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Year : 2017  |  Volume : 1  |  Issue : 1  |  Page : 16-17

Superficial fungal infection among patients with immune bullous diseases


1 Department of Dermatology, Faculty of Medicine, Tripoli Central Hospital, Tripoli University, Tripoli, Libya
2 Central Laboratory, Tripoli Medical Center, Tripoli, Libya

Date of Web Publication5-Jun-2017

Correspondence Address:
Hamida Al-Dwibe
Department of Dermatology, Faculty of Medicine, Tripoli Central Hospital, Tripoli University, Tripoli
Libya
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/LJMS.LJMS_7_17

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  Abstract 

Background/Objectives: Since no previous reported studies on superficial fungal infection (SFI) among patient with an immune bullous dermatosis exist in Libya, this study aimed to determine clinical and mycological aspects of SFI among those patients. Patients and Methods: This study was carried out in a Bullous clinic at Tripoli Central Hospital from May 2010 to October 2010. Patients were examined clinically for evidence of SFI, and scrapings were obtained from suspicious lesions for mycological investigation. Results: Clinical diagnosis of SFI was made in 31/79 (39.2%) female patient cases with immune bullous diseases. Their age ranged from 28 to 80 years (40 ± 13.3 years; mean ± standard deviation) and the main age group affected was 31–40 years (51.6%). A total of 20 (64.5%) of patients had pemphigus foliaceus, 4 (12.90%) pemphigus vulgaris, 3 (9.68%) herpetiform pemphigus, 2 (6.45%) bullous pemphigoid, 1 (3.2%) pemphigus vegetans, and 1 (3.23%) had IgA pemphigus. The majority (87.1%) were living in rural area, 90% of them were homemakers, and 19.4% had a diabetes mellitus. Fingernail involvement was seen in 38.9%, and toenail and tinea pedis were seen in 25% of cases equally. Distal subungual onychomycosis was the predominant clinical entity. Direct microscopic examination was positive in 51.4% and positive culture was obtained in 54.1%. Candida species were the main isolated organism from fingernails and dermatophytes from toenails. Conclusion: This study revealed that SFI was more frequent among female patients with pemphigus foliaceus and Candida species was the main isolated organism from the fingernails.

Keywords: Candida, dermatophytes, immune bullous dermatosis, superficial fungal infection


How to cite this article:
Al-Dwibe H, El-Fergani N, El-Zurghany A, Sharfiddin S, Khalifa Z. Superficial fungal infection among patients with immune bullous diseases. Libyan J Med Sci 2017;1:16-7

How to cite this URL:
Al-Dwibe H, El-Fergani N, El-Zurghany A, Sharfiddin S, Khalifa Z. Superficial fungal infection among patients with immune bullous diseases. Libyan J Med Sci [serial online] 2017 [cited 2017 Jun 24];1:16-7. Available from: http://www.ljmsonline.com/text.asp?2017/1/1/16/207560




  Introduction Top


Superficial fungal infections (SFIs) are diseases caused by fungi that capable of utilizing keratin for their nutrition and invading the keratinized tissues of the skin, hair, and nails.[1] Cutaneous fungal infections can be caused by dermatophytes, yeasts, and nondermatophyte molds although dermatophytes cause most of these infections.[2],[3] Fungus was the first human pathogen that was identified and isolated by Remark in 1839, and Trichophyton schoenleinii was the first isolated human fungus from patients with favus.[1] SFIs are the most frequent occurring human infection worldwide and affect more than 20%–25% of the world population.[2] During the last decades, there has been a significant increase in studies concerning fungal infections in humans because of increase prevalence of immunosuppression conditions and opportunistic nature of these organisms. In addition, the identification of the causative organisms is of the choice for correct management of these cases. However, no enough data exist about SFI among immune bullous patients, except a study done by Tuchinda et al. in 1989 which determined that 24% of vesiculobullous patients, especially those with pemphigus on immunosuppression agents, had onychomycosis, while Belgnaoui et al. reported that 50% of patients had a fungal infection.[4],[5] Thus, the aim of our study was to determine the clinical and mycological aspects of SFI among patients with various immune bullous diseases.


  Patients and Methods Top


This cross-sectional study was carried out in a Bullous clinic at Tripoli Central Hospital from May 2010 to October 2010. In each bullous case, a detailed history was obtained in a special preformed working sheet and patients were examined clinically for evidence of SFI. Samples including nail clippings, subungual debris, hair, and skin scrapings were obtained from suspicious lesions for mycological investigation. The collected specimens were analyzed microscopically using 20% potassium hydroxide solution and cultured on two media; Sabouraud glucose agar with chloramphenicol and gentamicin (SCG) and SCG and cycloheximide (SCGC). Cultures were incubated at 30°C for up to 4–6 weeks and checked three times a week for growth. Identification of the isolates was done on the basis of microscopic and macroscopic morphology, growth on SCGC, germ tube test, and other special tests. The SPSS Microsoft program was used for analysis of data.


  Results Top


Clinical diagnosis of SFI was made in 31 (39.24%) female patients out of 79 cases with immune bullous diseases seen during the period of study. The age of patients ranged from 28 to 80 years with mean ± standard deviation (SD) of 40 ± 13.3 years and the age group 31–40 years was the main affected group account for 51.6% of the patients. Twenty (64.52%) of patients had pemphigus foliaceus, 4 (12.90%) pemphigus vulgaris, 3 (9.68%) herpetiform pemphigus, 2 (6.45%) bullous pemphigoid, 1 (3.23%) pemphigus vegetans, and 1 (3.23%) IgA pemphigus. Majority of patients (79.2%) were living in rural area, 90% of them were homemakers, and 19.4% had diabetes mellitus. 63.3% engaged in home manual work, and 96.7% of them gave history of exposure to chemicals. Duration of systemic steroid therapy ranged from 0.02 to 30 years (7.3 ± 9.2 years; mean ± SD) and 82.8% of them had duration of treatment 1 year or more. Fingernail involvement was seen in 38.9%, toenail and tinea pedis were seen in 25% of cases equally. Distal and lateral subungual onychomycosis was the predominant clinical entity accounted for about 64.5% of cases. Direct microscopic examination was positive in 51.4% and positive culture was obtained in 54.1%. Out of the 20 isolates, Candida species was the main isolated organism from fingernails, followed by Candida albicans, and dermatophytes, especially Trichophyton verrucosum (T.V) from toenails.

Candida species was the most frequently isolated organism (45%), followed by C. albicans (30%), T.V (15%), Fusarium spp.(5%), and Rhodotorula (5%).


  Discussion Top


SFI is a worldwide infection and most common presentation in dermatology clinical practice, accounted for about more than 20%–25% of the world population.[2] The results of our study showed that the frequency of SFI accounted about 39.2% of the total examined patients with IBD which is less than reported by Belgnaoui et al.[5] and the reason for that may be related to small sample size. The increased frequency of onychomycosis of fingernails in patients with pemphigus foliaceus in our study could be related to the following factors: Most of our patients were homemakers, 63.3% engaged in home manual work, and 96.7% of them gave history of exposure to chemicals and humid environments. In addition, 35.5% were on long-term corticosteroid therapy for 1 year or more. Isolation of Candida species from fingernails of these patients is concurred with studies done on immunocompetent and autoimmune patients.[6],[7]


  Conclusion Top


This preliminary study revealed that SFI was more frequent among female patients with pemphigus folicaeous from rural localities and Candida species were the main isolated organisms from the fingernails of these patients. Further studies are needed to evaluate the prevalence of SFI among patients with immune bullous diseases and to determine the clinical and mycological aspects of SFI among those patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Todd P. A guide to fungal skin infections. Practitioner 1997;241:744-9.  Back to cited text no. 1
    
2.
Bassiri-Jahromi S, Khaksari AA. Epidemiological survey of dermatophytosis in Tehran, Iran, from 2000 to 2005. Indian J Dermatol Venereol Leprol 2009;75:142-7.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Foster KW, Ghannoum MA, Elewski BE. Epidemiologic surveillance of cutaneous fungal infection in the United States from 1999 to 2002. J Am Acad Dermatol 2004;50:748-52.  Back to cited text no. 3
    
4.
Tuchinda P, Boonchai W, Prukpaisarn P, Maungprasat C, Suthipinittharm P. Prevalence of onychomycosis in patients with autoimmune diseases. J Med Assoc Thai 2006;89:1249-52.  Back to cited text no. 4
    
5.
Belgnaoui FZ, Senouci K, Chraibi H, Aoussar A, Mansouri F, Benzekri L, et al. Predisposition to infection in patients with pemphigus. Retrospective study of 141 cases. Presse Med 2007;36(11 Pt 1):1563-9.  Back to cited text no. 5
    
6.
Midgley G, Moore MK, Cook JC, Phan QG. Mycology of nail disorders. J Am Acad Dermatol 1994;31(3 Pt 2):S68-74.  Back to cited text no. 6
    
7.
Boonchai W, Kulthanan K, Maungprasat C, Suthipinittham P. Clinical characteristics and mycology of onychomycosis in autoimmune patients. J Med Assoc Thai 2003;86:995-1000.  Back to cited text no. 7
    




 

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Abstract
Introduction
Patients and Methods
Results
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