Volume 32 - No.12 - December 1989
`
`A 2547 E
`
`Diagnosis,
`
`UFy@@s@§
`
`
`herapv and Prophylaxis of Fungal Diseases
`
`Official Publication / Publikationsorganz
`Deutschsprachige Mykologische Gesellschaft e.\/.
`
`——
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`“"
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`*‘“‘5“
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`:77 .»;:~». K
`
`Therapy and Prophylaxis of Fungal Diseases
`
`
`
`Diagnosis,
`
`Volume 32
`
`December
`
`.
`
`Caused by Non-Dermatophytic
`
`Contents/ lnhaltsverzeichnis
`M. Goihman-Yahr, Ismery Cabe/Io de Brito, Maria Cecilia Bastardo de A/bornoz,
`603
`Maria Helena de Gomez, J. Pereira, Ana de Roman, Blanca San Martin and T. Molina:
`Functions of Polymorphonuclear Leukocytes and Individuality of Jorge Lobo’s Disease:
`Absence of the Specific Leukocyte Digestive Defect Against Paracoccidioides brasiliensis
`tumlichkeiten bei der Jorge—Lobo—Mykose:
`Funktionen polymorphkernlger Leukozyten und Eigen
`Abwesenheit des spez. Leukozyten-Abbaudefektes gegen Paracoccidioides brasiliensis
`R. C. Summerbe//, J. Kane and S. Kra/‘den:
`Onychomycosis, Tinea Pedis and Tinea Manuum
`Filamentous Fungi
`Nicht-Dermatophyten-Fadenpilze als Erreger von Onychomykosen, Tinea pedis und
`Tinea manuum
`G. Carefta, I-T Mancianti and L. Ajel/o:
`Dermatophytes and Keratinophilic Fungi in Cats and Dogs
`Dermatophyten und keratlnophile Pilze bei Katzen und Hunden
`R. Rachel:
`ldentification of Certain False-Positive Results in the Cand-Tec® Test for Candidal Antigen
`—Tec®-Test zum Candida-
`Die Erkennung bestimmter fa|sch—positiver Ergebnisse im Cand
`Antigennachweis
`M. Ma//ié, B. Montés, J. C. Lebecq and J.—M. Bastide:
`In Vitro Antifungal Activity of Saperconazole (R 66905) Against Candida and Torulopsis
`Die antimyzetische Aktivitat von Saperconazol (R 66905) in vitro gegen Candida und Torulopsis
`G. /nselmann, Ute Holzlohner and H-7? Heidemann:
`638
`Effect of 5-Fluorocytosine and 5-Fluorouracil on Human and Rat Hepatitic Cytochrome P 450
`Wirkung von 5-Fluocytosin und 5-Fluorouracil auf Leber—Cytochrom-P 450 in Mensch u. Ratte
`
`G. Gargani, S. Zeochi Or/and/', E..Campisi, G. Pini and G. E. Orlandini:
`644
`Scanning Electron Microscopic Pattern of Recurrent Vaginitis by Candida albicans
`in the Mouse
`Die rezidivierende Candida a|bicans—Vaginitis der Maus im rasterelektronenmikrosk. Bild
`F Symoens, Ph. Willenz, V. Rouma, C. P/anard and N. Noland:
`lsoelectric Focusing Applied to Taxonomic Differentation of the Trichophyton
`mentagrophytes Complex and the Related Trichophyton interdigitale
`Die Anwendung der isoelektrischen Fokussierung auf die taxonomische Diferenzierung des
`Trichophyton mentagrophytes—Komp|exes und des verwandten Trichophyton interdigitale
`O. S. Kinsman and K. Pitblado:
`Candida albicans Gastrointestinal Colonization and Invasion in the Mouse: Effect of
`Antibacterial Dosing, Antifugal Therapy and lmmunosupression
`Die gastrointestinale Candida a|bicans—Besied|ung und —lnvasion der Maus: Einf|uB der
`antibakteriellen Dosierung, der antimyzetischen Therapie und der lmmunsuppression
`C. De Vroey and /-T Gatt/'
`Nomenclatural Communication: Cryptococcus neoformans var. gattii
`676
`Vanbreuseghem and Takashio 1970
`Member News, Deutschsprachige Mykologische Gesellschaft
`Mitteilungen der Deutschsprachigen Mykologischen Gesellschaft
`Congress-CaIendar/Kongrelikalenderz
`608
`Caption of the Cover Illustration/Legende zum Titelbild:
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`609
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`620
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`627
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`631
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`652
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`664
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`675
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`678
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`
`Onychomycosis, Tinea Pedis and Tinea Manuum
`Caused by Non-Dermatophytic Filamentous Fungi
`
`Nicht-Dermatophyten-Fadenpilze als Erreger Von
`Onychomykosen, Tinea pedis und Tinea manuum
`
`R. C. Summe1'be111,J. Kane‘ and S. Krajdenz
`
`‘Mycology, Ontario Ministry of Health, Laboratory Services Branch, Toronto, Ontario, Canada
`3St. Joseph’s Health Centre, Toronto, Ontario, Canada
`
`Key words: AspergillL2x_.s‘ya'0wii — Gymmrscella dalzkalicnsis —- Hendersonula roruloidea —
`Scopzzlarzopszs brevzcaulrs — Scymlzdumz /zyalinum — dermatomycosis — onychomycosis — tinea
`Schliisselwiirter: Aspergil/us sydowii — Gymnascella dankaliensis — I-Iendersonula toruloidea -
`Scopulurzapsts brevzcaulzs — Scylalrdium lzyalimun -— Dermatomykose — Onychomykose -- Tinea
`
`Summary: Over 4000 cases of fungal nail,
`sole and palm infection recorded during a
`three-year study period were investigated to
`determine the prevalence and significance
`of etiologic agents other than dermato-
`phytes and yeasts. Littman’s oxgall agar,
`which permitted isolation of cyclohexi-
`mide-sensitive species but restricted over-
`growth by fast growing contaminants, was
`used to promote isolation of these disease
`agents. Non-dermatophytic filamentous
`fungi made up 2.3 % of the confirmed etio-
`logic agents obtained overall, and con-
`stituted 3.3 % of the agents obtained from
`nail infections. The most common species
`were Scopulariopsis brevicaulis, Henderso-
`nula toruloidea, and Aspcrgillus sydowii.
`Scytalidium hyalinum was recorded for the
`first time from Canada, and an instance of
`nail infection by Gymnascella dankaliensis
`was recorded. Only H. toruloidea and Sc.
`Izyalinum caused palm and sole infections.
`
`Zusammenfassung: Uber 4000 Fiille von
`Pilzinfektionen der Néigel, Fulisohlen und
`Handfliichen wurden wiihrend eines 3-Jah-
`
`reszeitraumes auf das Vorkommen von
`
`als
`Nicht-Dermatophyten-Fadenpilzen
`Erreger untersucht. Zur Isolierung dieser
`Pilze wurde Littmans Rindergalle-Agar
`benutzt, der die Isolierung Cycloheximid-
`empfintllicher Arten erlaubt, jedoch das
`Uberwuchern
`durch
`schnellwachsende
`Kontaminanten verhindert. Nicht-Derma-
`
`tophyten-Fatlenpilze machten 2,3 % der
`nachgewiesenen Gcsamterreger und 3,3 %
`der Erreger von Nagelinfektionen aus. Die
`hiiufigsten Arten waren Scopulariopsis bre-
`vicaulis, Hendersonula
`toruloidca und
`Aspergillus sydowii. Scytalidium hyalinum
`wurde dabei zum erstenmal
`in Canada
`
`nachgewicscn, weiterhin wurde eine durch
`Gymnascella
`dankaliensis
`verursachte
`Nagelmykose gefunden. H. toruloidea und
`Sc. hyalinum waren bei Palmar- und Plan-
`tarinfektionen alleinige Erreger.
`
`Introduction
`
`Over the past three decades, careful work by
`mycologists and physicians has firmly estab-
`
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`
`R. C. Summerbell et al.: Dermatomycosis Caused by Non-Dermatophytic Hyphomycetes
`
`lished certain non-dermatophytie filamen-
`tous fungi as etiological agents of onycho-
`mycosis,
`tinea pedis and tinea manuum
`(Rippon 1988, Zaias 1972, Moore 1986).
`Most prevalent among the non-dermato-
`phytic fungi causing onychomycosis is Sco-
`pulariopsis brevicaulis (Fischer ‘1960, Frag-
`ner and Belsan 1974, Onsberg 1980), but
`other confirmed agents include members of
`the genera Alter//zaria (Ernst 1983), Asper-
`gillus, /lCl‘(3I710I/lI'L(I’I1 and Fusaritmt (Rippon
`1988), as well as He/1a'ers()rzu/a tom/oidea,
`Scytalidium /rzyalinum (Campbell
`and
`Mulder 1977, Moore 1986), Cladosparium
`carri0m'i (Barde and Singh 1984), Pyre//10-
`c/rzaeta unguis-/'z0mim's (English 1980) and
`Botryodiplodia theobromae (Restrepo et al.
`1976). Besides causing onychomycosis, H.
`toruloidea and Sc. hyalirzmn are also able to
`cause paronyehia as well as
`infections
`resembling classic tinea pedis and tinea
`manuum (Moore 1986; Gentles and Evans
`1970; Hay and Moore 1984). One feature
`possessed by the great majority of filamen-
`tous fungi responsible for non-dermato-
`phytic onychomycosis and tinea is a low
`tolerance of cycloheximide (Fischer 1960,
`Moore 1986, Restrepo et al. 1976, Gugnani
`et al. 1986). Although species such as S. bre-
`vicaulis and /lspergillus terreus may grow as
`restricted
`colonies
`on
`cyc1oheximide—
`amended media (Fragner and Belsan 1974,
`Onsberg etal. 1978), others, such as H. toru-
`Zoidea, B. t/zeobromae, and Sc. hyalinmn,
`are usually completely inhibited (Moore
`1986, Gugnani et al. 1986, Restrepo et al.
`1976). Some authors have contradicted
`others by stating that a large proportion of S.
`brcvicaulis
`isolates are inhibited (e.g.,
`Fischer 1960). Unfortunately, cyclohexi—
`mide concentrations are not given in most
`cases, but it appears likely that S. brevicaulis
`reaches a threshold of tolerance within the
`range of concentrations commonly used by
`clinical laboratories (100—5()0 ug/ml.)
`To be certain of obtaining all possible
`non-dermatophytie agents of onychomy-
`cosis and tinea, the Ontario Ministry of
`Health medical mycology laboratory intro-
`
`ducedapolicyofinoculating allnail samples
`and sole and palm skin samples on a cyclo-
`heximide—free medium in addition to the
`normal cycloheximide—supplemented iso-
`lation media. Littman’s oxgall agar, a general
`growth medium which restricts fungal col-
`ony diameter (Littman 1947), was used as
`the
`cycloheximide—free medium. This
`medium is known to be efficacious for the
`isolation of pathogenic fungi from various
`clinical materials (Littman 1948). The pur-
`pose of the present study was to determine
`the frequency and characteristics of non-
`dermatophyte
`filamentous
`fungal
`nail,
`palm, and sole infections detected in Onta-
`rio by means of this technique. Only isolates
`that could be definitively linked with nail
`infections by rigorous criteria were included
`in the survey.
`
`Materials and Methods
`
`Nail and skin samples were obtained in the
`routine practice of physicans’ offices and
`inoculated onto Sabouraud’s peptone-glu-
`cose agar supplemented with cyclohexi-
`mide (100 ug/ml), chloramphenicol (100
`ug/ml) and gentamicin (50 ug/ml). All nail
`specimens and atypical sole and palm speci-
`mens were inoculated on Littman’s oxgall
`medium (Difco Laboratories, Detroit,
`Mich.) supplemented with chlorampheni-
`col and gentamicin as above. In addition, all
`nail specimens and those skin specimens
`positive for fungal microscopic structures
`were inoculated onto casamino acids-ery-
`thritol—albumin agar (CEA), a cyclohexi—
`mide— and
`antibacterial—supplemented
`medium used for inhibiting the growth of
`common contaminating yeasts and bacteria
`(Fischer and Kane 1974). Non—derinato—
`phytic isolates were subcultured for identifi—
`cation onto cycloheximide—free Sabou—
`raud’s agar and modified Leonian’s agar
`(Malloch 1981). When necessary, slide cul—
`tures were grown using cornmeal agar.
`Direct microscopy of skin scales and pul-
`verized nail fragments was done in a 25 ‘’/o
`
`‘ 610 ‘ CFAD v. Anacor, |PR2015-01776
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`attha F\|Lfv1.and may be
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`

`
`R. C. Summerbell et al.: Dermatomycosis Caused by Non-Dermatophytic Hyphomycetes
`
`"iv, Nu» I, 1"l.‘,V*"I?').'\\*'” ‘
`¥'t.
`
`:.».‘.;..‘..........
`..'.’fl
`i-
`«.
`if
`‘i
`1
`2"‘
`
`
`
`
`Figure
`2:
`Ioruloidca
`hyphae
`Figure 1: /tspergil/us syzlowii hyphae and conidio—
`in skin. Phase contrast. X 770
`phore in nail scrapings. X 310
`
`sodium hydroxide/ 5% glycerol solution.
`Fungal hyphae seen were classi fied as “regu-
`lar” (typical of dermatophytic filaments, i.e.,
`terete or with typical in vivo arthroconidia
`as depicted by Fragner 1987), “atypical”
`(distorted, frondose, or unusual dermato-
`phytic filaments or similar non—dermato—
`phytic filaments, resembling those depicted
`by Zaias 1966) and “irregular” (of an irregu-
`larly nodulose morphology generally not
`associated with dermatophytic filaments).
`Notations were made of hyphal pigment, if
`any, and of the presence of any conidiogen-
`ous structures or conidia, including budding
`yeast cells.
`Detailed records were compiled from
`Jan. 1, 1986 to Jan. 1, 1989. In addition,
`physicians were requested to supply clinical
`information about
`apparently unusual
`
`re-
`scrapings were
`Repeat
`cases.
`commended in all equivocal or unusual
`cases. Some Aspergillus and Fusarium iso-
`lates were not identified to the species level
`prior to the middle of 1986; subsequently,
`all species have been determined. Because
`nail samples were often submitted without
`information about which digit or limb the
`nail was from, this information was not com-
`piled except in some unusual cases.
`
`Results
`
`Criteria for inclusion in data set. Non—der—
`
`matophytic filamentous fungi were con-
`sidered to be definitively linked to infections
`if characteristic, unmistakeably non—der—
`matophytic structures were seen in the
`
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`
`R. C. Summerbell et a1.: Dermatomycosis Caused by Non-Dermatophytic Hyphomycetes
`
`Table 1: Etiologic agents isolated from fungally infected nails, soles and palms in Ontario, Canada from
`Jan. 1986 to Jan. 1989.
`
`Isolates
`from nails
`
`Isolates
`from soles
`
`Isolates
`from palms
`
`Species
`
`#
`
`1878
`
`534
`
`144
`
`42
`
`19
`
`13
`
`8
`
`3
`3
`
`%a
`
`70.6
`
`20.1
`
`5.4
`
`1 .6
`
`0.7
`
`0.5
`
`0.3
`
`0.11
`0.11
`
`#
`
`810
`
`420
`
`——
`
`—
`
`3
`
`—
`
`28
`
`—
`—
`
`——
`—-
`
`2
`
`%
`
`63.9
`
`33.2
`
`——
`
`—
`
`0.2
`
`—
`
`2.2
`
`——
`—
`
`#
`
`102
`
`18
`
`—
`
`—
`
`—
`
`—
`—
`
`1
`
`2
`
`%
`
`81.6
`
`14.4
`
`—
`
`—
`
`0.8
`
`—
`
`1.6
`
`-
`—
`
`1) Trichophyton
`rubrum
`2) Tr/chophyton
`mentagrophytes
`3) Candida
`albicans
`4) Scopu/ar/‘ops/s
`brevicau//s
`5) Hendersonu/a
`toru/oidea
`6) Aspergi//us
`sydowii
`7) Ep/'dermophy-
`ton floccosum
`8) Aspergillus
`flavus
`9) Aspergi//us sp.
`10) Scyta/id/‘um
`hya/inum
`11) Asperg///us
`terreus
`12) Fusar/um spp.
`13) M/crosporum
`can/s
`14) Tr/chophyton
`tonsurans
`15) Tr/chophyton
`verrucosum
`16) Tr/chophyton
`vio/aceum
`17) Gymnasce//a
`dan/<a/iens/5
`18) Microsporum
`gypseum
`19) Trlchophyton
`raubitschekii
`
`Total infective
`agents isolated
`Total clinical speci-
`mens received from
`body site
`
`3
`2
`2
`
`2
`
`2
`
`2
`
`2
`
`1
`
`1
`
`1
`
`0.11
`0.08
`0.08
`
`0.08
`
`0.08
`
`0.08
`
`0.08
`
`0.04
`
`0.04
`
`0.04
`
`——
`
`—
`
`—
`
`——
`
`1
`
`2
`
`3
`
`0.16
`—
`—
`
`—-—
`
`—
`
`—
`
`0.08
`
`—
`
`0.1 6
`
`0.2
`
`—
`——
`—
`
`——
`
`—
`
`—
`
`—
`
`—
`
`1
`
`1
`
`—
`—
`—
`
`—
`
`0.8
`
`—
`
`—
`
`-
`
`—
`
`0.8
`
`2662
`
`10398
`
`1267
`
`2940
`
`125
`
`882
`
`a. Percentage of total etiologic agents from body site (e.g., nails).
`
`tissue samples, e.g., filaments and copious
`limoniform conidia for some S. brevicaulis
`
`infections (Fischer 1960, Fragner 1987) or
`distorted filaments
`and conidiogenous
`heads
`for
`some Aspergillus
`infections
`
`(Figure 1). In addition, where fungal struc-
`tures were present in the tissue but not diag-
`nostic, and where the species isolated was
`not known to form distinctive structures in
`
`keratinous tissues, repeated, exclusive iso-
`
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`
`R. C. Summerbell et al.: Dermatomycosis Caused by Non-Dermatophytic Hyphomycetes
`
`lation of the species from the infected site
`was held to indicate infection.
`
`fungal agents of onychomycosis, was the
`fourth most common isolant overall from
`
`In the case of H. tomloidea and Sc. hyali-
`num, now firmly established as agents of
`onychomycosis and tinea of thickly kera-
`tinized skin (Moore 1986), infection was
`accepted in all cases where fungal filaments
`of compatible morphology (Figure 2;
`Gentles and Evans 1970; Clayton and Mid-
`gley 1985) were present in the tissue sample.
`Scopulariopsis brevicaulis, which is well
`established as an agent of onychomycosis
`but is also a common contaminant, was
`accepted as infective if it formed within the
`nail plate either filaments accompanied by
`masses of conidia or nodulose, “irregular”
`hyphae not resembling ordinary dermato-
`phyte hyphae or frondose hyphae of Trich0-
`phyton mentagroplrzytes (Zaias 1972). The
`applicability of the latter criterion was veri-
`fied by repeat isolation in several instances.
`In cases where S. brevicaulis was associated
`
`with relatively undistinguished “atypical”
`(see above) cylindrical hyphae, but grew
`from numerous inoculum pieces and was
`not associated with a dermatophyte, a nota-
`tion was made that the case was “suggestive”
`of an infection. Such “suggestive” infections
`were also noted for Aspergillus and Fusa—
`rium species. If the apparent agent of a “sug-
`gestive” infection was consistently isolated
`in later, repeat samples from the same
`patient and body site, the case was accepted
`as avalid infection. Despite the possibility of
`mixed infections, isolates of S. brevicaulis,
`/lspergillus and Fusarium which grew from
`specimens also yielding dermatophytes
`were disregarded. Nonetheless,
`the fre-
`quency of such instances was separately
`recorded.
`
`Frequency of accepted non—dermato—
`phytic nail infections. Table 1 shows the fre-
`quency of isolation of all pathogenic fungi,
`including dermatophytes and non—derma—
`tophytes, verified as etiologic agents of dis-
`ease in nails, soles, and palms within the
`three—year study period.
`S. brevicaulis, the most frequently iso-
`lated of the non—dermatophytic filamentous
`
`nails. The 42 accepted S. brevicaulis infec-
`tions made up only 1.6% of all nail infec-
`tions, but confirmed this species as a much
`more prevalent agent of nail infection than 7
`of the 9 dermatophyte species recorded. In
`addition,
`39
`“suggestive”
`cases,
`not
`included in Table 1, were recorded, and a
`further 26 isolates of S. brevicaulis were
`
`obtained from infections also yielding Tri-
`chophyton rubmm. Numerous isolates were
`also obtained from nail samples revealing
`no fungal hyphae or “regular”, dermato-
`phyte-like hyphae, but these instances were
`not enumerated.
`
`Hendersonula toruloidea was also regu-
`larly seen and was the fifth most common
`etiologic agent of nail infection overall. The
`difficulty of treating most H.
`toruloidea
`infections led to numerous repeat isolations
`from many of the affected patients, and it is
`important to stress that the 19 cases in Table
`1 represent individual patients, not isola-
`tions. Three of the cases involved fingernail
`infections. In direct microscopic examin-
`ations of infected tissue, hyphae of H. tom-
`loidea were scarcely distinguishable from
`dermatophytic hyphae, and were usually
`recorded as “regular” hyphae in the classifi-
`cation detailed above. Such hyphae, unusual
`mainly because they have a subtly percep-
`tible “ensheathed” or “double-contoured”
`
`(Clayton and Midgley, 1985) appearance
`not found in dermatophytic hyphae, are
`shown in Figure 2. Representative isolates
`of H.
`toruloidea were deposited in the
`University of Alberta Microfungus Collec-
`tion, Devonian Botanic Gardens, Edmon-
`ton, Alberta, Canada (UAMH) as UAMH
`6027 and 6028.
`
`Scytalidiurn hyalirzum, a species with
`morphologic and epidemiologic similarities
`to H.
`tomloidea, was uncommonly seen:
`only three isolates were encountered from
`nails. Its micromorphology in nail and skin
`tissue was as H. toruloidea. Representative
`isolates were deposited in UAMH as
`UAMH 5954, 6031, and 6032, and in the
`
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`

`
`R. C. Summerbell et al.: Dermatomycosis Caused by Non-Dermatophytic Hyphomycetes
`
`mycosis listed in Table 1 were distinguished
`from an additional 7 “suggestive” cases. The
`latter cases were characterized by single iso-
`lations from nails showing thickened and
`distorted hyphae highly atypical of derma-
`tophyte infection but suggestive of pre-
`viously documented Fusarium infections
`(DiSalvo and Fickling 1980; Rush—Munro
`et al. 1971; Zaias 1966). Of these “sugges-
`tive” isolations, five were of F. oxysporum,
`one was of E solani, and one was not identi-
`fied to species.
`In one case, Gynmascella darz/cczlicnsis, an
`ascomycetous fungus frequently isolated
`from human feet and nails (Currah 1985)
`but never confirmed as an infectious agent,
`was isolated exclusively and in profusion
`from an infected toenail. The nail material
`
`was heavily invested with irregular, nodu-
`lose, frequently rebranching hyphae of a
`type not produced by any dermatophyte
`(Figure 3). Although a repeat sample could
`not be obtained, this isolation was tenta-
`tively accepted
`representing a genuine
`case of non-dermatophytic onychomycosis.
`The isolates obtained were of slow growth
`rate and should have been partially or com-
`pletely overgrown by Sc0pulari0ps1's, Aspar-
`gillus,
`liendersonula, Fusarium, Scymli-
`dium or dermatophyte species if viable ino-
`culum ofany ofthese had been present in the
`nail sample.
`Sole and palm infections caused by non-
`dermatophytes. As Table 1 shows, the only
`non—dermatophytes demonstrated to pro-
`duce tinea-like infections of the soles or
`palms during the study period were Hender-
`sonula taruloidea and Scytalidium /tzya/i-
`mtm. Both species were uncommon; how-
`ever, Sc. /zyalirzum was almost as frequently
`isolated from soles as from nails. Only H.
`tomloidea was obtained from a palm infec-
`tion. As with nail infections, H. tomloidca
`and Sc. /zyali/mm sole and palm infections
`were at least as frequent as dermatophy-
`toses caused by species other than Tric/10-
`phyton rubrum, Tr. merztagrophytes, and
`Epidermophyto/1 floccosum. In addition to
`theinfections noted inTable 1, H. toruloidea
`
`3: Gymrmsce/lu
`Figure
`late hyphae in skin. X 770
`
`
`(l(1I1/mlieI1sis.'
`vesicu-
`
`Centraalbureau voor Schimmelcultures,
`Baarn, Netherlands, as CBS 200.88.
`Aspergillus sydowii, the sixth most com-
`mon agent of nail infection, was isolated
`from 18 “suggestive” cases as well as the 13
`confirmed cases listed in Table 1.A charac-
`
`teristic presentation of A. sydowii in nail
`material
`is shown in Fig.
`l. The closely
`related /lspergillus versicolor, a known
`agent of onychomycosis (Walshe and Eng-
`lish 1966, English and Atkinson 1973,
`1974), was isolated from 16 “suggestive”
`cases, but in no case did the patient’s physi-
`cian do a repeat sample for verification.
`Other /lspergillus infections caused by A.
`flavus, A. terreus, and undetermined species
`were confirmed by repetition. The two repe-
`tition—confirmed cases of Fusarimn onycho—
`
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`

`
`R. C. Summerbell et al.: Dermatomycosis Caused by Non-Dermatophytic Hyphomycetes
`
`was isolated from three infections specified
`only as from “foot”, and from one with site
`unspecified. One
`infection was
`also
`recorded from the pedal 4th/ 5th interdigi—
`tal space; its presence was confirmed by two
`successive repeat isolations. In total, then,
`H. tomloidea was recorded from 28 cases of
`various sorts.
`
`In no case was H. toruloidea or Sc. hyali-
`num recorded from a mixed infection with a
`
`dcrmatophyte or other potential etiologic
`agent.
`Contaminants. We recorded all fungal
`species isolated from nails, soles and palms
`positive for fungal filaments but yielding no
`dermatophyte culture. Species regularly
`isolated in such situations but never con-
`
`firmed as infectious were regarded as com-
`mon contaminants which might be mistaken
`for infectious agents if due caution were not
`exercised.
`
`The most common of these was the cyclo-
`heximide—tolerant Alternaria alternata, but
`others were also common: Acremorzium
`spp. (including A. strictzmz and A. scler0tige—
`/mm), Aspergillus fumigatus, A. niglr, A.
`0c/zraceus, Chaetomium globosum, Dacty-
`[aria constricla, Exophiala jcarzselmei, Mal-
`brarzchea spp., Metarrhizium arzisopliae,
`Myxotrichum deflexum, Paecilomyces [Haci-
`nus, Scopuluriopsis candida, TrI'ch0sp0r0n
`beigelii, Wangiella dermatitidis, and various
`species of Candida, Cladosporium, Fusa—
`rium, P€l’lfCfffiL(I7’l, and I/?:rlicillim'n. Several
`of these taxa are known rarely to cause nail
`infections but in the present study were
`obtained primarily or exclusively as con-
`tammants.
`
`The fungal hyphae seen in nail material
`and skin in association with common con-
`taminants fell within the range of morpho-
`logy of dermatophyte hyphae, and were
`interpreted as non—viable inoculum or as
`viable hyphae whose outgrowth was sup-
`pressed by the contaminants. Many addi-
`tional nail and skin specimens were received
`showing dcrmatophyte-type hyphae in
`direct microscopic examination but yield-
`ing no culture.
`
`Discussion
`
`Although the non—dermatophytic agents of
`onychomycosis and tinea of the extremities
`made up only 2.3% of the etiologic agents
`isolated in this study, many species were
`among the more regularly occurring agents
`of these infections. In onychomycosis, con-
`sidered alone, the prevalence of filamentous
`non—dermatophytes was somewhat higher:
`88 out ofa total of2662 infectiveisolates, or
`3.3 °/o. Most prominent among the species
`involved were Scopulariopsis brevicaulis,
`I-Iendersoimla toruloidea and Aspergi//us
`sydowii. The number of non—dermatophytic
`onychomycosis cases reported here maybe
`an underestimate, since some of the uncon-
`firmed “suggestive” cases may have been
`authentic. Particularly in Aspergillus and
`Fusarium infections, hyphae in nail tissue
`were often not distinctive. The similarity of
`some Fusarium and Aspergillus hyphae to
`frondose
`Trichophyton mentagrop/zytes
`hyphae in superficial white onychomycosis
`has been illustrated by Zaias (1966). Where
`we observed such hyphae in conjunction
`with non—dermatophyte isolations, sample
`repetition was required to confirm the exist-
`ence of an infection. Such repetition, how-
`ever, is an action which patients and physi-
`cians may not favour, particularly if non-
`specific antifungal therapy proves effica-
`ceous. Thus, the number of times infections
`with a given fungus are confirmed may
`reflect not only the frequency of infections
`caused by the organism, but also their
`relative annoyance to the patient and resist-
`ance to treatment. Certainly, infections by
`the normally recalcitrant (Moore, 1986)
`Hendersonula toruloidea often occasioned
`
`several repeat samples over an extended
`period of time; no other confirmed non-
`dermatophytic stiologic agent consistently
`showed this pattern of isolation.
`The routine use of Littman’s oxgall
`medium in our superficial
`(cutaneous)
`mycology
`diagnostic
`procedures was
`responsible for the frequent isolation of the
`sensitive I-I.
`toruloidea and Scytalidium
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`
`R. C. Summerbell et al.: Dermatomycosis Caused by Non-Dermatophytic Hyphomycetes
`
`hyalinum, as well as some Fusarium and
`Scopulariopsis isolates. Although H. mm-
`loidea and Se. hyalimmt occasionally grew
`on our relatively dilutely (1()0 ug/ ml),
`cycloheximide—supplemented primary iso-
`lation media, there were numerous instan-
`ces where only Littman agar served as a
`source of isolation. According to Moore
`(1986), only about 5 % of H. taruloidea iso-
`lates are tolerant of cycloheximide.
`Among the other non-dermatophytic eti-
`ologic agents studied, /lspergil/us species
`and most S. brevicaulis isolates grew on all
`isolation media. Littman agar did, however,
`frequently prove advantageous in prevent-
`ing these species as well as dermatophytes
`from being overgrown by fast-growing,
`cycloheximide—tolerant contaminants like
`Allermtria altemata. This appears to be the
`primary advantage of this medium over the
`cycloheximide-free Sabouraud agar used by
`other authors to isolate sensitive fungi from
`nails (English and Atkinson 1973; DiSalvo
`and Fickling 1980). Fusarium oxysporum
`generally did not grow ()n cycloheximide
`media, whereas F. S0[(lI’li showed limited
`growth with concomitant secretion of a
`vinaceous—brown soluble pigment. The sen-
`sitivity of nail-infecting F oxyspomm iso-
`lates to cycloheximide has been previously
`noted by DiSalvo and Fickling (1980).
`The number of lrlendersorzula tomloidea
`
`and Scytalidium //zyalimmi isolates obtained
`was unprecedented in Canada or elsewhere
`in North America. H. toruloiclea infection
`
`has been reported only once before from a
`Canadian patient (Carruthers et al. 1982)
`and is rarely recorded in the U.S.A. (Rippon
`1988). Although I-I. torul0ia'eaoceu1‘s natu-
`rally in Canada in coastal British Colum-
`bian populations of the tree Arbutus men-
`ziesi