I MYCOSES 34, 183-186 (1991) ACCEPTED: NOVEMBER 22, 1990

Dermatophytoses in Cusco (Peru)

Dermatophytosen in Cusco (Peru)

V. Vidotto], R. Garcia2, L.-M. Ponce3, M. Valverde3 and M. Bruatto'

Key words. Derrnatophytoses, tinea, derrnatophytes, epidemiology, Peru.

Schliisselworter. Derrnatophytosen, Tinea, Derrnatophyten, Epiderniologie, Peru.

Summary. A total of 90 cases of suspected der- matophytoses was observed over a period of 9 months in the city of Cusco (Peru) and in its en- virons. The age groups most commonly infected were 1-10 and 11-20 year old. The most common tineae diagnosed were tinea capitis (13.3%) and tinea unguium ( 1 1.1 yo). Only four species of der- matophytes were isolated: Microsporum canis (5 2.4 yo), Trichoph y ton men tagroph y tes ( 3 5.7 yo), Tr. rubrum (9.5%) and Epidermophyton floccosum (2.4%). Dry weather, low temperature and high altitude do not seem to affect proliferation and in- fections by dermatophytes.

Zusammenfassung. In Cusco (Peru) und seiner Umgebung wurden insgesamt 90 Patienten mit Verdacht auf Dermatophytose uber 9 Monate hin- weg beobachtet. Die am starksten infizierten Al- tersgruppen waren die 1-10- und l l-20jahrigen. Als haufigste Lokalisationen wurden Tinea capitis (13,3 yo) und Tinea unguium (1 1,l yo) beobachtet. Es wurden nur 4 Dermatophytenarten isoliert: Mi- crosporum canis (52,4 yo), Trichophyton mentagro- phytes (35,7 yo), Tr. rubrum (9,5 yo) and Epider- mophyton floccosum (2,4 %). Trockenes Klima, niedrige Temperatur und groRe Hohe scheinen das Auftreten und Wachstum von Dermatophyten nicht zu beeinflussen.

I Laboratorio di Micologia Medica, Istituto di Malattie Infettive, Universitl di Torino, Italy, * Centro Derrnatologico BelCn, Cusco, Peru, and Departarnento de Microbiologia de la Uni- versidad Nacional San Antonio Abad del Cusco, Peru.

Correspondence: Dr Valerio Vidotto, Laboratorio di Micologia Medica, Istituto di Malattie Infettive, Universitl di Torino, Corso Svizzera 164, 1-10149 Torino, Italy.

Introduction

Dermatophytoses constitute a health problem in many parts of the world [l]. In Peru the true status of ringworm infections has not yet been studied, nor have dermatophytes been isolated at high altitudes in other countries. Our study describes several cases of dermatophytoses in Cusco (Peru) and its envi- rons. This city, the capital of an underdeveloped region, is located at 3,450 m above sea level, with 60% relative humidity, 700 mm average annual precipitation and an average annual temperature of 11 "C (data for 1989).

The study was conducted to isolate and identify the dermatophytes causing infections among the pa- tients visiting the Centro Diagnostico Bden and De- partamento de Microbiologia, Facultad de Ciencias Biologicas de la Universidad Nacional San Antonio Abad del Cusco (U.N.S.A.A.C.), Cusco (Peru).

Patients and methods

Between March 1989 and December 1989, 90 cases of suspected dermatophytoses were clinically diag- nosed and studied at the Centro Diagnostico Bilen and Departemento de Microbiologia (U.N.S.A.A.C.), Cusco (Peru), by direct micro- scopic observation of the clinical specimens and by cultures.

Patients were generally from Cusco and its sur- rounding area (Table 1). Only patients without any predisposing factors (diabetes, renal insufficiency, cytotoxic therapies, hormonal dysfunction, immu- nosuppression, etc.) and who had not been treated with antimycotics or had suspended such therapy for at least 10 days, were included in this study. A clinical history was also obtained for each patient.

Samples of skin, hair and nails were taken from patients using scalpels, forceps and microscope

184 v. VIDOTTO ET AL.

Table 1. Peruvian study

Provenance of the patients surveyed in this

Total cases Positive cases Locality M F M F

Abancay Andahuaylas Anta Argentina cusco Lima Ollantaytambo Quillabamba

1 1 1 1

48 2 1 2

Total 33 57 16 26

M = males F = females

slides, that had been washed in ethanol and steri- lized on a Bunsen burner. Direct microscopic ob- servation of the samples was carried out by exam- ining the material in 10% KOH in sterile distilled water. Isolation of the fungus was performed by plating portions of the clinical specimen on Der- matophyte Test Medium, Difco (D.T.M.), incu- bated at 25 "C and examined for growth after 7, 14, 21, and 28 days. Negative cultures were excluded at the end of the fourth week [2]. Suspected der- matophyte colonies were subcultured on plates of Sabouraud dextrose agar (Difco). Standard meth- ods and criteria, based on the gross and microscopic morphology of the isolates, were used to identify the isolated strains [ 1-31.

Results

Out of a total of 90 patients with clinical symptoms of dermatophytoses, 57 were females and 33 males (M:F ratio was 0.58:l) [Table 11.

The different forms of tinea observed in the pa- tients, as related to their clinical diagnosis, micro- scopic examination with 10% KOH and culture of the clinical specimens are reported in Table 2. Some patients presented clinical symptoms at more than one site of the body, but only one sample from the most diffused tinea was withdrawn. In particularly, among the 24 cases of tinea unguium observed, three were on the finger nails (2 on both hands and one on one hand, no one confirmed), nineteen on toe nails (11 on both feet, 3 confirmed, and 8 on one foot, 5 confirmed). Two patients showed both finger and toe nails affected by confirmed derma- tophytoses. Direct observation in 10% KOH showed 38 positive cases (42.2%), while the etiol- ogical agent was isolated from 42 patients (46.6%). Through both direct observation in 10% KOH and cultures 31 cases were confirmed as positive for der-

Table 2. nical impressions and microscopic and cultural studies

Correlation of tineae encountered with first cli-

Clinical Tineae diagnosis

Tinea 24( 26.7%) unguium Tinea capitis 17( 18.9%) Tinea pedis 15( 16.7%) Tinea corporis 1 1 ( 12.2%) Tinea faciei 9( 10.9%)

manuum Tinea cruris 6( 6.7%)

Tinea 8( 8.9%)

Positive laboratory findings 10% KOH Culture

12( 13.3%) 10( 1 l.lo/o)

1 O( 1 1.1 yo) 12( 13.3%) 3( 3.3%) 5( 5.6%) 5( 5.6%) 6( 6.7%) I ( 1.1%) 2( 2.2%) 4( 4.4%) 4( 4.4%)

3( 3.3%) 3( 3.3%) I

Total 90( 100.0%) 38(42.2y0) 42(46.6y0)

matophyte infections. Eleven were found to be po- sitive only by culture, and 7 by direct observation only. From the same table, a prevalence of tinea unguium and tinea capitis can be observed.

Of the 90 patients, 32 (35.5%) were not treated before the clinical examination and sample collec- tion, whereas 30 (33.3%) were treated with different topical antimycotics, therapy interrupted at least 10 days before being examined and specimens collect- ed. The rest, 28 (31.3y0), were treated with different drugs (antibiotics, corticosteroids, antihistamines, etc.). No relevant differences were, however, ob- served in the results of the laboratory examination among the three groups of patients. Positive cases of dermatophytoses related to the sex of the patients and the isolated fungus are presented in Table 3. The prevalence of infected females over males (M:F ratio = 0.61:l) can be noted. The species of der- matophytes isolated from the patients were Micro- sporum canis, 22 (52.4%), Trichophyton menta- grophyres, 15 (35.7y0), among which one was var. interdigitale, Tr. rubrum, 4 (9.5%) and Epider-

Table 3. and the derrnatophyte species isolated

Tineae M F MC TM TR EF Total

Correlation of the tineae to the sex of patients

Tinea unguium 5 5 1 6 3 - 10 Tinea capitis 3 9 10 2 - - 12

Tinea corporis 3 3 6 - - - 6 Tinea faciei 1 1 1 1 - - 2 Tinea manuum 2 2 4 - - - 4 Tinea cruris 2 1 - 1 1 1 3 Total 16 26 22 15 4 1 42

Tinea pedis - 5 - 5 - - 5

M = males F = females MC = Microsporum canis TM = Trichophyton mentagrophytes TR = Trichophyton rubrum EF = Epidemophyton floccosum

mycoses 34, 183-186 (1991)

DERMATOPHYTOSES IN Cusco (PERU) 185

I

mophyton flocossum, 1 (2.4%). M. canis was more abundant in the cases of tinea capitis, tinea corporis and tinea manuum, whileTr. mentagrophytes was dominant in the cases of tinea unguium and tinea pedis (Table 3).

The age of the patients ranged between 5 months and 74 years (mean 36.31) (Table 4). The age groups with the most confirmed dermatophytoses were 1-10, 11-20 and 31-40 (Table 4). It is also noteworthy that M. canis was more common in pa- tients under 20 and Tr. mentagrophytes in patients aged between 20 and 40. Among the tineae, tinea capitis showed its highest prevalence in the 1-10 age group, with a great prevalence of infections among females. Tinea pedis was only confirmed in female patients (Table 4).

Out of the 90 patients observed, 29 (32.0%) de- clared that they had had contacts with domestic or stray animals (dogs, cats, hens and guinea pigs), 15 of whom gave a positive dermatophyte in culture. In some cases, it was also possible to observe the involved animals directly, some of which showed typical symptoms of ringworm. However, it was not possible to obtain clinical specimens for study.

I

Discussion

Tinea capitis was the most common tinea observed in young people (0-20 years old) in Cusco, as in other parts of the world (Table 4). Microsporum canis was the species most frequently isolated in Cusco, a finding in accordance with reports from India, Italy, Jordan, Kuwait, Portugal, Spain and elsewhere [3-113.

In Cusco, as in Jordan, tinea capitis was more prevalent in females children than in males (Table 3). As in Jordan, “the reason for this is not fully understood but could be partially attributed to the fact that male children (. . .) have their hair cut fairly short whereas (. . .) female children keep their hair long and may thus make it more difficult to keep it in a clean condition” [8]. Moreover, wearing longer hair usually brings about using combs and brushes more often, which may be shared by a group of people. All of these reason could probably explain the observed prevalence of tinea capitis be- tween the girls.

The most frequently isolated dermatophytes in tinea unguium were Tr. mentagrophytes var. men- tagrophytes and Tr. rubrum (Table 3). It is im- portant to note that tinea unguium and tinea man- uum together are the most common tinea observed in Cusco. Tinea pedis was only confirmed among the female patients (Table 3). This could be as- cribed to the fact that women, in contrast with men, generally do not wear shoes, particularly in the country side. Tinea corporis was also noted in Cusco

Table 4. confirmed tinea

Age groups of patients related to the different

42 Total 1 0 1 2 5 6 2 4 3

TU = tinea unguium TC = tinea capitis TP = tinea pedis TCo = tinea corporis TF = tinea faciei TM = tineamanuum TCr = tinea cruris

with M. canis as the major causative agent (Table 3). This is in contrast to what has been reported in such countries as Canada, Israel, Portugal, Spain, USA, etc., where Tr. mentagrophytes or Tr. rub- rum are the dominant species [4, 6, 9-17]. All of these tineae can be attributed to the poverty of life and to poor hygienic conditions, particularly in the rural areas.

The prevalence of M. canis (a zoophilic species) among the dermatophytes isolated in the course of our study (Table 3) can be attributed to the diffusion of stray and domestic animals (dogs, cats, guinea pigs, etc.). In particular, guinea pigs seem to be able to transmit dermatophytoses. Clinical symptoms of ringworm infections were observed in three of these animals and M. canis was isolated

mycoses 34, 183-186 (1991)

186 V. VIDOTTO ET AL.

from tinea manuum and tinea capitis in the patients who had been in contact with them.

It would be difficult to lower the prevalence and incidence of dermatophytoses in Cusco as in other underdeveloped countries. The elimination of ob- vious vectors, such as stray animals, improved con- ditions of life and hygiene, may be able to reduce dermatophytes, particularly M. canis.

Although only 90 cases are described in this re- port, many other suspected cases of dermatophy- toses were noted in and around Cusco (personal observation of Garcia & Vidotto). This support the contention that the dermatophyte species can thrive and proliferate under environmental conditions that would seem to be adverse to their widespread oc- currence. In fact, from our data, it appears that the high percentage of UV radiations, due to the high altitude, and the temperate and dry climate do not exclude dermatophyte infections.

Acknowledgement

The authors like to thank Dr L. Ajello, Atlanta, for kindly reviewing this manuscript.

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