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      Beyond the Superficial: Disseminated Trichophyton rubrum Infection in a Kidney Transplant Recipient

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          Abstract

          Superficial dermatophyte infections are common in the general population and are readily treated with topical antifungals. Deeper invasion is rare, and dissemination to visceral organs is extremely uncommon. We describe a 66-year-old renal transplant recipient who developed disseminated Trichophyton rubrum infection while undergoing treatment for acute humoral rejection. The infection presented as a facial rash with subsequent dissemination to the lungs and chest wall. All sites of infection improved with combination administration of oral posaconazole and terbinafine. In this work, we review the available literature regarding management of disseminated Trichophyton infection and discuss therapeutic interventions for disseminated dermatophytosis in immunosuppressed hosts.

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          Update in antifungal therapy of dermatophytosis.

          Aditya K. Gupta, Elizabeth Cooper (2015)
          Treatment of dermatophyte infection involves primarily oral and/or topical formulations of azoles or allylamines, particularly itraconazole and terbinafine. Topical medications applied once or twice daily are the primary treatment indicated for tinea corporis/cruris, and tinea pedis/manuum. Use of oral antifungals may be practical where the tinea involvement is extensive or chronic, or where application of a topical is not feasible. For tinea unguium (onychomycosis) and tinea capitis, oral therapies are the primary treatments provided. Recently, topical amorolfine and ciclopirox formulations have been approved for use in milder onychomycosis cases, and their role in the treatment of the different clinical forms of onychomycosis is currently being defined. Relapse of infection remains a problem, particularly with tinea pedis/unguium. Appropriate follow-up duration and education of patients on proper foot hygiene are also important components in providing effective therapy.
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            Emerging Terbinafine Resistance in Trichophyton: Clinical Characteristics, Squalene Epoxidase Gene Mutations, and a Reliable EUCAST Method for Detection

            Ditte Saunte, Rasmus K. Hare, Karin M. Jørgensen … (2019)
            In recent years, cases involving terbinafine-resistant Trichophyton isolates have been reported increasingly, particularly in India. We present 14 cases of terbinafine treatment failure in Trichophyton -infected Danish patients due to acquired resistance. Patients infected with Trichophyton rubrum ( n = 12) or Trichophyton interdigitale ( n = 2) with elevated terbinafine MICs during 2013–2018 were included. Antifungal susceptibility testing (AFST) was performed following a modified EUCAST E.Def 9.3.1 method (5 days of incubation) with or without cycloheximide and chloramphenicol (CC) supplementation of the growth medium. The squalene epoxidase (SE) target gene was sequenced, and 3-dimensional enzyme homology modeling was performed. Most patients (12/14 [86%]) were male. The mean age was 53.5 years (range, 11 to 77 years). The mean duration of infections was 4.8 years at the time of resistance detection. Prior systemic terbinafine treatment was documented for all patients, and topical therapy for 62% (information was missing in one case). Overall, nine isolates (64%) displayed high terbinafine resistance (MICs, 4 to >8 mg/liter), while two (14%) displayed moderate (MICs, 1 to 2 mg/liter) and three (21%) displayed low (MICs, 0.125 to 0.25 mg/liter) terbinafine resistance compared with control isolates. MICs generated with or without CC supplementation were similar, but CC prevented contamination. Known and novel SE amino acid substitutions (F397L, L393F, L393S, F415S, H440Y F484Y, and I121M V237I) were detected in resistant but not control isolates. Three-dimensional homology modeling suggested a role of the novel I121M and V237I alterations. Terbinafine resistance has been detected in Denmark using a modified EUCAST method, which facilitated susceptibility testing of dermatophytes. Action is needed for this emerging public health problem.
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              Infectious complications of antilymphocyte therapies in solid organ transplantation.

              Steven J. Fishman, N P Issa (2009)
              Antilymphocyte therapies are widely used for immunosuppression in solid organ transplantation. These agents have varied mechanisms of action, with resulting differences in the intensity and duration of immunosuppression and in associated infectious complications. Induction therapy with antithymocyte globulins is associated with a greater incidence of cytomegalovirus, Epstein-Barr virus, and BK polyomavirus infections, compared with therapy with interleukin (IL)-2a receptor antagonists. However, long-term experience with the IL-2a receptor antagonists is lacking. By contrast, the treatment of graft rejection with T cell-depleting antibodies is associated with an increased risk of opportunistic infections. This is likely a reflection of the intensification of immunosuppression in the treatment of graft rejection and, often, a failure to link the use of antilymphocyte agents to prophylaxis for infection. The use of T cell-depleting agents, especially in the treatment of acute graft rejection, must be linked to monitoring and risk-adjusted prophylaxis for Pneumocystis, other fungi, Epstein-Barr virus, BK polyomavirus, and cytomegalovirus infection.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Open Forum Infect Dis
                Journal ID (iso-abbrev): Open Forum Infect Dis
                Journal ID (publisher-id): ofid
                Title: Open Forum Infectious Diseases
                Publisher: Oxford University Press (US )
                ISSN (Electronic): 2328-8957
                Publication date Collection: July 2020
                Publication date (Electronic): 05 July 2020
                Publication date PMC-release: 05 July 2020
                Volume: 7
                Issue: 7
                Electronic Location Identifier: ofaa281
                Affiliations
                [1 ] Department of Medicine, Beth Israel Deaconess Medical Center , Boston, Massachusetts, USA
                [2 ] Harvard Medical School , Boston, Massachusetts, USA
                [3 ] Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center , Boston, Massachusetts, USA
                [4 ] Department of Pathology, Beth Israel Deaconess Medical Center , Boston, Massachusetts, USA
                Author notes
                Correspondence: Caitlin A. Trottier, MD, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215 ( catrotti@ 123456bidmc.harvard.edu ).
                Author information
                http://orcid.org/0000-0001-7486-7780
                Article
                Publisher ID: ofaa281
                DOI: 10.1093/ofid/ofaa281
                PMC ID: 7566364
                SO-VID: 6b0bea0a-a1bd-4dcc-b329-259d12b9e53f
                Copyright © © The Author(s) 2020. Published by Oxford University Press on behalf of Infectious Diseases Society of America.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence ( http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                History
                Date received : 30 April 2020
                Date: 22 June 2020
                Date accepted : 01 July 2020
                Date: 30 July 2020
                Page count
                Pages: 4
                Categories
                Subject: Novel Id Cases
                Subject: AcademicSubjects/MED00290

                Keywords: disseminated dermatophytosis,literature review,trichophyton,transplant
                Data availability:
                Keywords: disseminated dermatophytosis, literature review, trichophyton, transplant

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