High morbidity and mortality caused by mycotic infections has been a cause for concern. Trials for various vaccines against fungal pathogens have not been approved by the US Food and Drugs Administration because of the high cost of production and lack of a single suitable candidate. Most fungal infections require cell-mediated immunity for their clearance. This has been the basis for the development of various vaccines. We discuss the various trials of candidate vaccines, the protective efficacy as well as their shortcomings. Recent research suggests that a universal vaccine can be prepared which may be effective against most fungal pathogens.
ABSTRACT Dermatophytosis continues to be a worldwide problem, constituting a large bulk of cases attending the dermatology outpatient's department in tropical countries. Variable climatic conditions and multiple etiological agents, whose individual prevalence varies with time, prompted an attempt to define the current pattern and etiologic prevalence in our locality, and compare them with earlier studies from different centers. Of consenting patients clinically diagnosed to have superficial fungal infections, 1975 were investigated in the laboratory. All the specimens collected from patient skin, hair or nails were subjected to direct microscopy examination in 10% potassium hydroxide (KOH) and fungal culture. Confirmed diagnosis was made only if specimen was KOH and/or culture positive. Male : female ratio was 1.65 : 1. Tinea corporis (21.4%), onychomycoses (14.7%) and tinea capitis (6.2%) were the most common laboratory‐confirmed infections. Only 909 patients (47%) out of 1035 clinically suspected patients had evidence of fungal infection by either microscopy and/or culture. Of these 909 patients, 787 (86.5%) were both KOH and culture positive, 25 (2.7%) were KOH negative and culture positive, while 97 (10.6%) were KOH positive but culture negative. In 1051 patients (53%), no evidence of fungal infection was seen. Trichophyton rubrum was the most commonly isolated dermatophyte (55.2%) followed by Trichophyton mentagrophytes (19.6%) and Trichophyton tonsurans (2.9%). Candida sp. accounted for 16% of all isolates. Non‐dermatophyte moulds (NDM) were isolated only in patients with onychomycoses. Our study revealed a male preponderance, tinea corporis as the commonest clinical type, and dermatophytes as the commonest mycological isolates, which is in agreement with earlier studies. Relying on clinical diagnosis alone without laboratory confirmation may result in overestimation of the problem as evidenced in other studies as compared to our study. Rarely reported NDM appear to be important etiological agents of onychomycoses.
To study the utility of Galactomannan (GM) antigen as a screening marker for diagnosing invasive pulmonary aspergillosis (IPA) in coronavirus disease 2019 (COVID-19) patients.The serum samples from patients with severe COVID-19 diseases admitted to the Critical Care Unit were collected on the 5th day of admission for GM screening. The samples were analysed by enzyme linked immune sorbent assay (ELISA) and GM index of more than 1 was considered as positive. All GM positive patients were serially followed until discharge or death.The GM was raised in serum of 12 out of 38 patients, indicating an incidence of possible COVID-19 associated IPA (CAPA) in 31.57% of patients. The median age of these CAPA patients was 56.5 years, males were significantly more affected than females. The inflammatory marker serum ferritin was raised in all 12 patients (median value of 713.74 ng/ml), while IL-6 was raised in 9 patients (median value of 54.13 ng/ml). None of these patients received antifungals. Their median length of hospital stay was 20 days (IQR: 12, 34 days). All these patients succumbed to the illness.The serum GM appears to be sensitive diagnostic tool to identify early IPA in COVID-19 patients and pre-emptive antifungal therapy could play a role in salvaging these patients.
The South-Asian epidemic of anti-fungal therapeutic failures (AFTF) is on the rise. Although many demographic, environmental, and socioeconomic factors have been implicated in the genesis of this problem, two pharmacological issues warrant attention. While detailed discussions on the role of topical corticosteroid (TCS) in the changing landscape of the superficial mycotic infections in this region have been making headlines, another equally, rather more important pharmacological factor seems to have been undermined by the hype around TCS. The fastidious pharmacokinetic properties and related practical aspects of the triazole group of oral and topical antifungals, especially oral itraconazole seem to contribute significantly to the persistence of AFTF epidemic. In this paper, we shall discuss the broad aspects of the spectral precariousness of oral triazole antifungals with special emphasis to itraconazole, a concept known as the “azole menace” in the overall pathogenesis and tenacity of the AFTF epidemic.
This chapter brings to light the role of laboratory assistance in determining the infectious cause of onychosis. The authors have discussed the conventional techniques and newer rapid diagnostic methods used to detect and differentiate bacterial, fungal, or viral causes of onychosis as well as checking the drug susceptibility patterns. A prompt and accurate support by microbiological laboratory aids the clinician in diagnosis and prognosis, as well as in guiding the treatment of the affected nail unit.
Dermatophytes are the most frequently implicated agents in toenail onychomycosis and oral terbinafine has shown the best cure rates in this condition. The pharmacokinetics of terbinafine favors its efficacy in pulse dosing.To compare the efficacy of terbinafine in continuous and pulse dosing schedules in the treatment of toenail dermatophytosis.Seventy-six patients of potassium hydroxide (KOH) and culture positive dermatophyte toenail onychomycosis were randomly allocated to two treatment groups receiving either continuous terbinafine 250 mg daily for 12 weeks or 3 pulses of terbinafine (each of 500 mg daily for a week) repeated every 4 weeks. Patients were followed up at 4, 8 and 12 weeks during treatment and post-treatment at 24 weeks. At each visit, a KOH mount and culture were performed. In each patient, improvement in a target nail was assessed using a clinical score; total scores for all nails and global assessments by physician and patient were also recorded. Mycological, clinical and complete cure rates, clinical effectivity and treatment failure rates were then compared.The declines in target nail and total scores from baseline were significant at each follow-up visit in both the treatment groups. However, the inter-group difference was statistically insignificant. The same was true for global assessment indices, clinical effectivity as well as clinical, mycological, and complete cure rates.The short follow-up in our study may have led to lower cure rates being recorded.Terbinafine in pulse dosing is as effective as continuous dosing in the treatment of dermatophyte toenail onychomycosis.
Patients with preeclampsia admitted to the intensive care unit (ICU) may have risk factors for acute kidney injury (AKI). Although the use of neutrophil gelatinase-associated lipocalcin (NGAL) to predict AKI is previously validated, we could locate only scanty data regarding the epidemiology of AKI and role of NGAL in preeclamptic patients admitted to ICU.Patients with preeclampsia admitted to our ICU were included. The incidence and severity of AKI during the entire ICU stay were assessed using kidney disease improving global outcomes criteria, while the a priori risk factors and serum NGAL were also evaluated.A total of 52 preeclamptic patients admitted to ICU were included, among whom the majority had eclampsia (75%). AKI developed in 25 (48.1%) patients with stages 1, 2, and 3 in 56, 36, and 8%, respectively. The incidence of sepsis (16 vs 0%), shock (40 vs 7.4%), and anemia (84 vs 59.3%) was significantly greater in patients with AKI (p < 0.05). ICU mortality (28 vs 3.7%), duration of ICU, and hospital stay were significantly higher in patients who developed AKI (p < 0.05). There was no association of serum NGAL [274 (240-335) ng/mL] with AKI or the mortality (p = 0.725, 0.861); there was, however, a significant discriminatory value for eclampsia [p = 0.019; area under curve = 0.736 (95% confidence interval: 0.569-0.904)].Although AKI is common among patients with preeclampsia admitted to ICU, serum NGAL does not predict its occurrence.Tyagi A, Yadav P, Salhotra R, Das S, Singh PK, Garg D. Acute Kidney Injury in Severe Preeclamptic Patients Admitted to Intensive Care Unit: Epidemiology and Role of Serum Neutrophil Gelatinase-associated Lipocalcin. Indian J Crit Care Med 2021;25(9):1013-1019.
<b><i>Introduction:</i></b> Nail unit infestation by scabies mites (ungual scabies) is uncommon. It usually presents with distal subungual lesions, leading to recurrent and persistent disease by acting as a reservoir of infection. Periungual involvement in scabies with nail loss is rare and may lead to severe nail damage. <b><i>Case Presentation:</i></b> We report a 14-year-old boy on chemotherapy for acute lymphocytic leukemia (ALL) who presented with extensive scaling and crusted plaques of scabies. Nail unit revealed periungual crusted plaques with paronychia and onychomadesis involving five digits. It was associated with partial to complete nail loss. Dermoscopy of periungual crusted plaques showed greyish-white scales with brown dots and globules. A sinuous burrow with a brown-triangular structure was visualized in the web space. KOH mount from skin scrapings showed the scabies mites. Treatment of scabies led to a marked improvement. <b><i>Conclusion:</i></b> Though ungual scabies is generally a benign disease, proximal periungual involvement with damage to nail matrix is possible, leading to nail loss. We review manifestations of nail unit scabies reported in literature. Treatment options used and outcomes are also analyzed. The importance of nail-directed therapy in preventing relapses of scabies cannot be undermined.
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