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A Filipino woman in her forties had facial erythema that was being self-treated with over-the-counter (OTC) drugs purchased outside of Japan. The drugs included clobetasol propionate, antibiotic, and antifungal components. Her facial erythema symptoms were worse during summertime. KOH direct examination of annular erythema was positive for fungal hyphae and negative for Demodex folliculorum. Fungal culture revealed Trichophyton indotineae based on internal transcribed spacer sequence analysis. Minimal inhibitory concentration for terbinafine was 0.06 µg/mL. We made a diagnosis of tinea faciei with steroid rosacea. We treated the patient with oral itraconazole. Physicians should be aware of increasing T. indotineae infections and increasing self-medication using topical OTC steroids combined with antifungals and antibiotics not only in India but also among foreign people living in other countries such as Japan.

We herein report a case of kerion celsi of the scalp and tinea corporis due to Trichophyton tonsurans. A 17-year-old Japanese male high school student who practiced judo had alopecic patches with severe inflammation on the scalp. We performed a fungal culture and identified the causative fungus as T. tonsurans. A plate culture of T. tonsurans showed lemon-yellow colonies with yellow-green fluorescence under UVA light, which are typical findings for Microsporum canis. However, genetic analysis of the ribosomal RNA gene of the isolate facilitated differential diagnosis of T. tonsurans.In contrast to dermatophytosis due to other dermatophytes, the clinical features of infection caused by T. tonsurans, an anthropophilic dermatophyte, are initially not very apparent and, thus, are frequently overlooked. We herein present a case of a severe type of kerion celsi caused by T. tonsurans with a fluorescence pattern mimicking M. canis colonies under UVA light. We suspect that yellow pigment metabolites, such as riboflavin, which are fluorescent under UV when secreted into the culture medium, are the virulence factors for not only M. canis, but also T. tonsurans, as shown in the present case.

The taxon Aspergillus section Fumigati comprises several causative agents of aspergillosis. Here, the distribution of Aspergillus sect. Fumigati in outdoor environments of Izu and Ogasawara Islands was investigated. Different strains were isolated from soil samples collected from 68 sites on 9 islands (Izu-oshima, Toshima, Shikinejima, Kozushima, Miyakejima, Hachijojima, Mukojima, Chichijima, and Hahajima), including different landscapes, and identified using morphological characteristics and calmodulin (CaM) sequences. Seven Aspergillus sect. Fumigati species were identified. The occurrence frequency of Aspergillus fumigatus was higher in forest sites on the islands, except for Ogasawara Islands, whereas that of species other than A. fumigatus was higher in bare land and grassland sites on all islands. The occurrence frequency of A. fumigatus was more than 50% on islands between Izu-oshima and Toshima, decreased on islands between Shikinejima and Hachijojima, and was zero on Ogasawara Islands. Considering other Aspergillus species, Aspergillus felis showed high occurrence frequency on islands between Izu-oshima and Shikinejima, Aspergillus pseudoviridinutans on islands between Kozushima and Hachijojima, and Aspergillus udagawae on Ogasawara Islands. At two study sites (grassland and forest sites), the soil was sampled throughout the year to evaluate whether the occurrence frequency of each fungal species was affected by sampling season. At the grassland site, A. pseudoviridinutans was isolated at more than 90% frequency, regardless of the sampling season. A. fumigatus occurrence frequency at the forest site ranged from 0% to 60% and greatly varied among sampling seasons. Thus, differences in island location and landscape affected the distribution of Aspergillus sect. Fumigati.

In this study, we aimed to clarify the phylogenetic distribution of Exophiala dermatitidis in Japan and describe the characteristics of genotypes. We examined 67 clinical and environmental isolates that were morphologically identified and preserved as E. dermatitidis and we confirmed the identification on the basis of the ribosomal DNA internal transcribed spacer region. Genotype sequences were aligned and compared using maximum likelihood phylogenetic tree analyses of the ITS1 region. Additionally, the strains of each genotype were tested for mycological characteristics, such as growth temperature, growth rate, and drug sensitivity. The 67 strains examined were isolated from Japan, the United States, Brazil, Venezuela, and China. In accordance with the establishment of a phylogenetic tree for the ITS1 region, 45 of the 49 Japanese strains were classified as genotype A, two as genotype B, and two as genotype D (A2 according to the method of Matos et al. (2003)). Chinese strains were divided into genotypes A and D (A2), and South American strains were classified into genotypes A, B, B2, and C2, while all strains from the U.S. belonged to genotype A. New genotype groups B2 and C2 were identified in Brazilian and Venezuelan strains, respectively. There were no specific differences among the genotypes or isolated regions in the antifungal susceptibility test for all E. dermatitidis isolates. However, genotypes B2 and D (A2) exhibited growth at higher temperatures than the other genotypes.

The genus Prototheca consists of achlorophyllic algae that are ubiquitous in the environment and also occur in animal intestines; occasionally, infections in humans and animals are observed. In this study, we conducted tests of assimilative abilities and thermotolerance in comparison with morphological characteristics of six opportunistic species (Prototheca blaschkeae, Prototheca bovis, Prototheca ciferrii, Prototheca cutis, Prototheca miyajii, and Prototheca wickerhamii) along with Prototheca paracutis. Five of the seven species could be differentiated by physiological characteristics, but P. wickerhamii and P. cutis had identical profiles. Of the cattle-associated species, only P. bovis was able to grow at 42°C. Both type strains of P. cutis and P. miyajii were most susceptible to ravuconazole compared with the other azoles.

Aspergillus fumigatus-related species are responsible for causing aspergillosis, which is a fatal infectious disease. Recently, there has been a series of reports of A. fumigatus-related species that are resistant to azole drugs used in clinical practice for the treatment of fungal infections. Some of these species have been isolated from outdoor environments. Testing the drug susceptibility of the strains from outdoor environments, therefore, is important. In this study, we isolated and cultured 72 strains of A. fumigatus-related species from the outdoor environment in Japan. The isolates identified via morphological observation and molecular phylogenetic analysis were Aspergillus felis, Aspergillus lentulus, Aspergillus pseudoviridinutans, Aspergillus udagawae, and Aspergillus wyomingensis. The results of the drug susceptibility testing revealed that A. felis (6 of 14 strains) and A. pseudoviridinutans (13 of 17 strains) were resistant to itraconazole (ITCZ), with 4 mg/L or higher minimum inhibitory concentrations (MICs). The voriconazole (VRCZ)-resistant strains with 4 mg/L or higher MICs were A. felis (14 of 14), A. lentulus (4 of 4), A. pseudoviridinutans (15 of 17), A. udagawae (23 of 34), A. wyomingensis (1 of 3), and A. pseudoviridinutans (1 of 3). Among them, A. felis (1 of 14) and A. pseudoviridinutans (7 of 17) demonstrated 8 mg/L or higher MICs for ITCZ and VRCZ. These results indicate that A. fumigatus-related species resistant to ITCZ and VRCZ are widely distributed in outdoor environments in Japan.

A 57-year-old male patient with >10-year history of type 2 diabetes presented with a left big toenail deformity and pain. A physical examination revealed a white and yellow-to-brown patch on the nail as well as thickening and ingrowth of the nail plate. The nail plate was opened using nippers, and a fungal culture revealed Trichophyton interdigitale with yellow yeast. The yeast isolate was identified as Kocuria koreensis, a Gram-positive aerobic coccoid with keratinolytic properties that is part of the normal flora of the skin. We created an ex vivo onychomycosis model of T. interdigitale infection of the human nail by placing a sterilized normal nail on the cultured slant. K. koreensis initially spread over the normal nail, and T. interdigitale then penetrated the nail plate. After one year and six months, a spiral ingrown nail developed. A histopathological examination of the spiral revealed onychomycosis with superficial and deep abscesses of Gram-positive cocci infection. We performed PCR from paraffin-embedded material, and the sequences obtained were identical to those of T. interdigitale and K. koreensis. These results suggest that the development of onychomycosis by T. interdigitale is introduced and accelerated by K. koreensis, and the symbiosis of these microorganisms is suspected in the nail. This ex vivo model has a number of limitations. Therefore, further research on co-infected cases is needed to confirm this hypothesis.

Tinea imbricata and tinea pseudoimbricata are variant types of tinea corporis characterized by annual-ring-shaped erythema. Although the skin lesions manifest similar symptoms, these two diseases are classified based on causative fungi. The former is caused by Trichophyton concentricum, an anthropophilic dermatophyte, and the latter is caused by dermatophytes other than T. concentricum, commonly zoophilic fungi such as Trichophyton mentagrophytes complex. Here, we report a 27-year-old Japanese male diagnosed with tinea pseudoimbricata attributed to Trichophyton tonsurans, an anthropophilic dermatophyte. We suspected that application of steroid ointment caused the annular pattern of his skin lesions. After three months use of topical luliconazole cream, treatment was finished. We also summarize the knowledge about tinea pseudoimbricata through previous reports with bibliographical consideration.

We present a 76-year-old Japanese male with tinea faciei, tinea corporis, and tinea unguium with dermatophytoma. We performed fungal culture and confirmed the causative fungus to be Trichophyton rubrum. We treated the patient using oral fosravuconazole l-lysine ethanolate (F-RVCZ). More than one year has passed since the end of treatment, but there has been no recurrence. This case suggests that F-RVCZ is effective for tinea other than tinea unguium.

Wood's lamp was demonstrated to be useful in three cases of dermatophytoma treated during clinical dermatological practice. Clinical signs of onychomycosis are longitudinal yellow and white striae on the nail plate and are diagnosed by KOH direct microscopic examination. For its treatment, surgical debridement is recommended. Usefulness of the Wood's lamp for diagnosis of tinea capitis caused by Microsporum canis is standard. In the first and second cases, we used Wood's lamp (Woody™) to make a clear margin for debridement of onychomycosis. In the third case, onychomycosis was unsuccessfully treated using topical 5% luliconazole nail solution for 1 year and 10 months with yellow nail discoloration. Under Wood's lamp, we were able to distinguish luliconazole crystal staining from onychomycosis. This method is simple and quick, and useful for nail observation in dermatology clinics.

The incidence of non-dermatophyte mould onychomycosis has been increasing worldwide for the past several decades, but it is not well recognized in Japan. Recent molecular techniques and phylogenetic analyses contributed to the identification of uncommon and emerging species. We came across 13 (0.5%) cases of non-dermatophyte onychomycosis among a total of 2,591 onychomycosis cases in 106,703 outpatients during the past 5 years (January 2015-December 2019). The cases included 5 patients with Aspergillus species, 4 patients with Fusarium species, and one patient each with Scopulariopsis brevicaulis and Botryosphaeria dothidea, respectively. Botryosphaeria dothidea is closely related phylogenetically to Neoscytalidium dimidiatum. In Japan, at the time of writing this report, there are 26 reported cases of ungual aspergillosis and 18 cases of hyalohyphomycosis caused by Fusarium species. We summarize these cases and report the symptoms and mycological features.

We present a 17-year-old Japanese male high school student, who had applied steroid ointment for atopic dermatitis, with fingernail onychomycosis due to Trichophyton tonsurans. He was found positive for T. tonsurans infection based on hairbrush culture performed due to an epidemic of T. tonsurans infection in his judo club. The hairbrush culture method is very important in screening for this infection, and dermatologists should examine the entire body of athletes who are found positive using this method. For the diagnosis of T. tonsurans infection, other than the skin and hair, the nails should also be checked by dermoscopy because the fingernail may be the origin of this fungus.

In Japan, Fusarium species are known etiological agents of human fungal infection; however, there has been no report of a large-scale epidemiological study on the etiological agents of fusariosis. A total of 73 Fusarium isolates from patients with invasive fusariosis (IF, n= 36) or superficial fusariosis (SF, n= 37), which were obtained at hospitals located in 28 prefectures in Japan between 1998 and 2015, were used for this study. Fusarium isolates were identified using Fusarium- and Fusarium solani species complex (FSSC) -specific real-time PCR and partial DNA sequences of the elongation factor-1 alpha (EF-1α) gene and the nuclear ribosomal internal transcribed spacer (ITS) region. FSSC was predominately isolated from both patients with IF and SF (IF, 77.8% and SF, 67.6%). Distribution of the phylogenetic species of FSSC isolates from patients with IF and SF exhibited different spectra; specifically, F. keratoplasticum (FSSC 2) (25.0%) was the most frequent isolate from patients with IF, whereas F. falciforme (FSSC 3+4) (32.4%) was the most frequent isolate from patients with SF. Fusarium sp. (FSSC 5) was the second most frequent isolate from both patients with IF and SF (IF, 22.2% and SF, 24.3%). Notably, F. petroliphilum (FSSC 1) was isolated only from patients with IF. Each species was isolated from a broad geographic area, and an epidemic was not observed. This is the first epidemiological study of Fusarium species causing IF and SF in Japan.

Sporotrichosis is a fungal infection caused by the Sporothrix species, which have distinct virulence profiles and geographic distributions. We performed a phylogenetic study in strains morphologically identified as Sporothrix schenckii from clinical specimens in Japan, which were preserved at the Medical Mycology Research Center, Chiba University. In addition, we examined the in vitro antifungal susceptibility and growth rate to evaluate their physiological features. Three hundred strains were examined using sequence analysis of the partial calmodulin gene, or polymerase chain reaction（PCR）method using newly designed species-specific primers; 291 strains were Sporothrix globosa and 9 strains were S. schenckii sensu stricto (in narrow sense, s. s.). S. globosa strains were further clustered into two subclades, and S. schenckii s. s. strains were divided into three subclades. In 38 strains of S. globosa for which antifungal profiles were determined, 4 strains (11%) showed high minimal inhibitory concentration (MIC) value for itraconazole. All tested strains of S. schenckii s. s. and S. globosa showed low sensitivity for amphotericin B. These antifungals are used for treatment of sporotrichosis when infection is severe. S. schenckii s. s. grew better than S. globosa; wherein S. globosa showed restricted growth at 35℃ and did not grow at 37℃. Our molecular data showed that S. globosa is the main causal agent of sporotrichosis in Japan. It is important to determine the antifungal profiles of each case, in addition to accurate species-level identification, to strategize the therapy for sporotrichosis.

Fonsecaea species are major etiologic agents of Chromoblastomycosis (CBM). By genetic analysis, the genus Fonsecaea has recently been revised and classified into F. pedorosoi, F. monophora and F. nubica. Here we report a severe chronic case of CBM caused by F. monophora. A 55-year-old Filipino male developed progressive skin lesions on the left lateral ankle in 1973, when he worked at a coconut plantation in the Philippines. In 1999, he received medical treatments for enlarged, multiple lesions on the left lower limb. When he moved to Japan in 2005, the lesions were remarkably improved and he discontinued taking the medicine. On our first examination in October 2008, a large, reddish, cicatricial plaque was observed on the left lower aspect of his leg. Several tumorous lesions surrounded the plaque, indicating that the therapies performed before had been insufficient. In addition, there were many patchy scars scattered on the thigh and the upper part of the lower leg. The diagnosis of CBM was made by the presence of muriform cells. Black, pulverulent colonies were yielded in culture of skin scrapings and tissues. Although the fungus could not be identified by microscopic morphology, r-RNA ITS sequence analysis enabled identification of Fonsecaea monophora. The patient responded well to oral voriconazole combined with local thermotherapy using pocket warmers. The tumoral masses subsided in 6 months, leaving pink scars with negative fungal culture. Voriconazole treatment was continued for 18 months. It seems that drugs are insufficiently delivered in the cicatricial lesions because of the paucity of blood flow, suggesting that a long-term follow-up is necessary for such a case., (Copyright © 2011 The Japanese Society for Medical Mycology)

This study aimed to examine the genotype distribution of Candida albicans and the major genotypes involved in superficial candidiasis. The genotypes of C. albicans isolated from the infection sites of patients with superficial candidiasis (referred to as infection isolates) were analyzed by fragment analysis using 4 microsatellite markers (HIS3, CDC3, CAI and CAIII). Genotypes of the infection isolates were compared with those of C. albicans isolated from oral mucosa of non-candidiasis patients (referred to as oral isolates). Isolates of C. albicans showed 4 major genotypes for HIS3/CAI (" a " for 148 : 148 / 23 : 23," b " for 148 : 160 / 33 : 41," c " for 148 : 164 / 32 : 41 and " d " for 152 : 152 / 18 : 27). The genotypes " a "," b " and " d " were commonly found in oral (4.7, 8.8 and 7.6%, respectively) and infection (6.6, 9.2 and 15.4%, respectively) isolates. No isolates of genotype " c " were isolated from infection sites. The genotype " a " was found in the isolates from patients with genitalia candidiasis. Genotyping of multiple isolates from an individual patient showed that C. albicans from infection sites was genetically homogenous as compared with that of oral isolates, even in the same patient with candidiasis.

We report a case of primary cutaneous Aspergillus caldioustus infection caused by nerve block therapy. A 67-year-old Japanese woman had been treated with oral predonisolon and tacrolimus for adult-onset Still disease and interstitial pneumonia. She presented with a 2-month-history of the lesions on the left back. A biopsy specimen from the skin lesion revealed granulomatous inflammation with hyphae. Culture of the pus and the skin specimen confirmed the diagnosis of cutaneous Aspergillus infection. The sequence of β- tubulin gene was analyzed to confirm the mycological diagnosis and the causative agent was identified as A. caldioustus. The patient was treated with surgical removal of the lesions and oral 200 mg/day itraconazole but she died of infectious interstitial pneumonia due to Pneumocystis jiroveci and Cytomegalovirus infection Percutaneous infection may have been responsible for the incidence of localized infection. There was no evidence of systemic aspergillosis. A. caldioustus is an emerging opportunistic fungal pathogen in immunocompromised patients. Immunocompromised patients who have persistent traumatic atypical skin lesion need to be ruled out of such rare fungus infection. An opportunistic infection in Immunocompromised patients can be life-threatening and prompt treatment based on accurate diagnosis is important., (Copyright © 2011 The Japanese Society for Medical Mycology)

Genotype characteristics and distribution of commensal Candida albicans should be studied to predict the development of candidiasis, however, extensive genotype analysis of commensal C. albicans has not been made. In this study, 508 C. albicans isolates were collected from patients with/without candidiasis and divided into 4 isolate groups (SG-1, oral cavity of non-candidiasis patients; SG-2, patients with cutaneous candidiasis; SG-3, patients with vaginal candidiasis; SG-4, patients with candidemia). These isolates were characterized to study the relationship between genotypes and pathogenicity using microsatellite analysis. Using CDC3 and CAI, 5 genotypes (I, 111: 115/33: 41; II, 115: 119/23: 23; III, 115: 123/18: 27; IV, 115: 123/33: 40; and V, 123: 127/32: 41) were found in 4.2%, 8.9%, 7.1%, 2.2% and 3.1% of the isolates, respectively. Genotypes II and III were commonly found in all isolate groups. These genotypes were further divided into 28 types by additional HIS3 and CAIII microsatellite markers. In this analysis, C. albicans with type 6 and type 23 was widely distributed as a commensal species in the oral cavity of non-candidiasis patients and found to be related with candidiasis development. Additionally, genotypes I and IV were found in SG-2 and/or SG-4, suggesting that the fungus with those genotypes is also involved in this development. In contrast, genotype V was not identified in any infective isolates.