Abstract
Chronic recalcitrant dermatophytoses, due to Trichophyton (T.) mentagrophytes Type VIII are on the rise in India and are noteworthy for their predominance. It would not be wrong to assume that travel and migration would be responsible for the spread of T. mentagrophytes Type VIII from India, with many strains resistant to terbinafine, to other parts of the world. From September 2016 until March 2020, a total of 29 strains of T. mentagrophytes Type VIII (India) were isolated. All patients were residents of Germany: 12 females, 15 males and the gender of the remaining two was not assignable. Patients originated from India (11), Pakistan (two), Bangladesh (one), Iraq (two), Bahrain (one), Libya (one) and other unspecified countries (10). At least two patients were German-born residents. Most samples (21) were collected in 2019 and 2020. All 29 T. mentagrophytes isolates were sequenced (internal transcribed spacer (ITS) and translation elongation factor 1-α gene (TEF1-α)). All were identified as genotype VIII (India) of T. mentagrophytes. In vitro resistance testing revealed 13/29 strains (45%) to be terbinafine-resistant with minimum inhibitory concentration (MIC) breakpoints ≥0.2 µg/mL. The remaining 16 strains (55%) were terbinafine-sensitive. Point mutation analysis revealed that 10/13 resistant strains exhibited Phe397Leu amino acid substitution of squalene epoxidase (SQLE), indicative for in vitro resistance to terbinafine. Two resistant strains showed combined Phe397Leu and Ala448Thr amino acid substitutions, and one strain a single Leu393Phe amino acid substitution. Out of 16 terbinafine-sensitive strains, in eight Ala448Thr, and in one Ala448Thr +, new Val444 Ile amino acid substitutions were detected. Resistance to both itraconazole and voriconazole was observed in three out of 13 analyzed strains. Treatment included topical ciclopirox olamine plus topical miconazole or sertaconazole. Oral itraconazole 200 mg twice daily for four to eight weeks was found to be adequate. Terbinafine-resistant T. mentagrophytes Type VIII are being increasingly isolated. In Germany, transmission of T. mentagrophytes Type VIII from the Indian subcontinent to Europe should be viewed as a significant public health issue.
Highlights
There is a veritable epidemic of varieties of chronic recalcitrant dermatophytoses due to Trichophyton (T.) mentagrophytes Type VIII in India [1]
Twenty-nine patients with different clinical variants of dermatophytoses caused by T. mentagrophytes Type VIII (India) were diagnosed all over Germany (Table 1) between September
Germany, and from cultures sent for fungal species identification of T. mentagrophytes Type VIII
Summary
There is a veritable epidemic of varieties of chronic recalcitrant dermatophytoses due to Trichophyton (T.) mentagrophytes Type VIII in India [1]. A wide variation in clinical features is seen. Tinea cruris, tinea faciei and their combinations are the most common presentations. Lesions often show a minimal to a high degree of inflammation, and large lesions with a tendency to coalesce and spread are common. Severe itching is common [2]. There has been an undeniable association between the occurrence of extensive and hard to treat tinea and long-term abuse of potent and super-potent topical corticosteroids, predominantly clobetasol propionate [1,3]
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