mycoses
Diagnosis,Therapy and Prophylaxis of Fungal Diseases
Original article
Dermatophytosis and immunovirological status of HIV-infected and AIDS patients from Sao Paulo city, Brazil Bosco Christiano Maciel da Silva,1,2 Claudete Rodrigues Paula,1 Marcos Ereno Auler,1 Luciana da rcia Cristina Naomi Yoshioka,4 Alexandre Fabris,5 Silva Ruiz,1 Jairo Ivo dos Santos,3 Ma 5,6 da Silva Duarte2 and Walderez Gambale1 Luiz Guilherme Martins Castro, Alberto Jose 1 Laboratory of Mycology, Department of Microbiology, Biomedical Science Institute II (ICB II), University of Sa~o Paulo, Sa~o Paulo, Brazil, 2Laboratory of Medical Investigation in Dermatology and Immunodeficiency (LIM 56), Faculty of Medicine, University of Sa~o Paulo, Sa~o Paulo, Brazil, 3Department of Clinical Analysis, Federal University of Santa Catarina, Florianopolis, Brazil, 4Center for Reference and Training in STD/AIDS, Sa~o Paulo, Brazil, 5Dermatology Division, Clinics Hospital of the Faculty of Medicine, University of Sa~o Paulo, Sa~o Paulo, Brazil and 6Center for Cutaneous Oncology, Albert Einstein Israelite Hospital, Sa~o Paulo, Brazil
Summary
Over the past decades, more people became infected with human immunodeficiency virus (HIV) and developed acquired immunodeficiency syndrome (AIDS). Because of that the incidence of fungal infections rose dramatically. It happened because this virus can modify the course of fungal diseases, leading to altered clinical pictures. The aim of this study was to evaluate epidemiological and biological aspects of dermatophytosis in HIV-positive and AIDS patients living in the city of S~ ao Paulo, Brazil. A total of 84 (44 HIV-positive and 40 AIDS) patients were enrolled in this study. The patients were tested for dermatophyte infections, as well as for the CD4+/CD8+ and HIV viral load counts. Tinea unguium was most frequently observed in AIDS patients, whereas Tinea pedis was mostly observed in HIV-positive patients. The most frequent dermatophyte species was Trichophyton rubrum. CD4+ counts and CD4+/ CD8+ ratios were not associated with a higher risk for dermatophytosis. On the other hand, viral load higher than 100 000 copies/ml was associated with a higher frequency of dermatophytosis. The results suggest to that although dermatophytosis is common in HIV-positive and AIDS patients, the degree of immunosuppression does not seems to correlate with increased risk of this fungal infection. In addition, high viral load as a predictive risk factor for dermatophyte infection should be subject of further evaluations.
Key words: HIV, AIDS, dermatophytosis, Tinea, Trichophyton rubrum, Brazil.
Introduction The incidence of fungal infections increased dramatically in the last decades as the number of human Correspondence: Dr B. C. M. da Silva, MSc, PhD, Laboratory of Medical Investigation in Dermatology and Immunodeficiency (LIM 56), Faculty of Medicine, University of S~ ao Paulo, Av. Dr. Eneas de Carvalho Aguiar, 470, Predio 2, 3° andar, Cerqueira C esar, S~ ao Paulo, SP, CEP: 05403-000, Brazil. Tel.: (55 11) 3061 7193. Fax: (55 11) 3081 7190. E-mail: [email protected] Submitted for publication 27 August 2013 Revised 17 December 2013 Accepted for publication 17 December 2013
© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 371–376
immunodeficiency virus (HIV)-infected and other immunocompromised patients. Predictably, fungi have been associated with immunodeficiency for a long time are responsible for the most fungal infections in these patients. However, infections due to fungal species not usually associated with immunodeficiency are also frequently reported in patients infected with HIV, as this immunosuppressive virus can determine changes in the course of fungal diseases, leading to altered clinical pictures.1–3 Dermatophytosis, like other fungal infections, generally displays more intense clinical signs in HIV-infected patients than in immunocompetent ones.3–7 However, dermatophyte infections in HIV-infected patients are less
doi:10.1111/myc.12169
B. C. M. da Silva et al.
frequently studied, possibly because of low morbidity and no mortality. This is also observed in patients from developing countries, including Brazil, where the vast majority of HIV-infected population resides.6–11 Therefore, to investigate this mycosis in patients with several stages of HIV infection, we evaluated the suspected clinical and epidemiological characteristics of dermatophytosis in HIV-positive and AIDS patients living in the city of S~ ao Paulo, Brazil.
Materials and methods
For measurement of plasma HIV-1 RNA concentrations (viral load), EDTA-treated plasma samples were prepared and stored at 70 °C until testing. The average interval between collection of blood and freezing of plasma samples was approximately 6 h. A sensitive branched-DNA (bDNA) assay (Siemens Medical Solutions Diagnostics, Tarrytown, NY, USA) was used to quantify HIV-1 RNA in duplicate 1.0-ml samples. The linear range of this assay is between 50 and 50 000 copies ml 1 of plasma. Additional details about the bDNA assay and its performance are reported elsewhere.15–18
Patients
Eighty-four patients were screened with suspected dermatophytosis by an experienced dermatologist and were evaluated in this study. These patients were divided as HIV-positive group with 44 patients and AIDS group with 40 patients. This study was approved by the Research Ethics Committees of participating institutions. All patients enrolled in this study were tested by enzyme-linked immunosorbent assay methodology to evaluate HIV infection. A patient was regarded as positive when two different serum samples were positive for anti-HIV antibodies by referred methodology and confirmed by Western blotting assay. The definition of AIDS was done according to the Centers for Disease Control and Prevention (CDC, USA).12 The patients were assisted at the Center for Reference and Training in STD/AIDS (S~ ao Paulo, Brazil), the AIDS Home of the Faculty of Medicine of the University of S~ao Paulo and the Clinics Hospital of the Faculty of Medicine of the University of S~ ao Paulo. A questionnaire on epidemiological and clinical data was voluntarily answered and a written informed consent was provided by all patients. The patients were treated with highly active antiretroviral therapy (HAART) and those with CD4+ T cell counts below 200 ll 1 were given oral fluconazole, itraconazole or ketoconazole for prophylactic purposes. Immunological and virological tests
T lymphocytes subsets (CD4+ and CD8+) of the patients were measured in ethylenediamine tetraacetic acid (EDTA)-treated whole blood by staining it with fluorescent dye-conjugated monoclonal antibodies that were specific for CD3+, CD4+ e CD8+ lymphocytes (Becton Dickinson Biosciences, San Jose, CA, USA), as previously reported.13,14
372
Mycological examination
The laboratory diagnosis of dermatophytosis was carried out by direct microscopy and culture of the material obtained from patient’s lesions. For direct microscopy, the samples (skin, nail scraping and broken hairs) were clarified in 20% potassium hydroxide before microscopically examined. The clinical specimens were also inoculated on slant tubes with Sabouraud-dextrose agar containing chloramphenicol and cycloheximide (Mycobiotic agar, Difco, Detroit, MI, USA), and were incubated for up to 4 weeks at 25 °C. The identification of dermatophyte species was done by the gross colony morphology and microscopic fungal characteristics in lactophenol cotton blue slide mounts. Statistical analysis
The Fisher’s exact test was used to evaluate the differences’ significance in the frequency between the groups. The critical level of significance was 0.05.
Results As shown in Table 1, the mean age of the patients did not differ significantly between the groups (38.4 and 40.3 years for HIV-positive and AIDS patients respectively). Regarding the schooling years, HIV-positive patients had higher schooling years than AIDS patients (P < 0.001). Dermatophyte infections were quite similar between patients of HIV-positive and Aids groups (38.6% and 47.5% respectively). Considering the isolated species, Trichophyton rubrum was the most frequently identified dermatophyte species in both HIV-positive and AIDS groups (12, 70.6% and 18, 94.7% respectively), whereas Trichophyton mentagrophytes (T. mentagrophytes)
© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 371–376
Dermatophytosis in HIV and AIDS patients
Table 1 Demographic characteristics of the patients. Characteristics
HIV positive (n = 44)
Table 3 Clinical symptoms of patients. AIDS (n = 40) Clinical symptoms
Age (years) Mean value Range Gender Male Female Schooling years Up to 8 years 9–12 years >12 years
38.4 23–59
40.3 26–58
37 (84.1%) 7 (15.9%)
32 (80.0%) 8 (20.0%)
16 (36.3%) 19 (43.2%) 9 (20.5%)
25 (62.5%) 11 (27.5%) 4 (10.0%)
and Microsporum canis (M. canis) were less frequently isolated (Table 2). Regarding the clinical dermatophyte manifestations, four clinical variants were observed among the patients: Tinea pedis, Tinea unguium, Tinea cruris and Tinea corporis. A higher frequency of T. unguium was observed in AIDS patients group than in HIV-positive patients group (P = 0.0218), whereas T. pedis was more frequently observed in HIV-positive patients group (Table 2). The most common clinical symptoms shown by patients were: skin scaling, itching, nail abnormalities (discoloured nails, dull, thickened and/or brittle nails) and erythema (Table 3). Ninety per cent (90.0%) of AIDS patients presented lesions on the nails, a proximal white subungual onychomycosis, as compared with the HIV-positive group (Fig. 1). On the other
Skin scaling Itching Nail abnormalities Erythema Small papular vesicles Fissures
HIV positive (n = 44) (%)
AIDS (n = 40) (%)
43 33 21 22 6
17 12 36 6 0
(97.7) (75.0) (47.7) (50.0) (13.6)
5 (11.3)
(42.5) (30.0) (90.0) (15.0) (0.0)
3 (7.5)
Figure 1 Tinea pedis and Tinea unguium caused by Trichophyton
rubrum in an AIDS patient. Spreading infection can be seen on the dorsal surface of the foot. Proximal white subungual onychomycosis can be seen in the toenail.
Table 2 Clinical variants and dermatophyte species observed in the patient groups.
Patients with dermatophytosis Clinical variants Tinea pedis Tinea unguium Tinea cruris Tinea corporis Dermatophyte species Trichophyton rubrum Trichophyton mentagrophytes Microsporum canis
HIV positive (n = 44) (%)
AIDS (n = 40) (%)
17 (38.6)1
19 (47.5)2
11 3 2 1
7 13 1 2
(64.7) (17.7) (11.7) (5.9)
(36.8) (68.4) (5.3) (10.5)
12 (70.6) 4 (23.5)
18 (94.7)3 4 (21.0)
1 (5.9)
1 (5.3)
1
Number of patients with dermatophytosis.
2
In the AIDS group, one patient was presented with Tinea pedis, Tinea unguium and Tinea corporis, and two other patients presented Tinea pedis and either Tinea unguium or Tinea cruris.
3
More than one species isolated from some patients.
© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 371–376
Figure 2 Tinea pedis in a HIV-positive patient, displaying skin
scaling and erythema.
hand, T. pedis cases displaying skin scaling, diffuse hyperkeratosis of the foot sole as well as itching and erythema were observed more frequently in HIV-positive patients (Fig. 2). Small papular vesicles and fissures were observed in a few cases in both groups.
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Table 4 Frequency of dermatophytosis according to CD4+ counts and CD4+/CD8+ ratio. CD4+ count (per ll)
Patients with dermatophytosis Patients without dermatophytosis Total
CD4+/CD8+ ratio
≤200
>200
≤0.5
>0.5
29 (45.3) 35 (54.7) 64 (100.0)
7 (35.0) 13 (65.0) 20 (100.0)
13 (59.1) 9 (40.9) 22 (100.0)
23 (37.1) 39 (62.9) 62 (100.0)
Values within parenthesis are expressed in percentage.
Regarding the immunological and virological markers, HIV-positive and AIDS patients with dermatophytosis displayed CD4+ T cells count of 512 and 126 cells ll 1, and CD8+ T cells of 1108 and 817 cells ll 1 respectively. The CD4+/CD8+ T cells ratio was 0.52 for HIV-positive and 0.18 for AIDS patients. The mean plasma viral load count was 15 683 copies ml 1 for HIV-positive patients group and 240, 347 copies ml 1 for AIDS patients group. To evaluate the possible association between the patient’s immunological or virological status and the frequency of dermatophytosis, the patients were regrouped according to their number of CD4+ T cells, the CD4+/CD8+ ratio and their plasma viral load. As shown in Table 4, the CD4+ counts or CD4+/CD8+ ratio did not correlate with a higher frequency of dermatophytosis. In addition, patients with viral load greater than 100 000 copies ml 1 presented a significantly higher frequency of dermatophyte infections than patients of the same groups with viral load below 100 000 copies ml 1 (P = 0.0484) (Table 5).
Discussion In this study, we evaluated the possible correlation between the frequency of dermatophyte infections and the virological and immunological status of the HIVinfected patients. Regarding the patient demographic data, a predominance of male gender among two groups was observed, in agreement with the report of Brazilian Ministry of Health 19 and two Indian Table 5 Viral load in dermatophytosis and non-dermatophytosis
patients. Viral load (copies ml 1)
Patients with dermatophytosis Patients without dermatophytosis Total
>100 000
≤100 000
10 (66.7) 5 (33.3) 15 (100.0)
26 (37.7) 43 (62.3) 69 (100.0)
Values within parenthesis are expressed in percentage.
374
studies.20,21 On the other hand, HIV-positive patients presented a higher number of schooling years than AIDS patients. In this regard, the only report dealing with schooling years in Brazilian AIDS patients was published by Fonseca et al. [22] who found that patients at risk of AIDS had generally less schooling years. As already pointed out by some authors, HIV-positive patients are prone to develop T. pedis and/or T. unguium.23–25 Indeed, these two clinical forms of dermatophytosis have been the most frequently observed in our HIV-positive and AIDS patients. However, they were not exclusive to these groups, as these two clinical forms were also observed in dermatophytosis cases of the general population.6,7,26–31 Our findings are in agreement with Aly and Berger [23] who reported that T. pedis was the most common type of dermatophytosis in patients infected by HIV, and was usually manifested by typical interdigital maceration with scaling and diffuse hyperkeratosis of the foot sole. Trichophyton rubrum was the most frequent dermatophyte specie isolated from HIV-positive and AIDS patients. This finding agreed with results from previous studies.9,10,24,31–33 However, this dermatophyte specie was also similarly isolated in HIV-negative individuals from the same geographical area.29 The second-most common specie was T. mentagrophytes. Other studies have reported that this species was more associated with acute infections than the species T. rubrum.6,10 Unfortunately, a more detailed clinical evaluation of severity of the lesions and the duration of the infection could not be performed in our patients. Although dermatophytes usually produce infections in the corneal layers of the skin and its annexes, the dermatophyte–host interactions involve complex immunological mechanisms such as cell-mediated immunity. The main efferent branch of the immunological response is the CD4+ T cell, whose activation plays a role, still to be better defined, in the host immune response to dermatophyte infection.30 Although we found no overall statistical differences on the dermatophytosis frequencies between the two patient groups, the frequency of dermatophytosis was
© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 371–376
Dermatophytosis in HIV and AIDS patients
higher in AIDS patients with low CD4+ T cell count, thus confirming previous studies on this subject.10,21,27–31 In our results, we observed a higher frequency of T. unguium in the AIDS group than in the HIV-positive patients, whereas T. pedis was more frequently observed in HIV-positive group. HIV infection may be associated with a higher incidence of nail infections.27–31 Although 90% of the AIDS patients of our study displayed nail lesions, T. unguium was isolated only in 68.4% of the diagnosed cases, as yeast were also causing lesions on the nails of these patients. In this regard, most cases of white proximal subungual onychomycosis were observed in AIDS patient group. According to Dompmartin et al. [28], this form of T. unguium is associated with HIV infection but is uncommon in the immunocompetent population. Some authors have reported that HAART and the prophylactic fluconazole for invasive fungal infections, mostly in patients with CD4+ T cells counts below 200 ll 1, has reduced the incidence of dermatophytosis in the HIV-positive and AIDS population.31,32 In our study, we suggest that these prophylactic measures could have little effect on dermatophyte infections, as many patients diagnosed with dermatophytosis were given several antifungals, such as ketoconazole, itraconazole, fluconazole and amphotericin B at the time of the study. In agreement with previous studies, we observed that skin scaling, itching, nail abnormalities (discoloured nails, dull, thickened or brittle nails) and erythema were the commonest clinical symptoms shown by the patients.32–34 Seventy-five per cent (75%) of HIV-positive patients and 30% of AIDS patients reported itching. In this respect, Blanes et al. [34] investigated the predominance and causes of itching in HIV-infected patients in Spain. Thirty-one per cent of patients reported itching, and interdigital T. pedis was described as one of the most frequent dermatological entities responsible for this symptom. Also, patients reporting itching had also higher viral loads. The lack of correlation between the frequency of dermatophytosis and the clinical stage of the patients was further supported by the comparison of the CD4+/ CD8+ ratio in patients with or without dermatophytosis. On the other hand, a significantly higher frequency of dermatophytosis was seen in HIV-infected patients with high viral load. In conclusion, the present results confirm that dermatophytosis occurs throughout the course of HIV infection, highlights the importance of this mycosis in nail disorders affecting HIV-positive patients as well as suggesting that viral load could be a predictive value for dermatophyte
© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 371–376
infections in patients infected by HIV. However, more studies are necessary establishing a relationship between higher risk for dermatophyte infection and the HIV virological status of the patients.
Acknowledgments The authors wish to thank Dr. Bernard Larouze (France) and the Brazilian AIDS Program by the Brazil-France AIDS Technique Cooperation Program. This work was ~o de supported by grant 00/00668-1 from Fundacßa Pesquisa do Estado de S~ Amparo a ao Paulo (FAPESP).
Conflict of interests The authors have declared that no conflicts of interest exist.
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© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 371–376
Diagnosis,Therapy and Prophylaxis of Fungal Diseases
Original article
Dermatophytosis and immunovirological status of HIV-infected and AIDS patients from Sao Paulo city, Brazil Bosco Christiano Maciel da Silva,1,2 Claudete Rodrigues Paula,1 Marcos Ereno Auler,1 Luciana da rcia Cristina Naomi Yoshioka,4 Alexandre Fabris,5 Silva Ruiz,1 Jairo Ivo dos Santos,3 Ma 5,6 da Silva Duarte2 and Walderez Gambale1 Luiz Guilherme Martins Castro, Alberto Jose 1 Laboratory of Mycology, Department of Microbiology, Biomedical Science Institute II (ICB II), University of Sa~o Paulo, Sa~o Paulo, Brazil, 2Laboratory of Medical Investigation in Dermatology and Immunodeficiency (LIM 56), Faculty of Medicine, University of Sa~o Paulo, Sa~o Paulo, Brazil, 3Department of Clinical Analysis, Federal University of Santa Catarina, Florianopolis, Brazil, 4Center for Reference and Training in STD/AIDS, Sa~o Paulo, Brazil, 5Dermatology Division, Clinics Hospital of the Faculty of Medicine, University of Sa~o Paulo, Sa~o Paulo, Brazil and 6Center for Cutaneous Oncology, Albert Einstein Israelite Hospital, Sa~o Paulo, Brazil
Summary
Over the past decades, more people became infected with human immunodeficiency virus (HIV) and developed acquired immunodeficiency syndrome (AIDS). Because of that the incidence of fungal infections rose dramatically. It happened because this virus can modify the course of fungal diseases, leading to altered clinical pictures. The aim of this study was to evaluate epidemiological and biological aspects of dermatophytosis in HIV-positive and AIDS patients living in the city of S~ ao Paulo, Brazil. A total of 84 (44 HIV-positive and 40 AIDS) patients were enrolled in this study. The patients were tested for dermatophyte infections, as well as for the CD4+/CD8+ and HIV viral load counts. Tinea unguium was most frequently observed in AIDS patients, whereas Tinea pedis was mostly observed in HIV-positive patients. The most frequent dermatophyte species was Trichophyton rubrum. CD4+ counts and CD4+/ CD8+ ratios were not associated with a higher risk for dermatophytosis. On the other hand, viral load higher than 100 000 copies/ml was associated with a higher frequency of dermatophytosis. The results suggest to that although dermatophytosis is common in HIV-positive and AIDS patients, the degree of immunosuppression does not seems to correlate with increased risk of this fungal infection. In addition, high viral load as a predictive risk factor for dermatophyte infection should be subject of further evaluations.
Key words: HIV, AIDS, dermatophytosis, Tinea, Trichophyton rubrum, Brazil.
Introduction The incidence of fungal infections increased dramatically in the last decades as the number of human Correspondence: Dr B. C. M. da Silva, MSc, PhD, Laboratory of Medical Investigation in Dermatology and Immunodeficiency (LIM 56), Faculty of Medicine, University of S~ ao Paulo, Av. Dr. Eneas de Carvalho Aguiar, 470, Predio 2, 3° andar, Cerqueira C esar, S~ ao Paulo, SP, CEP: 05403-000, Brazil. Tel.: (55 11) 3061 7193. Fax: (55 11) 3081 7190. E-mail: [email protected] Submitted for publication 27 August 2013 Revised 17 December 2013 Accepted for publication 17 December 2013
© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 371–376
immunodeficiency virus (HIV)-infected and other immunocompromised patients. Predictably, fungi have been associated with immunodeficiency for a long time are responsible for the most fungal infections in these patients. However, infections due to fungal species not usually associated with immunodeficiency are also frequently reported in patients infected with HIV, as this immunosuppressive virus can determine changes in the course of fungal diseases, leading to altered clinical pictures.1–3 Dermatophytosis, like other fungal infections, generally displays more intense clinical signs in HIV-infected patients than in immunocompetent ones.3–7 However, dermatophyte infections in HIV-infected patients are less
doi:10.1111/myc.12169
B. C. M. da Silva et al.
frequently studied, possibly because of low morbidity and no mortality. This is also observed in patients from developing countries, including Brazil, where the vast majority of HIV-infected population resides.6–11 Therefore, to investigate this mycosis in patients with several stages of HIV infection, we evaluated the suspected clinical and epidemiological characteristics of dermatophytosis in HIV-positive and AIDS patients living in the city of S~ ao Paulo, Brazil.
Materials and methods
For measurement of plasma HIV-1 RNA concentrations (viral load), EDTA-treated plasma samples were prepared and stored at 70 °C until testing. The average interval between collection of blood and freezing of plasma samples was approximately 6 h. A sensitive branched-DNA (bDNA) assay (Siemens Medical Solutions Diagnostics, Tarrytown, NY, USA) was used to quantify HIV-1 RNA in duplicate 1.0-ml samples. The linear range of this assay is between 50 and 50 000 copies ml 1 of plasma. Additional details about the bDNA assay and its performance are reported elsewhere.15–18
Patients
Eighty-four patients were screened with suspected dermatophytosis by an experienced dermatologist and were evaluated in this study. These patients were divided as HIV-positive group with 44 patients and AIDS group with 40 patients. This study was approved by the Research Ethics Committees of participating institutions. All patients enrolled in this study were tested by enzyme-linked immunosorbent assay methodology to evaluate HIV infection. A patient was regarded as positive when two different serum samples were positive for anti-HIV antibodies by referred methodology and confirmed by Western blotting assay. The definition of AIDS was done according to the Centers for Disease Control and Prevention (CDC, USA).12 The patients were assisted at the Center for Reference and Training in STD/AIDS (S~ ao Paulo, Brazil), the AIDS Home of the Faculty of Medicine of the University of S~ao Paulo and the Clinics Hospital of the Faculty of Medicine of the University of S~ ao Paulo. A questionnaire on epidemiological and clinical data was voluntarily answered and a written informed consent was provided by all patients. The patients were treated with highly active antiretroviral therapy (HAART) and those with CD4+ T cell counts below 200 ll 1 were given oral fluconazole, itraconazole or ketoconazole for prophylactic purposes. Immunological and virological tests
T lymphocytes subsets (CD4+ and CD8+) of the patients were measured in ethylenediamine tetraacetic acid (EDTA)-treated whole blood by staining it with fluorescent dye-conjugated monoclonal antibodies that were specific for CD3+, CD4+ e CD8+ lymphocytes (Becton Dickinson Biosciences, San Jose, CA, USA), as previously reported.13,14
372
Mycological examination
The laboratory diagnosis of dermatophytosis was carried out by direct microscopy and culture of the material obtained from patient’s lesions. For direct microscopy, the samples (skin, nail scraping and broken hairs) were clarified in 20% potassium hydroxide before microscopically examined. The clinical specimens were also inoculated on slant tubes with Sabouraud-dextrose agar containing chloramphenicol and cycloheximide (Mycobiotic agar, Difco, Detroit, MI, USA), and were incubated for up to 4 weeks at 25 °C. The identification of dermatophyte species was done by the gross colony morphology and microscopic fungal characteristics in lactophenol cotton blue slide mounts. Statistical analysis
The Fisher’s exact test was used to evaluate the differences’ significance in the frequency between the groups. The critical level of significance was 0.05.
Results As shown in Table 1, the mean age of the patients did not differ significantly between the groups (38.4 and 40.3 years for HIV-positive and AIDS patients respectively). Regarding the schooling years, HIV-positive patients had higher schooling years than AIDS patients (P < 0.001). Dermatophyte infections were quite similar between patients of HIV-positive and Aids groups (38.6% and 47.5% respectively). Considering the isolated species, Trichophyton rubrum was the most frequently identified dermatophyte species in both HIV-positive and AIDS groups (12, 70.6% and 18, 94.7% respectively), whereas Trichophyton mentagrophytes (T. mentagrophytes)
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Dermatophytosis in HIV and AIDS patients
Table 1 Demographic characteristics of the patients. Characteristics
HIV positive (n = 44)
Table 3 Clinical symptoms of patients. AIDS (n = 40) Clinical symptoms
Age (years) Mean value Range Gender Male Female Schooling years Up to 8 years 9–12 years >12 years
38.4 23–59
40.3 26–58
37 (84.1%) 7 (15.9%)
32 (80.0%) 8 (20.0%)
16 (36.3%) 19 (43.2%) 9 (20.5%)
25 (62.5%) 11 (27.5%) 4 (10.0%)
and Microsporum canis (M. canis) were less frequently isolated (Table 2). Regarding the clinical dermatophyte manifestations, four clinical variants were observed among the patients: Tinea pedis, Tinea unguium, Tinea cruris and Tinea corporis. A higher frequency of T. unguium was observed in AIDS patients group than in HIV-positive patients group (P = 0.0218), whereas T. pedis was more frequently observed in HIV-positive patients group (Table 2). The most common clinical symptoms shown by patients were: skin scaling, itching, nail abnormalities (discoloured nails, dull, thickened and/or brittle nails) and erythema (Table 3). Ninety per cent (90.0%) of AIDS patients presented lesions on the nails, a proximal white subungual onychomycosis, as compared with the HIV-positive group (Fig. 1). On the other
Skin scaling Itching Nail abnormalities Erythema Small papular vesicles Fissures
HIV positive (n = 44) (%)
AIDS (n = 40) (%)
43 33 21 22 6
17 12 36 6 0
(97.7) (75.0) (47.7) (50.0) (13.6)
5 (11.3)
(42.5) (30.0) (90.0) (15.0) (0.0)
3 (7.5)
Figure 1 Tinea pedis and Tinea unguium caused by Trichophyton
rubrum in an AIDS patient. Spreading infection can be seen on the dorsal surface of the foot. Proximal white subungual onychomycosis can be seen in the toenail.
Table 2 Clinical variants and dermatophyte species observed in the patient groups.
Patients with dermatophytosis Clinical variants Tinea pedis Tinea unguium Tinea cruris Tinea corporis Dermatophyte species Trichophyton rubrum Trichophyton mentagrophytes Microsporum canis
HIV positive (n = 44) (%)
AIDS (n = 40) (%)
17 (38.6)1
19 (47.5)2
11 3 2 1
7 13 1 2
(64.7) (17.7) (11.7) (5.9)
(36.8) (68.4) (5.3) (10.5)
12 (70.6) 4 (23.5)
18 (94.7)3 4 (21.0)
1 (5.9)
1 (5.3)
1
Number of patients with dermatophytosis.
2
In the AIDS group, one patient was presented with Tinea pedis, Tinea unguium and Tinea corporis, and two other patients presented Tinea pedis and either Tinea unguium or Tinea cruris.
3
More than one species isolated from some patients.
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Figure 2 Tinea pedis in a HIV-positive patient, displaying skin
scaling and erythema.
hand, T. pedis cases displaying skin scaling, diffuse hyperkeratosis of the foot sole as well as itching and erythema were observed more frequently in HIV-positive patients (Fig. 2). Small papular vesicles and fissures were observed in a few cases in both groups.
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Table 4 Frequency of dermatophytosis according to CD4+ counts and CD4+/CD8+ ratio. CD4+ count (per ll)
Patients with dermatophytosis Patients without dermatophytosis Total
CD4+/CD8+ ratio
≤200
>200
≤0.5
>0.5
29 (45.3) 35 (54.7) 64 (100.0)
7 (35.0) 13 (65.0) 20 (100.0)
13 (59.1) 9 (40.9) 22 (100.0)
23 (37.1) 39 (62.9) 62 (100.0)
Values within parenthesis are expressed in percentage.
Regarding the immunological and virological markers, HIV-positive and AIDS patients with dermatophytosis displayed CD4+ T cells count of 512 and 126 cells ll 1, and CD8+ T cells of 1108 and 817 cells ll 1 respectively. The CD4+/CD8+ T cells ratio was 0.52 for HIV-positive and 0.18 for AIDS patients. The mean plasma viral load count was 15 683 copies ml 1 for HIV-positive patients group and 240, 347 copies ml 1 for AIDS patients group. To evaluate the possible association between the patient’s immunological or virological status and the frequency of dermatophytosis, the patients were regrouped according to their number of CD4+ T cells, the CD4+/CD8+ ratio and their plasma viral load. As shown in Table 4, the CD4+ counts or CD4+/CD8+ ratio did not correlate with a higher frequency of dermatophytosis. In addition, patients with viral load greater than 100 000 copies ml 1 presented a significantly higher frequency of dermatophyte infections than patients of the same groups with viral load below 100 000 copies ml 1 (P = 0.0484) (Table 5).
Discussion In this study, we evaluated the possible correlation between the frequency of dermatophyte infections and the virological and immunological status of the HIVinfected patients. Regarding the patient demographic data, a predominance of male gender among two groups was observed, in agreement with the report of Brazilian Ministry of Health 19 and two Indian Table 5 Viral load in dermatophytosis and non-dermatophytosis
patients. Viral load (copies ml 1)
Patients with dermatophytosis Patients without dermatophytosis Total
>100 000
≤100 000
10 (66.7) 5 (33.3) 15 (100.0)
26 (37.7) 43 (62.3) 69 (100.0)
Values within parenthesis are expressed in percentage.
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studies.20,21 On the other hand, HIV-positive patients presented a higher number of schooling years than AIDS patients. In this regard, the only report dealing with schooling years in Brazilian AIDS patients was published by Fonseca et al. [22] who found that patients at risk of AIDS had generally less schooling years. As already pointed out by some authors, HIV-positive patients are prone to develop T. pedis and/or T. unguium.23–25 Indeed, these two clinical forms of dermatophytosis have been the most frequently observed in our HIV-positive and AIDS patients. However, they were not exclusive to these groups, as these two clinical forms were also observed in dermatophytosis cases of the general population.6,7,26–31 Our findings are in agreement with Aly and Berger [23] who reported that T. pedis was the most common type of dermatophytosis in patients infected by HIV, and was usually manifested by typical interdigital maceration with scaling and diffuse hyperkeratosis of the foot sole. Trichophyton rubrum was the most frequent dermatophyte specie isolated from HIV-positive and AIDS patients. This finding agreed with results from previous studies.9,10,24,31–33 However, this dermatophyte specie was also similarly isolated in HIV-negative individuals from the same geographical area.29 The second-most common specie was T. mentagrophytes. Other studies have reported that this species was more associated with acute infections than the species T. rubrum.6,10 Unfortunately, a more detailed clinical evaluation of severity of the lesions and the duration of the infection could not be performed in our patients. Although dermatophytes usually produce infections in the corneal layers of the skin and its annexes, the dermatophyte–host interactions involve complex immunological mechanisms such as cell-mediated immunity. The main efferent branch of the immunological response is the CD4+ T cell, whose activation plays a role, still to be better defined, in the host immune response to dermatophyte infection.30 Although we found no overall statistical differences on the dermatophytosis frequencies between the two patient groups, the frequency of dermatophytosis was
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Dermatophytosis in HIV and AIDS patients
higher in AIDS patients with low CD4+ T cell count, thus confirming previous studies on this subject.10,21,27–31 In our results, we observed a higher frequency of T. unguium in the AIDS group than in the HIV-positive patients, whereas T. pedis was more frequently observed in HIV-positive group. HIV infection may be associated with a higher incidence of nail infections.27–31 Although 90% of the AIDS patients of our study displayed nail lesions, T. unguium was isolated only in 68.4% of the diagnosed cases, as yeast were also causing lesions on the nails of these patients. In this regard, most cases of white proximal subungual onychomycosis were observed in AIDS patient group. According to Dompmartin et al. [28], this form of T. unguium is associated with HIV infection but is uncommon in the immunocompetent population. Some authors have reported that HAART and the prophylactic fluconazole for invasive fungal infections, mostly in patients with CD4+ T cells counts below 200 ll 1, has reduced the incidence of dermatophytosis in the HIV-positive and AIDS population.31,32 In our study, we suggest that these prophylactic measures could have little effect on dermatophyte infections, as many patients diagnosed with dermatophytosis were given several antifungals, such as ketoconazole, itraconazole, fluconazole and amphotericin B at the time of the study. In agreement with previous studies, we observed that skin scaling, itching, nail abnormalities (discoloured nails, dull, thickened or brittle nails) and erythema were the commonest clinical symptoms shown by the patients.32–34 Seventy-five per cent (75%) of HIV-positive patients and 30% of AIDS patients reported itching. In this respect, Blanes et al. [34] investigated the predominance and causes of itching in HIV-infected patients in Spain. Thirty-one per cent of patients reported itching, and interdigital T. pedis was described as one of the most frequent dermatological entities responsible for this symptom. Also, patients reporting itching had also higher viral loads. The lack of correlation between the frequency of dermatophytosis and the clinical stage of the patients was further supported by the comparison of the CD4+/ CD8+ ratio in patients with or without dermatophytosis. On the other hand, a significantly higher frequency of dermatophytosis was seen in HIV-infected patients with high viral load. In conclusion, the present results confirm that dermatophytosis occurs throughout the course of HIV infection, highlights the importance of this mycosis in nail disorders affecting HIV-positive patients as well as suggesting that viral load could be a predictive value for dermatophyte
© 2014 Blackwell Verlag GmbH Mycoses, 2014, 57, 371–376
infections in patients infected by HIV. However, more studies are necessary establishing a relationship between higher risk for dermatophyte infection and the HIV virological status of the patients.
Acknowledgments The authors wish to thank Dr. Bernard Larouze (France) and the Brazilian AIDS Program by the Brazil-France AIDS Technique Cooperation Program. This work was ~o de supported by grant 00/00668-1 from Fundacßa Pesquisa do Estado de S~ Amparo a ao Paulo (FAPESP).
Conflict of interests The authors have declared that no conflicts of interest exist.
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