Biomedical subjects
Publications and source records attributed to H C Korting.
The case of a young suckling is reported in whom widespread candidosis of the napkin area was followed by the clinical signs of both erythema multiforme and dermatitis seborrhoides infantum. Both these diseased states are considered as candidids.
Maceration, hyperkeratosis and vesicles are well known as typical clinical correlates of dermatophyte infection of the feet. It seems, however, still to be controversial whether bullae also belong to the clinical spectrum. In a 48-year-old female Trichophyton rubrum could be cultured from the fluid obtained by aspiration of an interdigital bulla. In another case Trichophyton mentagrophytes could be isolated from the interdigital space but not from a bulla found on the sole, microscopic investigation, however, being positive. This emphasizes the hypothesis that blisters found on the foot can be due to dermatophytes.
Fifty Candida albicans strains isolated from the oral cavities of HIV-infected patients were typed with 14 different lectins by means of agglutination reactions. Sixteen different lectin types could be distinguished, the most frequent type representing 22% of strains. A change in the lectin type was found in about half of the Candida albicans strains representing control cultures from identical individuals. A simplified typing scheme based on three lectins seems to be almost as efficacious for epidemiological application.
Fifteen male patients with manifest oral candidosis due to Candida albicans, suffering from AIDS-related complex (ARC) or full-blown AIDS, were investigated both clinically and microbiologically before and about 1 and 4 weeks after 7 to 10 days of treatment with 200 mg ketoconazole p.o. per day. Candida albicans was quantitated in mouthwash fluid. The antimicrobial susceptibility of the Candida albicans isolates was assessed using the IC30 test. In the short term, clinical cure was obtained in 87%, mycological cure in 53%. In the long term, the corresponding figures were 56 and 9%, respectively. Eradication of Candida albicans was not possible if IC30 values exceeded 256 micrograms ml-1. While pretreatment counts of Candida albicans in those patients also taking zidovudine did not differ from those in the rest of the study population, both the clinical and the mycological efficacy of ketoconazole seem to be higher both in the short and the long term when administered together with zidovudine. In consideration of the high relapse rate after about 4 weeks, an interval treatment protocol with oral ketoconazole is proposed.
In a randomized controlled trial three different treatment protocols with the new broad-spectrum peroral antifungal saperconazole were evaluated. The treatment regimens were as follows: 100 mg per day for 7 days, 200 mg per day for 7 days, 100 mg per day for 14 days. Of four assessable cases of dermatophytosis of glabrous skin treated with one of these three therapeutic regimens, one was cured. In this patient, however, the dermatophytosis relapsed after the end of the observation period, but due to a different microorganism. While partial improvement was seen in the other cases definite cure was not obtained. No adverse events were recorded.
Skin scrapings from the toe clefts, soles and nail plates of 138 HIV-infected patients at various stages were examined for the presence of dermatophytes using both microscopy and culture. Dermatophytes, in particular Trichophyton rubrum, could be grown in 58 cases (42%). Although cultures were more often positive in late stages of disease, there was no close correlation with the clinical stage or the T4/T8 ratio. Susceptibility to itraconazole, but not to other antimycotics, was correlated with the immune status (P < 0.05). Pedal dermatophyte infection does not seem to be a major problem in HIV infection.
In clinical practice the suspicion of onychomycosis in a diseased nail plate is not infrequently substantiated by microscopic evaluation of scrapings using a KOH preparation but not by culture. As this may be partly due to inadequate sampling an alternative sampling method may in principle be beneficial. Based on good anecdotal reports of high-speed fraising this method was used in 24 patients. If culture again proved negative high-speed fraising was repeated in conjunction with nail biopsy. In the majority of cases high-speed fraising provided specimens allowing culture of the causative organism. If not, nail biopsy was of additional help. As repeated high-speed fraising is a non-invasive non-laborious method it can be advocated as an additional routine step in the diagnosis of clinically and microscopically suspected onychomycosis initially unproven by culture. Microscopic examination of a biopsy should be considered if material obtained by repeated high-speed fraising does not reveal fungi upon culture.
Seborrhoeic dermatitis is a common entity that conventionally is difficult to treat. Recently, topical ketoconazole has been proven successful. To determine if other azoles, and in particular the more modern ones, are also helpful in this condition, a double-blind multicentre randomized controlled trial was performed in patients suffering from seborrhoeic dermatitis involving individuals 16 years and older without human immunodeficiency virus (HIV) infection. One hundred patients were enrolled and treated according to a random plan with either bifonazole 1% cream or the corresponding vehicle once daily for 4 weeks. All patients were evaluated at the beginning of the study, as well as after 2 and 4 weeks, i.e. the treatment period proper, and after 6 weeks of follow-up. Clinical evaluation was based on scores of 0-3 for the following parameters: erythema, papules, infiltration, scaling, itch. In addition, mycological evaluation was performed using adequate contact plates for quantitative determination of Malassezia furfur. In the end, 92 patients were at least partially evaluable. In general, the verum preparation tended to be more efficacious, e.g. the score for erythema amounted to 0.75 after 4 weeks as compared with 0.88 in the control group, the baseline values being 2.18 and 2.04 respectively. With itch, the corresponding figures were 0.17 and 0.33 as compared with 1.42 and 1.38 before treatment. While in statistical terms there was significant difference in these parameters, such a difference was demonstrated by clinical judgement at follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)
A 29-year-old female suffering from full-blown AIDS received fluconazole 400 mg day-1 for a long period for treatment of oral candidosis, pseudomembranous type. She had previously received this drug repeatedly for the same reason, yet manifest disease persisted. She was therefore put on parenteral amphotericin B, which led to clinical, but not mycological, cure in the short term. IC30 testing revealed a minimum inhibitory concentration (MIC) > 128 micrograms ml-1 for fluconazole. The isolate, however, was susceptible in vitro to ketoconazole, itraconazole and amphotericin B. The same antimicrobial susceptibility pattern was found with a second isolate obtained later. Resistance to fluconazole might become a major problem in HIV-infected patients receiving this drug for long periods.
We report on three siblings, children of a farmer, aged 3-8 years, suffering from tinea capitis due to Microsporum canis. Initially, the infection was treated systemically with griseofulvin as well as externally for 5 months without success. Therapy was changed to itraconazole 33 mg per day orally. Laboratory investigations followed every 4-6 weeks. Dependent on the dose per kg body weight the children were cured clinically after 2-5 months and microbiologically after 5-8 months. Thus, itraconazole seems to be superior to conventional treatment with Microsporum canis-induced tinea capitis.
Microsporum canis is one of the most common zoophilic dermatophytes. If transmitted to humans, inflammatory lesions may develop, e.g. on the scalp. M. canis was isolated from a 5-year-old boy living in a suburban area who suffered from a long-standing, mildly inflammatory lesion on the scalp that had been treated for several months with anti-eczematous regimens. There had been no contact with animals, e.g. cats or dogs, in the previous months, but the lesions had developed a few weeks after the family had bought a used car from a dog owner. Indeed, M. canis could be grown on contact plates from the car's interior. This case illustrates that attention should be paid to the often neglected diagnosis of M. canis-induced tinea capitis and to unusual routes of infection.
The term tinea axillaris has been used only a few times in the literature. In this paper we describe a male patient with widespread tinea corporis and unguium affecting also both axillary regions. Trichophyton verrucosum was isolated as the causative agent. The patient admitted to no direct contact with infected animals, but had lived in a rural area until a year before the infection became widespread. Topical treatment with glucocorticosteroids probably promoted propagation over large parts of his body and may have led to the infection of the axillary region, an unusual site for fungal infection. Treatment with itraconazole over 4 weeks led to complete clearing of all lesions on glabrous skin. Thereafter, itraconazole pulse therapy was used to treat the nail infection.
Systemic candidosis is currently a major concern among certain groups of patients at particular risk because of recent treatment modalities. To prevent spread of Candida albicans, in particular, from the orogastrointestinal tract antimycotic treatment would appear beneficial. So far, however, suitable drugs are rare. Polyenes, and in particular oral nystatin, are the main ones considered so far. More recently, the oral azoles have provided therapeutic alternatives. In this review the current role of nystatin and, in particular nystatin tablets, which are better accepted than suspensions at higher dose levels, is described, focusing on efficacy and safety as determined in controlled trials. Recent evidence suggests that oral application of nystatin tablets can be considered both efficacious and safe in the appropriate context. The relative potency of oral nystatin and systemic azoles, particularly ketoconazole and fluconazole, awaits final determination.
A 45-year-old human immunodeficiency virus (HIV)-infected patient has suffered for a period of 4 years from recurrent and, later on, persistent oral pseudomembranous candidosis. The Candida isolates proved to be resistant to azole derivates in vitro and in vivo. Treatment with amphotericin B parenterally was successful in February 1996, but had to be stopped when chemotherapy for lymphoma was started. In August 1996, the patient showed a shift from the pseudomembranous to the erythematous type of oral candidosis; antiretroviral combination therapy including the HIV protease inhibitor saquinavir had been started 4 months previously. In July 1997, the patient was still suffering from a persistent oral candidosis of the erythematous type.
The introduction of HIV protease inhibitors was accompanied by reduction in HIV-associated opportunistic infections. Therefore, we performed a retrospective study of HIV-infected patients to evaluate the effects of therapy with an HIV protease inhibitor (PI) on oral candidosis. This was of special interest, because an important virulence factor of Candida albicans is the secreted aspartic protease (SAP), which is assigned to the same class of aspartic proteases as HIV protease. Sixty-two patients were examined five times over a period of 2 years. There was a hint at a difference in the frequencies of C. albicans carrier state and manifest oral candidosis in favour of treatment with a PI. In addition, loss of Candida colonization and manifest oral candidosis was observed only in patients with elevation of CD4 cells upon PI. This might explain the effect, which also might go back to a direct inhibition of yeast SAP.
A 38-year-old woman infected with human immunodeficiency virus (HIV) presented with persistent oral candidosis in which non-albicans Candida strains were the predominant yeasts in most of the examinations performed over a period of 6 years. Oral treatment with fluconazole had no effect on clinical signs of oral candidosis. In 8 of a total of 11 specimens, Candida glabrata, Candida parapsilosis and Candida tropicalis were at least suspected as the causative pathogens of oral candidosis. The non-response to fluconazole in our patient could be explained by in vitro resistance to fluconazole of detected Candida glabrata and Candida tropicalis isolates.
A 29-year-old trumpeter, suffering from debilitating folliculitis barbae candidomycetica, was successfully treated with fluconazole 50 mg daily for a period of 4 weeks. Because of the strong local inflammation, oral treatment was initially combined with topical corticosteroid application.
Tinea mammae is a dermatophyte infection of the breast. Although rarely reported in this anatomical location, it can mimic other dermatoses. In this paper we describe an 85-year-old man with an erythema at the left breast which had enlarged over the previous 3 weeks. Trichophyton rubrum was isolated. Digital 20-MHz sonography revealed a reduction in echogenicity of the corium and a widened corium. Treatment with fluconazole over 5 weeks led to clearing of the lesion at the glabrous skin. At the end of therapy no difference between the involved and uninvolved skin areas was found sonographically.