B). Another generalized case had numerous white macules on the chest, abdomen, back, and limbs, and the lesions were aggravated by emotional stress but mitigated by physical activity. The white spots on the trunk were visible mainly in a standing position, but disappeared partially in a horizontal position. Only two patients had mild palmar hyperhidrosis or insomnia. Routine laboratory tests were normal. A clinical diagnosis of Bier spots was made on the basis of the clinical features. All patients received no special management. We report here one of the largest series describing Bier spots. Only 21 cases in 11 English articles since 1985 and 42 cases in 15 Chinese reports since 1994 have been found on MEDLINE and the China National Knowledge Infrastructure (CNKI) database, respectively, though Bier spots are relatively common according to personal clinical experience and some authors’ observations. Patients often seek no consultation because the condition is fully asymptomatic. Among the 63 reported and six presented cases, the clinical features of Bier spots are summarized as follows: (1) patients 20 to 40 years of age (range, 1575 years of age) are predominantly affected, and men outnumber women by a ratio of 2:1; (2) multiple Fig 1. Scattered white macules on both arms and backs of hands (A). In the same patient, these lesions disappear when the arms are raised (B).

Is acquired symmetrical acrokeratoderma a new dermatosis? Two case reports and Chinese literature review

Background  A series of cases characterized by symmetrical acral hyperkeratosis, mainly involving the dorsal surface of the hands, feet, and wrists, but sparing the palmoplantar areas, as well as rapid immersion upon exposure to water have been recently described in China, but similar disorders have not been reported in the English literature.

Cutaneous Chromoblastomycosis Caused by Veronaea botryosa in a Patient with Pemphigus Vulgaris and Review of Published Reports

Chromoblastomycosis and phaeohyphomycosis represent two poles of a disease spectrum caused by melanized fungi. Veronaea botryosa belongs to a small genus of saprobic fungi that occasionally cause human infections. To date, 11 cases of V. botryosa-induced cutaneous phaeohyphomycosis have been actually reported since 1990 after exclusion of 2 duplicated cases. We report the first case to our knowledge of cutaneous chromoblastomycosis caused by V. botryosa in a patient with pemphigus vulgaris. A 61-year-old man with 5-year history of pemphigus vulgaris and long-term treatment of corticosteroids and immunosuppressive agents developed multiple nodules on the dorsum of right wrist and hand after wrist trauma. Skin biopsy showed numerous brown muriform cells and a few septate hyphae in the tissue. Veronaea botryosa was isolated from the biopsy samples and then identified based on morphologic observation and DNA sequencing. The patient underwent immediate withdrawal of cyclophosphamide and gradual decrease in prednisone. Skin lesions healed after 5-month itraconazole therapy with an interval of 1-month terbinafine and one cycle of liquid nitrogen cryotherapy. Our results demonstrate that V. botryosa could induce both chromoblastomycosis and phaeohyphomycosis. Combined use of itraconazole and cryotherapy may be preferable to treat this infection.

Sporadic dystrophic epidermolysis bullosa with albopapuloid and prurigo- and folliculitis-like lesions

A case of sporadic dystrophic epidermolysis bullosa (DEB) with albopapuloid and prurigo‐ and folliculitis‐like lesions is reported. Histopathology of the scalp biopsy showed hyperkeratosis, a subepidermal cleft near the orifice of a hair follicle, dermal fibrosis, and a moderate perivascular and perifollicular lymphohistiocytic inflammatory cell infiltrate in the papillary dermis, without neutrophilic infiltrate in the orifice of the hair follicle. It is uncertain whether the present case should be classified as DEB pruriginosa or represents a new subtype of DEB.

Cutaneous and Systemic Pathogenicity of a Clinical Isolate of Cladosporium sphaerospermum in a Murine Model

The pathogenicity of a clinical isolate of Cladosporium sphaerospermum was determined in a murine model. BALB/c mice were given two intraperitoneal injections of 150 mg/kg cyclophosphamide or normal saline on days 4 and 1 preinoculation, and were then challenged with 0.2 ml of C. sphaerospermum inoculum (2 × 10(7) CFU/ml) by topical application on an abrasive wound or by subcutaneous or intravenous injection. Histopathology and inverse fungal culture were performed on the skin lesions and viscera, and pulmonary fungal burden was also determined. Inoculated skin developed localized infections after dermabrasive or subcutaneous challenge in all mice, but the maximum area and number of positive cultures from skin lesions were higher for immunocompromised mice. In the intravenously inoculated mice, all immunocompetent animals survived for the 4-week period of the experiment, while 60% of immunocompromised animals died by 5 days postinoculation. The incidence of disseminated infection and the pulmonary fungal burden of immunosuppressed mice were higher than those of immunocompetent animals. Cutaneous and systemic infections can be established by subcutaneous and intravenous challenge with C. sphaerospermum in BALB/c mice, with the lungs being the most susceptible tissue in systemic infection.

Spontaneous Remission of Subcutaneous Scedosporiosis Caused by Scedosporium dehoogii in a Psoriatic Patient

To date, only one case of post-traumatic endophthalmitis caused by Scedosporium dehoogii has been reported, but its contamination or colonization might not be precluded due to the absence of pathogenic isolation and/or pathological examination. We report the first case to our knowledge of S. dehoogii-induced subcutaneous scedosporiosis in a psoriatic patient. A 58-year-old man with 5-year history of psoriasis vulgaris and immunosuppressant therapy developed pyrexia and multiple subcutaneous abscesses on both knees. Direct microscopy of the yellowish pus showed masses of bright green short spores. Skin biopsy revealed some branched septate hyphae within the granuloma. Two aspirated pus specimens collected at a 1-week interval produced white cottony colonies on Sabouraud dextrose agar. Bacterial cultures of one blood and two purulent samples were negative, and fungal culture of blood sample was not performed. The isolate was identified as S. dehoogii using β-tubulin phylogeny and species-specific PCR with primer MSDE1/MSA2. Without addition of antifungal treatment, subcutaneous lesions disappeared spontaneously after immunosuppressant withdrawal and no relapse occurred during 64-month follow-up. The spontaneous recovery may result from immune reconstitution following immunosuppressant discontinuation.

First case of congenital idiopathic hypohidrosis in China

A 43-year-old Chinese man presented with generalized hypohidrosis, which he had had since birth, without obvious abnormalities of other skin appendages except a sparse beard and axillary hairs. The sweat test revealed localized sweating on the face, axillae and palms. Histopathologic examination showed that the sweat glands were absent in the forearm and thigh, but some eccrine and apocrine sweat glands were present in the right axilla. S-100 was expressed in the nerve terminals surrounding the acini and ducts of the eccrine sweat glands, while PGP9.5 was positive in the acini of apocrine glands and the nerve terminals surrounding the eccrine glands in the axilla. To our knowledge, this is the first case of congenital idiopathic hypohidrosis in China.

Overexpression of NLRP3, NLRC4 and AIM2 inflammasomes and their priming-associated molecules (TLR2, TLR4, Dectin-1, Dectin-2 and NFκB) in Malassezia folliculitis

The activation of NLRP3, NLRC4 and AIM2 inflammasomes is pivotal for innate immunity against some pathogenic fungi, but their role in the pathogenesis of Malassezia folliculitis (MF) remains unclear. The objective of the study was to determine the expression of 4 canonical inflammasomes (NLRP1, NLRP3, NLRC4 and AIM2) and their priming‐associated molecules (TLR2, TLR4, Dectin‐1, Dectin‐2 and NFκB) in MF lesion. Expression of NLRP1, NLRP3, NLRC4, AIM2, caspase‐1, IL‐1β, TLR2, TLR4, Dectin‐1, Dectin‐2 and NFκB was detected by immunohistochemistry in skin lesion of 23 MF patients and normal skin of 12 healthy subjects. Furthermore, NLRP1, NLRP3, NLRC4, AIM2, caspase‐1 and IL‐1β mRNA was measured by quantitative real‐time PCR (qRT‐PCR) in 12 MF cases and 10 controls. Immunohistochemical analysis revealed that NLRP3, NLRC4, AIM2, Casp‐1, IL‐1β, TLR2, TLR4, Dectin‐1, Dectin‐2 and NFκB expression was up‐regulated in the epidermis and dermal inflammatory cells of MF lesion compared with control skin (P < .01‐.05), but NLRP1 expression was not different between both groups (P > .05). qRT‐PCR showed that levels of NLRP3, Casp‐1 and IL‐1β mRNA were significantly increased (P < .01‐.05), whereas those of NLRP1, NLRC4 and AIM2 mRNA were slightly augmented compared to control skin (P > .05). Our observation suggests that simultaneous activation of NLRP3, NLRC4 and AIM2 inflammasomes may play an important role in the pathogenesis of MF.

Comparison of modified Chicago sky blue stain and potassium hydroxide mount for the diagnosis of dermatomycoses and onychomycoses

The diagnostic value of modified Chicago sky blue (CSB) stain and potassium hydroxide (KOH) mount for superficial mycoses was compared using fungal culture as gold standard. The sensitivity and screening time of the CSB stain were superior to the KOH mount. The CBS stain is simple, quick and reliable for diagnosing superficial mycoses.