Chronic Fungal Disease Research Articles

Disseminated Rhinosporidiosis Destroying the Talus: A Case Report

Rhinosporidiosis is a chronic granulomatous fungal disease caused by Rhinosporidiosis seeberi. It usually affects the mucocutaneous tissue of the nose; bone involvement is rare. We report the clinical features, diagnosis, and management of rhinosporidiosis involving the face, forehead, and right foot. As antimicrobial therapy was ineffective, a below-knee amputation was performed.

Onychomycosis - epidemiology, diagnosis and management

Onychomycosis is a fungal infection of nails caused by dermatophytes, yeasts or nondermatophyte molds and represents about 30% of mycotic cutaneous infections. Increasingly onychomycosis is being viewed as more than a mere cosmetic problem. In spite of improved personal hygiene and living environment, onychomycosis continues to spread and persist. The prevalence rate of onychomycosis is determined by age, predisposing factor, social class, occupation, climate, living environment and frequency of travel. Onychomycosis in immunocompromised patients can pose a more serious health problem. Dermatophytes are the most frequently implicated causative agents in onychomycosis. Previously regarded as contaminants, yeasts are now increasingly recognised as pathogens in fingernail infections, as are some moulds. Clinical diagnosis of onychomycosis is based on the patients' history; a physical examination, microscopy and culture of nail specimens. The treatment of onychomycosis has been attempted throughout the ages, but only in the last two decades have safe, effective systemic treatments been available for this chronic superficial fungal disease. Oral Griseofulvin and Ketoconazole; once the agents of choice for the treatment of onychomycosis, have been superseded by newer systemic compounds that have a higher cure and lower relapse rates, cause fewer side effects and are suitable for short-term dosing.

The efficacy of oral treatment with pramiconazole in pityriasis versicolor: a phase II a trial

Conflicts of interest: This study was supported by Barrier Therapeutics. J.A. and L.V. are full‐time employees of Barrier Therapeutics. M.B. is a member of the scientific advisory board of Barrier Therapeutics. J.F. is clinical investigator; he is not a consultant for Barrier Therapeutics and he has no stocks in the company. Sir, the efficacy of pramiconazole (R126638) has recently been tested in a first series of patients with pityriasis versicolor. This chronic superficial fungal disease is usually located on the upper trunk, neck or upper arms. Under the influence of predisposing factors Malassezia changes in pityriasis versicolor from blastospores into hyphae.1 Pramiconazole is a broad‐spectrum antifungal belonging to the class of triazoles. In vitro and in vivo data have demonstrated activity against several dermatophytes and Malassezia spp.2 3–4 The aim of the present study was to evaluate the effects of a single dose of 200 mg of pramiconazole given orally during three consecutive days in a group of 19 patients with pityriasis versicolor.

Neuropathology: A Reference Text of CNS Pathology

2nd ed, by David Ellison, Seth Love, Leila Chimelli, Brian N. Harding, James Lowe, and Harry V. Vinters, 754 pp, with illus plus index and CD-ROM, Philadelphia, Pa, Mosby, 2004.This is a superb second edition of a book that was first published in 1997 and has since become one of the cornerstones of neuropathology education and practice. As stated by the authors, the aim of the first edition was to provide a reference book that was heavily biased toward the use of color illustrations, yet included much more information than an atlas. The second edition maintains this concept. It contains 47 chapters within 10 sections that cover a wide range of aspects of central nervous system (CNS) pathology and has incorporated new developments in this rapidly growing field with referenced material ending in 2002.As in the first edition, the second edition uses different colors to identify pathogenesis and etiology, clinical aspects, and differential diagnosis and practical advice on diagnosis to help orientate readers to the text. The book contains a wealth of illuminating charts, tables, drawings, and beautiful illustrations of gross and microscopic pathology, with many of the figures new to the second edition. The new edition contains more than twice as many references as its predecessor, and they are now subdivided thematically where appropriate. An accompanying CD-ROM contains more than 2500 images of the text's illustrations and represents an invaluable source of learning and teaching.The first of the 10 sections provides a detailed description of pathologic reactions in the CNS. The second section is devoted to pediatric neuropathology. The book contains chapters that discuss fetal and neonatal hypoxic-ischemic lesions, malformations, hydrocephalus, white matter lesions (leukodystrophies), and neurodegenerative disorders of gray matter in childhood. A chapter of miscellaneous pediatric disorders covers vascular diseases, epilepsy in childhood, and pediatric trauma.Section 3 (vascular disorders) has separate chapters on adult hypoxic and ischemic lesions, vascular disease and infarcts, and hemorrhage. Section 4 covers CNS trauma, and section 5 provides a detailed presentation of infectious diseases of the CNS. There are separate, beautifully illustrated chapters that cover acute and subacute or chronic viral infections, rickettsial and mycoplasma infections, acute bacterial infections and brain abscesses, chronic bacterial infections, fungal diseases, and parasitic infections of the CNS. A section devoted to demyelinating diseases discusses multiple sclerosis, acute \[bu791\]disseminated encephalomyelitis, acute hemorrhagic leukoencephalopathy, and trigeminal neuralgia.Section 7 covers nutritional and metabolic disorders with separate chapters devoted to vitamin deficiencies, systemic metabolic disease, lysosomal and peroxisomal disorders, and mitochondrial encephalopathies. Section 8 discusses toxic CNS injury. In this section, neurodegenerative diseases are presented in chapters on classification and pathogenesis, motor neuron disorders, parkinsonism and akinetic-rigid disorders, ataxic disorders, hyperkinetic movement disorders, dementias, and prion diseases. Thalamic and pallidal degenerations, neuroaxonal dystrophy, and autonomic failure are presented in the last chapter of this section. The 10th section covers CNS neoplasia and paraneoplastic disorders.This second edition will be of great value for pathology, neurology, and neurosurgery residents and should be on the shelf of all practicing pathologists.

Miniseminar: Situations and solutions in endoscopic sinus surgery

This miniseminar will present an open forum discussion on the management of several interesting and challenging cases of controversial management. Pathology ranging from chronic rhino sinusitis, noninvasive and invasive fungal disease, lateral mucoceles of the frontal and sphenoid sinus, and skull base lesions including CSF rhinorrhoea, encephaloceles of the frontal and sphenoid sinus, and benign and malignant tumors. Multimedia video clips of intraoperative situations, such as intraoperative CSF leaks, orbital injury, retro-orbital hemotoma, anterior ethmoid artery trauma, medial rectus injury, will be presented and their management discussed. Digital video clips of how these “situations” were managed will be presented. A case presentation format presented in form of multimedia will be used. CT, MRI scans, and endoscopic slides will be complemented with intraoperative video clips and post-operative results. Audience interaction by a touch pad response system will be encouraged. The panel is chosen to provide a worldwide viewpoint of management of sinus pathology and intraoperative situations. About 10–12 interesting cases will be presented.

Blastomycosis of the Vocal folds with Life-Threatening upper Airway Obstruction: A Case Report

Blastomycosis is a chronic fungal disease that primarily affects the lower respiratory tract. The acute inflammatory phase of the primary pulmonary infection is characterized by a lymphohematogenous spread to extrapulmonary sites, especially the skin. The presence of disseminated infection with Blastomyces dermatitidis in the larynx is unusual. In areas of the United States where this fungus is endemic, failure to consider laryngeal involvement might lead to inappropriate therapy and thus worsening inflammation and airway compromise.

Optimum imaging for inverted papilloma.

Inverted papilloma is the most common benign tumour of the nose and paranasal sinuses, and usually arises in the lateral wall of the nasal cavity and the middle meatus. The diagnosis is suggested on computed tomography (CT) when there is a mass continuous from the middle meatus into the adjacent maxillary antrum, through an expanded maxillary ostium. The mass may contain areas of high density or calcification, and there may be sclerosis of the wall of the affected sinus. The main advantage of magnetic resonance imaging (MRI) is in defining the extent of the tumour, and in differentiating it from adjacent inflammatory tissue, but there are no certain signal intensity or enhancement characteristics to help differentiate inverted papilloma from sinus malignancy. In the differential diagnosis, antro-choanal polyp, malignant sinus tumours and chronic rhinosinusitis and fungal disease need to be excluded. The combination of bone deformity and sclerosis with the typical antro-meatal mass suggests a slow-growing tumour such as inverted papilloma.

Isolated tracheal rhinosporidiose -a case report.

Rhinosporidiosis is a chronic fungal granulomatous disease which usually involves the mucous membrance of the nose and nasopharynx.We are reporting here a rare case of Rhinosporidiosis affecting the trachea alone without any involvement of mucous membrance or skin elsewhere.

Management of seborrheic dermatitis and pityriasis versicolor.

Pityriasis (tinea) versicolor and seborrheic dermatitis are two very common skin diseases. Pityriasis versicolor is a chronic superficial fungal disease usually located on the upper trunk, neck, or upper arms. In pityriasis versicolor, the lipophilic yeast Malassezia (also know as Pityrosporum ovale or P. orbiculare) changes from the blastospore form to the mycelial form under the influence of predisposing factors. The most important exogenous factors are high temperatures and a high relative humidity which probably explain why pityriasis versicolor is more common in the tropics. The most important endogenous factors are greasy skin, hyperhidrosis, hereditary factors, corticosteroid treatment and immunodeficiency. There are many ways of treating pityriasis versicolor topically. Options include propylene glycol, ketoconazole shampoo, zinc pyrithione shampoo, ciclopiroxamine, selenium sulfide, and topical antifungals. In difficult cases, short term treatment with fluconazole or itraconazole is effective and well tolerated. To avoid recurrence a prophylactic treatment regimen is mandatory. Seborrheic dermatitis is characterized by red scaly lesions predominantly located on the scalp, face and upper trunk. There are now many studies indicating that Malassezia plays an important role in this condition. Even a normal number of Malassezia will start an inflammatory reaction. Mild corticosteroids are effective in the treatment of seborrheic dermatitis. However, the disease recurs quickly, often within just a few days. Antifungal therapy is effective in the treatment of seborrheic dermatitis and, because it reduces the number of Malassezia, the time to recurrence is increased compared with treatment with corticosteroids. Antifungal therapy should be the primary treatment of this disease.

Pityrosporum species as a cause of allergy and infection.

Pityrosporum species as a cause of allergy and infection.

Chronic mycoses of the paranasal sinuses--value of endonasal paranasal sinus surgery

Many host factors even in immunocompetent patients may have an influence on development of a fungal diseases within the paranasal sinuses. Fungal sinusitis can occur in an acute form or more often to a chronic type of the disease. These mainly relatively asymptomatic chronic forms and further divided into a chronic noninvasive, chronic allergic, and chronic invasive disease. Endonasal microsurgery has significantly changed the management of chronic fungal sinusitis and allows adequate removal of pathologic tissue even in advanced situations. The aim of this study was to analyze the efficacy of endonasal surgery in chronic fungal sinusitis. In a retrospective study we assessed a group of 40 patients who had endonasal surgery for chronic fungal sinusitis. Patient records, CT and MRI scans, microbiology and histology as well as the postoperative clinical follow-up including endoscopic photo documentation were evaluated over a period of 5 years. All patients underwent endonasal surgery using endoscopic techniques. The microscopic was of additional help in a few cases with extended disease and multiple dehiscences of the skull base. Twenty-four patients had a chronic noninvasive of fungal sinusitis and 16 patients had a chronic invasive form. All these patients underwent endonasal surgery without external incision. The fungal disease was erradicated in 39 cases, and revision surgery was required in only one case in which involvement of the contralateral side was not initially detected. in two cases scar tissue in the middle meatus was later excised but without evidence of residual fungal disease. Only in 6 cases was antifungal chemotherapy required, where the disease had spread into surrounding tissue or the patient had severe symptoms. Endonasal microsurgical techniques are today the appropriate approach for managing chronic fungal sinus disease even in severe cases with radiologic evidence of expansion or invasion of surrounding tissue. Additional antifungal chemotherapy is only rarely indicated, specifically when the fungal disease invades surrounding tissue.

The pulmonary infiltration with eosinophilia syndrome.

The term eosinophilia denotes an absolute eosinophil count above 500 cells/microL. Eosinophilia has been noted in various inflammatory disorders: skin conditions (eczema, dermatitis, generalized drug reactions), malignancies (Hodgkin's disease and lung cancer), chronic granulomatous disorders (tuberculosis, sarcoidosis), fungal diseases (coccidioidomycosis, aspergillosis), drug- and chemical--related conditions, and idiopathic pulmonary infiltrate and eosinophilia syndromes. The incidence of pulmonary infiltration with eosinophilia is on the rise. Idiopathic pulmonary eosinophilia should be distinguished from the eosinophilic myeloproliferative syndrome. The diagnosis can usually be secured with the help of a good history and physical examination enhanced by simple laboratory tests on blood and sputum and a chest radiogram. The therapy is then directed to correct the initial injury.

Special features of the clinical use of oral terbinafine in the treatment of fungal diseases.

Terbinafine (Lamisil) is an antifungal drug, belonging to a class of drugs called the allylamines, which has recently become available for clinical use. This is a report of four special features which emerged during evaluation of the systemic use of orally administered terbinafine in the treatment of 2500 patients during the last 5 years. These features include: (i) distribution of terbinafine in skin, hair and nail tissue; (ii) use in short-duration treatment of chronic tinea pedis and onychomycosis; (iii) use in patients with serious infections often associated with local or generalized immunological defects; and (iv) tolerability and safety of the drug. The diffusion of terbinafine into thickened, chronically infected tissue and into nails, and its recognized fungicidal action are the most likely features responsible for its success in the treatment of chronic fungal diseases, including those with immunological defects. Terbinafine is well tolerated, particularly when compared with other available systemic antifungal drugs.

Epidemiology and ecology of pityriasis versicolor.

Pityriasis versicolor is a chronic superficial fungal disease. It is usually localized on the upper part of the chest or on the back, neck, or upper arms. Lesions may be red, brown, or white. They are often slightly scaling, papular, or nummular, or they may coalesce to involve larger areas of the body. The conidia and short hyphae of the lipophilic yeast Malassezia furfur (syn. Pityrosporum orbiculare) can be detected by microscopy.KeywordsAtopic DermatitisSeborrheic DermatitisPityriasis VersicolorHuman Stratum CorneumTinea VersicolorThese keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Clinical Significance of Pseudallescheria boydii: A Review of 10 Years' Experience

Pseudallescheria boydii is a recognized cause of mycetoma, a chronic fungal disease that usually affects the extremities. Isolated case reports have also implicated P. boydii in infections of other sites. We report the first large series (83 isolates) of P. boydii in 46 patients, including the second report of P. boydii brain abscess and disseminated infection in a noncompromised host. Between 1974 and 1984 at our institution, P. boydii was cultured from a variety of sites: respiratory tract, 36; soft tissue, 25; bone, 9; gastric aspirate, 4; maxillary sinus, 2; wound, 2; urine, 2; brain abscess, 1; ear, 1; and toenail, 1. Pulmonary colonization proved to be the most common form of pseudallescheriasis of the lung (34 of 36 cultures in this category); 28 of the 32 patients with pulmonary infections had received immunosuppressive therapy or had an underlying disorder. The importance of isolation of P. boydii from bone and soft tissue is supported in this series because all 9 cultures from bone and 21 of 25 cultures from soft tissue were associated with infection. Of 10 cases of infection, 5 were osteomyelitis and 2 were infected wounds; in addition, maxillary sinusitis, disseminated infection, and a lung abscess occurred in 1 patient each.

Bronchoalveolar lavage findings in pulmonary paracoccidioidomycosis.

Bronchoalveolar fluid cytology from six progressive pulmonary paracoccidioidomycotic patients showed an alveolitis of neutrophilic pattern which was independent of the of the duration of the chronic fungal disease. The percentage of neutrophils in paracoccidioidomycotic alveolitis was higher than in other neutrophilic alveolitis conditions.

Tinea Versicolor

This chronic superficial fungal disease of the skin is caused by the filamentous form of Pityrosporum orbiculare. Although the infection can be present on the neck, face, and extremities, it is most commonly found on the upper chest. Several factors are believed to affect host susceptibility to developing clinical disease. Whether P. orbiculare is a saprophytic colonizer or a pathogen remains unanswered. The Pityrosporum lacks aggressiveness as a disease-producing organism and responds fairly readily to therapies directed at reducing the number of filamentous forms on the skin.

Orally administered ketoconazole: route of delivery to the human stratum corneum.

Delivery of ketoconazole to human stratum corneum was studied. Thirteen healthy volunteers, three patients with chronic fungal disease and one patient with palmar-plantar hyperhidrosis were given 400 mg of ketoconazole daily for various lengths of time. The ketoconazole content of palmar stratum corneum, eccrine sweat, sebum, and serum was measured by high-pressure liquid chromatography (sensitivity, 0.005 to 0.010 microgram/ml). Palmar stratum corneum obtained after 7 and 14 days of daily administration contained up to 14 micrograms of ketoconazole per g. Ketoconazole was not found in sebum after 7 or 14 days of daily ingestion of the antimycotic agent. Sebum from three patients with chronic fungal infection treated for greater than 9 months contained ketoconazole (means, 4.7 micrograms/g). Thermogenic whole body eccrine sweat contained a mean of 0.059 microgram/ml on day 7 and 0.084 microgram/ml on day 14 of daily administration. Ketoconazole appeared in thermogenic whole body eccrine sweat and palmar hyperhidrotic sweat within 1 h after a single oral dose. Partition studies of ketoconazole containing eccrine sweat demonstrated a 10-fold greater concentration in the sediment phase (desquamated keratinocytes) compared with the clear supernatant phase. In vitro studies with [3H]ketoconazole-supplemented supernatant sweat revealed preferential binding to stratum corneum, hair, and nails and its partitioning to lipid-rich sebum. We conclude that eccrine sweat rapidly transports ketoconazole across the blood-skin barrier, where it may bind or partition to keratinocytes and surface lipids.

'Cure' in Chronic Fungal Disease

Sir .—Let me react to the article by Hayden et al in the Journal (131:927, 1977). We would point out that our case to which they kindly refer in their third reference also had apparent remission, but recurred thereafter. I believe strongly that the word cure is usually inappropriate in chronic fungal disease and certainly so if only short-term follow-up is available. For Hayden et al, as for us, intraarticular amphotericin B was something to do. I doubt very much that it was substantially better than the policy of no action whatsoever. I would refer the interested reader to our article on coccidioidal arthritis 1 for yet another look at how imperfect is our treatment of chronic fungal disease by amphotericin B, whether by the topical or intravenous route.