Journal de Mycologie Médicale (2017) 27, 166—179

Available online at ScienceDirect

www.sciencedirect.com

ORIGINAL ARTICLE/ARTICLE ORIGINAL

Incidence and biodiversity of yeasts,

and non-dermatophytes in

superficial skin in Assiut, Egypt

Incidence et biodiversite´ des levures, des dermatophytes,

et non dermatophytes, agents de mycoses superficielles dans le

gouvernorat d’Assiout — ´Egypte

A.H. Moubasher, M.A. Abdel-Sater *, Z. Soliman

Department of Botany and Microbiology, Faculty of Science, Assiut University Mycological Centre, Assiut

University, Assiut, Egypt

Received 1st October 2016; received in revised form 28 December 2016; accepted 11 January 2017

Available online 7 February 2017

KEYWORDS Summary

Skin infections; Objective. — The aim was to identify the incidence of the causal agents from dermatophytes,

Yeasts; non-dermatophytes and yeasts in Assiut Governorate employing, beside the morphological and

Dermatophytic; physiological techniques, the genotypic ones.

Non-dermatophytic; Patients. — Samples from infected nails, skin and hair were taken from 125 patients.

PCR Materials and methods. — Patients who presented with , , tinea

corporis, and tinea pedis during the period from February 2012 to October 2015 were

clinically examined and diagnosed by dermatologists and were guided to Assiut University

Mycological Centre for direct microscopic examination, culturing and identification.

Results. — Onychomycosis was the most common infecting (64.8% of the cases) followed by

tinea capitis (17.6%). Direct microscopic preparations showed only 45 positive cases, while 96

cases showed positive cultures. Infections were more frequent in females than males. Fifty-one

fungal species and 1 variety were obtained. Yeasts were the main agents being cultured from

46.02% of total cases. Non-dermatophytes were the second etiologic agents. Aspergillus was

responsible for infecting 19.47% of total cases and dermatophytes appeared in only 15.93% of the

cases.

* Corresponding author.

E-mail address: [email protected] (M.A. Abdel-Sater).

http://dx.doi.org/10.1016/j.mycmed.2017.01.005

1156-5233/# 2017 Elsevier Masson SAS. All rights reserved.

Diversity of mycobiota in superficial infections 167

Conclusions. — Yeasts were the main causal agents followed by non-dermatophytic fungi

(mainly species of Aspergillus, then Alternaria, Scopulariopsis and Fusarium). Both direct

microscopic preparations and culturing are recommended for mycological evaluation of clinical

specimens. Sequence analysis of ITS region is recommended for yeast identification.

# 2017 Elsevier Masson SAS. All rights reserved.

Re´sume´

MOTS CLÉS Objectif. — Ce travail a pour but de connaître les agents de mycoses superficielles chez l’homme

dans le gouvernorat d’Assiout, en utilisant le diagnostic morphologique, les techniques physio-

Mycoses superficielles ;

logiques et génétiques.

Levures ;

Patients. — Les échantillons prélevés ont concerné la peau, les cheveux, et des ongles infectés

Dermatophytes et non

de 125 malades.

dermatophytes ;

PCR Mate´riel et me´thodes. — Nous avons examiné les patients atteints de teigne des ongles, du corps

et du cuir chevelu de février 2012 à octobre 2015. Ces cas ont été diagnostiqués cliniquement par

des dermatologistes, à la faculté de médecine, université d’Assiout. Après prélèvement des

échantillons nous avons réalisé un examen microscopique et des cultures sur milieux appropriés

pour identifier les champignons par les moyens morphologiques et génétiques, utilisés au centre

de mycologie de l’université d’Assiout.

Re´sultats. — Les cas d’onychomycose sont les plus répandus dans les infections superficielles

(64,8 %). La teigne du cuir chevelu vient au deuxième rang après l’onychomycose (17,6 %)

L’examen microscopique direct des échantillons a révélé l’ de 43 cas, mais le résultat

des cultures mycologiques a été positif dans 96 cas. On a observé que les infections dermiques

superficielles ont été plus répandues chez les femmes que chez les hommes. Cinquante et une

espèces fongiques ont été isolées. Les levures étaient la cause principale de l’infection avec

46,02 % des cas total, les non dermatophytes occupaient la deuxième place. Des Aspergillus ont

été isolés dans 19,47 % des cas, les dermatophytes ont été isolés seulement dans 15,93 % des cas.

Conclusion. — En premier, les levures étaient la cause principale des infections, suivies par les

non-dermatophytes : Aspergillus, Alternaria, Scopulariopsis, et Fusarium. Il est donc recom-

mandé d’utiliser les techniques d’examen direct et de faire des cultures mycologiques des

échantillons étudiés. Pour les levures, le séquençage de la région ITS est recommandée pour

l’identification.

# 2017 Elsevier Masson SAS. Tous droits réservés.

Introduction mainly T. rubrum, T. mentagrophytes while Candida albicans

is the major yeast causing onychomycosis of fingernails

[9,10]. Genetic predisposition, age, swimming, psoriasis,

Although not all fungi are pathogenic, some can cause serious

diabetes and immunodeficiency are the risk factors for ony-

diseases and pose a significant public health risk. Within the

chomycosis. Tinea unguium is most common in adults [11].

last three decades, fungi (especially yeasts of the Candida

Tinea manuum, in which palms and interdigital areas of

genus) are a major cause of nosocomial infections among

hands are affected, is usually caused by T. rubrum and other

immunocompromised patients but the leading cause remains

Trichophyton and Microsporum species. Tinea capitis (infec-

[1—3]. Fungal infections, particularly yeast infec-

tion of the scalp that range from mild scaling lesions to a

tions, represent the most widespread and prevalent mycotic

highly inflammatory reaction and usually caused by Micro-

diseases of man and animals [4]. Despite aggressive treat-

sporum or Trichophyton species) and (infection

ment with new licensed antifungal agents, these infections

may involve the trunk, shoulders and limbs and may range

are important causes of morbidity and mortality, especially

from mild to severe, commonly presenting as annular scaly

in immunocompromised patients [5].

lesions with sharply defined, raised, erythematous vesicular

Fungal infections are generally divided into four types;

edges) are most frequently seen in children. Tinea pedis

superficial, cutaneous, subcutaneous, and systemic mycosis.

(known also as Athlete’s foot in which toe webs and soles

Superficial and cutaneous infections are both sometimes

of the feet are most commonly affected with the common

referred to as superficial. Superficial mycoses are characte-

agents are T. rubrum, T. mentagrophytes var. interdigitale

rized by fungal invasion into the superficial stratum corneum

and E. floccosum) is more common in adults [11]. Tinea cruris

with little to no inflammatory response [6]. These infections

involve infections of groin, perianal and perineal sites and

are among the most common skin diseases affecting millions

most common in adult males, with T. rubrum and

of people throughout the world [7] and are common in hot and

E. floccosum are the most commonly implicated fungi.

humid climate of tropical countries [8]. Of these, onychomy-

Yeast pathogens include organisms from both Ascomycota

cosis is a fungal infection of nails caused by yeasts, derma-

(like Candida spp.) and Basidiomycota (like Cryptococcus

tophytic and non-dermatophytic fungi. The causative agents

spp.) phyla. is caused by species of Candida of onychomycosis of toenails (so called tinea unguium) are

168 A.H. Moubasher et al.

(most commonly C. albicans) that is part of the microbiome mycologically positive when fungal elements such as

in the human gastrointestinal tract (including the mouth) hyphae, spores, or yeast cells are observed.

and the vagina. Candida species are one of the largest groups

of pathogenic fungi with C. albicans, C. glabrata, Culturing

C. parapsilosis, C. tropicalis and C. krusei being the most Skin scrapings, hairs, pus, and nail fragments were placed on

common pathogens [12]. Also, of Rhodotorula, the surface of two types of media; Sabouraud Dextrose Agar

R. mucilaginosa, R. glutinis, and R. minuta are known to (SDA) which contained (g/L): glucose, 20; peptone, 10; agar,

cause disease in humans [13]. Species of Rhodotorula have 20; chloramphenicol 250 mg/L, and SDA supplemented with

been recognized as emerging yeast pathogens in humans in 0.5 g/L cycloheximide to reduce saprobic fungi. Cultures

the last three decades. While no cases of Rhodotorula were incubated at 25 8C for up to 4 weeks during which

infection were reported in the medical literature before the growing fungi were examined and identified. Pure cultu-

1985, the number of infections increased after that time, res were prepared for further investigations.

most likely because of the wider use of intensive treatments

and central venous catheters (CVCs) [14]. Trichosporon Phenotypic identification of the human pathogenic

contains also emerging opportunistic pathogens of humans, fungi

and is the third most commonly isolated non-candidal yeast. The fungi were identified based on their macro- and micro-

Trichosporon asahii and T. asteroides are the most impor- scopical features following the keys of [20] for dermatophy-

tant species causing disseminated disease in immunocom- tic and other opportunistic pathogens [21,22] for non-

promised patients [15]. dermatophytes and Barnett et al. [23], for yeasts.

Not many reports on superficial fungal infections are pre-

sented in Assiut [16—19]. This investigation comprises cases Physiological characterization of yeast strains

of superficial fungal infections referred to Assiut University Fermentation of sugars and oxidative utilization of carbon

Mycological Centre from Skin and Venereology Clinic at Assiut compounds were performed according to Barnett et al. [23].

University Hospitals and some other private clinics in the city. Assimilation of nine nitrogen compounds (potassium nitrate,

The aim was to identify and assess the incidence of the causal sodium nitrite, ethylamine, L-lysine, creatine, creatinine, D-

agents from dermatophytes, non-dermatophytes and yeasts glucosamine, imidazole, or D-tryptophan) was determined

in Assiut Governorate employing, beside the morphological [24]. Growth at high osmotic pressure, growth in the pre-

and physiological techniques, the genotypic ones. sence of cycloheximide and production of extracellular

starch-like compounds were also tested [24]. Identification

keys of Barnett et al. [23] were followed to assign each

Materials and methods

isolate to its species level. Confirmations of these identifi-

cations were carried out using the molecular technique.

Clinical examination and specimen’s collection

Biochemical activities were not performed for only 2 yeast

strains and these were identified genotypically.

Patients suggestive to have onyxis (onychomycosis) or alo-

pecia (tinea capitis, tinea corporis, tinea cruris and tinea

Genotypic identification of yeast strains

pedis) were clinically examined and diagnosed by dermato-

logists at Skin and Venereology Clinic, Assiut University

Growth of yeasts and DNA extraction

Hospitals or at some other private dermatology clinics in

The yeast strains were grown on yeast extract malt extract

the city. They were guided to Assiut University Mycological

agar (YM) plates and incubated at 25 8C for 2 days. A small

Centre (AUMC) for direct microscopic examination, culturing

amount of yeast growth was scraped and suspended in 100 mL

and identification of the causal agents. The study was carried

of distilled water and boiled at 100 8C for 15 minutes and

out during the period from February 2012 to October 2015.

stored at 70 8C.

Samples from infected nails, skin and hair were taken from

Yeast DNA was extracted and isolated using SolGent

125 patients. The surface of the affected area was first

purification bead in SolGent Company (Daejeon, South

scrubbed with cotton swab moistened with 70% ethyl alcohol

Korea). Internal transcribed spacer (ITS) sequences of

prior to sampling. Sterile scalpel, small Petri dish (4 cm

nuclear rDNA were amplified using primers ITS1, ITS4 as

diam.), glass slides, nail clipper and needles were used to 0

follow: universal primer ITS 1 (5 -TCC GTA GGT GAA CCT

collect skin scrapings, pus, hair fragments and cuttings from 0 0 0

GCG G-3 ), and ITS 4 (5 -TCC TCC GCT TAT TGA TAT GC-3 ).

finger or toenails. These samples were placed separately

Then amplification was performed using the polymerase

inside sterile plates, labeled with the required information

chain reaction (PCR) (ABI, 9700). The PCR reaction mixtures

about each patient.

were prepared using Solgent EF-Taq as follows: 10X EF-Taq

buffer 2.5 mL, 10 mM dNTP (T) 0.5 mL, primer (F-10p) 1.0 mL,

Mycological examination and culturing of primer (R-10p) 1.0 mL, EF-Taq (2.5U) 0.25 mL, template

specimens 1.0 mL, DW to 25 mL. Then, the amplification was carried

out using the following PCR reaction conditions: one round of

Direct microscopic examination (DME) amplification consisting of denaturation at 95 8C for 15 min

Wet slide preparations were made from each sample. The followed by 30 cycles of denaturation at 95 8C for 20 s,

slide preparation was treated with few drops of 20% annealing at 50 8C for 40 s and extension at 72 8C for

aqueous potassium hydroxide (KOH) and lactophenol cot- 1 min, with a final extension step of 72 8C for 5 min.

ton blue (LPCB), then gently heated to clear the material The PCR products were then purified with the SolGent PCR

and microscopically examined. Samples were regarded as Purification Kit-Ultra prior to sequencing. Then, the purified

Diversity of mycobiota in superficial infections 169

PCR products were reconfirmed (using size marker) by elec- (Table 1). The majority of cases of onychomycosis were

trophoresis of the PCR products on 1% agarose gel. Then, observed in adults with ages from 21 to 30 years while the

these bands were eluted and sequenced. Each sample was cases of tinea capitis were common in children under the age

sequenced in the sense and antisense direction. of 10 years, and those of tinea corporis were common in

children under the age of 10 years and adults over 50 years.

Phylogenetic analysis

Contigs were created from the sequence data using CLCBio

Identification of the etiologic agents

Main Workbench program. The sequence obtained from each

strain was further analyzed using BLAST from the National

The mycological analysis of the skin and nail samples revealed

Center of Biotechnology Information (NCBI) website.

the isolation of 51 fungal species and 1 variety belonging to 30

Sequences obtained along with those retrieved from Gen-

genera (6 species dermatophytic, 27 species and 1 variety of

Bank database were subjected to Clustal W analysis using

non-dermatophytic and 18 species of yeasts) (Table 2). The

MegAlign (DNAStar) software version 5.05 for the phyloge-

identification of dermatophytic and non-dermatophytic was

netic analysis. Sequence data were deposited in GenBank

based on their phenotypic (macro- and maicroscopic) featu-

and accession numbers are given for them.

res. Yeast identification was based on the phenotypic, phy-

siological and biochemical characteristics (Table 3) and was

Results

also confirmed by sequencing the ITS region of rRNA genes

(Table 4). Data presented in Table 3 revealed that Candida

Incidence of superficial mycoses species (and their teleomorphs nos. 1—12) and other yeast

species (nos. 13—19) gave same results with some tests,

During the period from February 2012 to October 2015, it was however many tests could be species-specific and these were

possible to study 125 of cases suggestive to have mycotic skin fermentation of D-glucose, assimilation of D-galactose,

diseases (onyxis or alopecia) in Assiut Governorate. Onycho- L-sorbose, D-glucosamine, D-ribose, L-arabinose, L-rham-

mycosis was the most common disease affecting 64.8% of the nose, sucrose, a, a-trehalose, methyl-a-D-glucoside, cellu-

total cases followed by tinea capitis (17.6%) and tinea cor- lose, salicin, arbutin, lactose, raffinose, melezitose, soluble

poris (8.8%). Madura foot was less frequently diagnosed starch, meso-erythritol, D-glucitol, D-mannitol, D-gluconate,

representing 3.2% while tinea amiantacea and oral candidia- D-glucuronate, citrate, butane 2, 3 diol, growth on cyclohe-

sis were isolated each from 1.6% of total cases. Tinea cruris, ximide, 60% D-glucose and 10% NaCl. It is interesting to report

tinea incognito and tinea pedis were represented each by one that assimilation of nitrogen sources tested were not diffe-

case (0.8% of total cases). rentiating for Candida species investigated, but only nitrite

Direct microscopic preparations showed only 45 positive was diagnostic for both Trichosporon species from all other

cases for fungal elements (Table 1). However, 96 cases out of yeasts. In addition, the following tests were diagnostic to

the 125 cases showed positive cultures while 29 cases were some species such as D-xylose (for S. fibuligera), xylitol

culture-negative. From these 82 cases emerged one fungus and (D. australiensis and G. candidus), galactitol (T. asahii),

14 cases showed mixed fungi. Five cases were due to mixed myo-inositol (S. fibuligera and T. dohaense) and 50%

yeast species, 4 cases were due to mixed filamentous fungal D-glucose (G. candidus and T. asahii). Representative strains

species, and 5 cases were due to yeast and filamentous fungi of all species encountered are deposited at the Culture

(Table 1). Some cases which proven fungal elements by DME Collection of Assiut University Mycological Center (AUMC)

were also culture-negative and they admitted that they did not and for yeast strains, the ITS gene sequences are deposited

stop the medical treatment at the time of sampling. However, at the National Center for Biotechnological Information

most cases were positive at least by one of both methods. (NCBI) GenBank and given accession numbers.

Incidence of superficial mycoses in relation to

Incidence and diversity of fungal species isolated

sex of patients

from the investigated cases

Superficial infections were more frequently encountered in

Results demonstrated that yeasts were the leading agents of

females than males (60.8% versus 39.2%). This trend was

superficial mycosis (recovered from 44 cases out of 125

markedly observed in cases of tinea capitis (63.64% versus

studied) followed by non-dermatophytic (39 cases) and der-

36.36%), onychomycosis (61.73% versus 38.27%), while in

matophytic species (17 cases), some of the cases with multi-

tinea amiantacea the numbers of females and males were

ple agents.

almost equal. On the other hand, males outnumbered fema-

Yeasts were cultured from 46.02% of total cases. They

les in cases of madura foot (75% versus 25%) and tinea

mostly affected nails (34 out of 59 cases) then tinea capitis

corporis (54.55% versus 45.45%). Oral candidiasis, tinea cru-

(7 out of 22), tinea corporis (3 out of 11), madura foot (2 out

ris, tinea incognito, and tinea pedis were encountered in

of 4) and the cases of tinea amiantacea (1 out of 1), tinea

females only (Table 1).

cruris (1 out of 1) and oral candidiasis (2 out of 2). Candida

was the leading yeast fungus affecting 23.01% of patients.

Incidence of superficial mycoses in relation to Candida parapsilosis was the main Candida species affecting

age of patients 14.16% of the patients, followed by C. albicans (4.42%),

and C. metapsilosis (1.76%). Rhodotorula mucilaginosa

Superficial infections showed marked variations in their dis- was isolated from 5.31% of total cases, followed by Saccha-

tribution among the different age groups of patients romycopsis (represented by S. fibuligera) and Geotrichum 170

Table 1 Distribution of onychomycosis and skin mycoses according to sex, age and number and % of positive cases. Re´partition de l’onychomycose et des mycoses cutane´es selon le sexe, l’aˆge et le nombre de % de cas positifs.

Clinical diagnosis Number Percentage Sex Age group DME; direct Culture (suggestive to be) of cases of total by years examination Positive Negative cases ,< 10 11—20 21—30 31—40 41—50 > 50 +ve % +ve +ve % +ve One Mixed ve % ve fungus fungi

Onychomycosis 81 64.80 50 31 10 15 27 12 9 8 21 25.92 59 72.84 49 10 22 27.16 Tinea capitis 22 17.60 14 8 12 5 — 41— 15 68.18 19 86.36 17 2 3 13.14 Tinea corporis 11 8.80 5 6 3 1 2113654.54 9 81.82 7 2 2 18.18 Pityriasis 2 1.6 1 1 1 1 —————— 1501 — 150 amiantacea Tinea cruris 1 0.8 1 —— — 1 ————— 1 100 1 ——— Tinea incognito 1 0.8 1 —— — — 1 ———— 1 100 1 ——— Tinea pedis 1 0.8 1 —— — — — 1 ——— 1 100 1 ——— Oral (tongue) 2 1.6 2 — 11 ———- 2 100 2 100 2 ——— candidiasis Madura foot 4 3.2 1 3 —— 11— 21253753 — 125 Total 125 100 76 49 27 23 31 19 12 13 45 36 96 76.80 82 14 29 23.2

+ve: posituve; ve: negative. A.H.

Moubasher

et

al.

Diversity of mycobiota in superficial infections 171

Table 2 Clinical finding (onyxis or alopecia) of patients together with their causal agents (either caused by one or more fungal

species) as revealed by culturing and/or direct microscopic examination (DME).

Clinique (onyxis ou alope´cie) des patients ainsi que de leurs agents causals (soit cause´s par une ou plusieurs espe`ces fongiques)

comme re´ve´le´ par culture et/ou examen microscopique direct.

Clinical finding Patient Causal agents by culturing DME

(Number of cases) Age/sex

Onyxis (suggestive to be Cases by one fungus (49)

onychomycosis) (81) 28/M Trichophyton rubrum (Castellani) Semon

12/M T. terrestre

6/M Ascotricha chartarum L. Ames

19/F Aspergillus clavatus Desmazieres +

6/F A. flavus Link

26/M A. flavus Link +

6/M A. flavus Link

47/F A. flavus Link +

28/M A. flavus Link

28/M A. flavus Link

35/M A. flavus var. columnaris Raper & Fennell

34/M A. fumigatus Fresenius

19/M A. niger van Tieghem

40/F A. niger van Tieghem

35/M A. niger van Tieghem

6/F A. niger van Tieghem

27/F A. niger van Tieghem

26/F A. terreus Thom

31/F Chaetomium sp. +

23/F Eurotium amstelodami Mangin

28/F Exophiala dermatitidis (Kano) de Hoog +

42/M Fusarium solani (Martius) Saccardo +

48/F Geomyces pannorum (Link) Sigler & J.W. Carmichael

48/F Rhizopus oryzae Went & Prinsen-Geerligs

26/F Scopulariopsis near to S. chartarum +

3/F Sterile mycelium

10/F Candida albicans (Robin) Berkhout +

6/F C. albicans (Robin) Berkhout +

31/F C. galli Péter, Dlauchy, Vasdinyei, Tornai-Lehoczki +

& Deák

42/F C. metapsilosis Tavanti, Davidson, Gow, Maiden & Odds +

28/M C. metapsilosis Tavanti, Davidson, Gow, Maiden & Odds +

26/F C. parapsilosis (Ashford) Langeron & Talice

48/F C. parapsilosis (Ashford) Langeron & Talice

54/M C. parapsilosis (Ashford) Langeron & Talice

29/F C. parapsilosis (Ashford) Langeron & Talice

21/M C. parapsilosis (Ashford) Langeron & Talice

19/F C. parapsilosis (Ashford) Langeron & Talice +

20/F C. parapsilosis (Ashford) Langeron & Talice

21/F C. parapsilosis (Ashford) Langeron & Talice

35/M C. parapsilosis (Ashford) Langeron & Talice

29/F Clavispora lusitaniae Rodrigues de Miranda

6/M Geotrichum candidum Link

58/F Pichia kudriavzevii Boidin, Pignal & Besson +

14/M P. sporocuriosa Péter, Tornai-Lehoczki & Vitányi

24/F Rhodotorula mucilaginosa (Jorgensen) Harrison

41/F Rhodotorula mucilaginosa (Jorgensen) Harrison

27/M Saccharomycopsis fibuligera (Lindner) Klöcker

20/F Trichosporon asahii Akagi ex Sugita, Nishikawa & Shinoda

40/F T. dohaense Taj-Aldeen, Meis & Boekhout

Mixed cases (10)

27/F Aspergillus niger + Embellisia sp. + Mucor racemosus +

+ Syncephalastrum racemosum

22/M Acremonium strictum + Alternaria alternata +

47/F Monascus ruber + Aspergillus terreus +

4/M Trichophyton sp. + Saccharomycopsis fibuligera

29/F Aspergillus niger + C. lustianae

172 A.H. Moubasher et al.

Table 2 (Continued )

Clinical finding Patient Causal agents by culturing DME

(Number of cases) Age/sex

26/F Ulocladium tuberculatum + Rhodotorula mucilaginosa

28/F Candida deformans + R. mucilaginosa +

20/F Geotrichum candidum + Kluveromyces lactis +

59/M R. mucilaginosa + C. parapsilosis +

39/F A. niger van Tieghem + R. mucilaginosa +

Tinea capitis (22)

Cases by one fungus (17 cases)

5/F Microsporum canis Bodin +

6/F Microsporum canis Bodin

8/M Microsporum canis Bodin

16/F Trichophyton violaceum +

12/F Trichophyton violaceum +

12/M Trichophyton violaceum +

7/M Trichophyton violaceum +

3.5/F T. schoenleinii (Lebert) Langeron & Miloch. ex Nann. +

5.5/F T. schoenleinii (Lebert) Langeron & Miloch. ex Nann. +

7/F Alternaria alternata (Fries) Keissler +

35/M Aspergillus sp. +

9/F Scopulariopsis brevicaulis (Sacc.) Bainier

10/F Candida albicans (Robin) Berkhout +

38/F Saccharomycopsis fibuligera (Lindner) Klöcker

20/F C. carpophila (Phaff & M.W. Mill.) Vaughan-Mart., +

Kurtzman, S.A. Mey. & E.B. O’Neill

35/F C. carpophila (Phaff & M.W. Mill.) Vaughan-Mart., +

Kurtzman, S.A. Mey. & E.B. O’Neill

44/M C. parapsilosis (Ashford) Langeron & Talice +

Mixed cases (2 cases)

7m/F Trichophyton sp. + C. parapsilosis +

5/F Dipodoascus australiensis + K. lactis +

Tinea corporis (11) Cases by one fungus (7 cases)

5.5/F T. schoenleinii (Lebert) Langeron & Miloch. ex Nann. +

12/M Trichophyton violaceum

28/M Trichophyton violaceum +

61/M Trichophyton violaceum +

51/M E. spinifera (Nielsen & Conant) McGinnis +

47/M Scopulariopsis candida

34/F C. parapsilosis (Ashford) Langeron & Talice

Mixed cases (2 cases)

21/F Thermoascus auranticus + Aspergillus campestris +

2d/boy M. caribica + C. parapsilosis +

Cases by one fungus

Tinea amiantacea (2) 11/M Saccharomycopsis fibuligera (Lindner) Klöcker

Tinea cruris (1) 28/F Lodderomyces elongisporus (Recca & Mrak)

van der Walt

Tinea incognita (1) 40/F Alternaria alternata (Fries) Keissler

Tinea pedis (1) 50/F Fusarium solani (Martius) Saccardo

Oral candidiasis (2) 10/F Candida albicans (Robin) Berkhout +

20/F Candida albicans (Robin) Berkhout +

Madura foot (4) 52/F C. parapsilosis (Ashford) Langeron & Talice +

59/M C. parapsilosis (Ashford) Langeron & Talice

39/F Aspergillus terreus Thom

Total positive cases (125) 96 culture-positive 45

(14 mixed cases + 82

caused by one fungus)

Total number of 6

dermatophytic species

Total number of 27 + 1 variety

non-dermatophytic species

Total number of yeast species 18

F: female; M: male.

Diversity of mycobiota in superficial infections 173

Table 3 Physiological comparison of strains tested of the most recorded yeast species.

Comparaison physiologique des souches teste´es des espe`ces enregistre´es.

Test/Species strain number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Fermentation (D-glucose) + + + + + + + + + w

Assimilation of carbon compounds

D-glucose + + + + + + + + + + + + + + + + + + +

D-galactose + w + + + + + + + + + + + + + + +

L-sorbose + + + + + + + + w + + +

D-glucosamine + + + + + w w w w + w + +

D-ribose + + + + + + + w + + +

D-xylose + + + + + + + + + + + + + + + + + +

L-arabinose + + + + + w + + + w + w + + +

L-rhamnose + w + + + + w + + w

Sucrose + + + + + + + + + + + + + + +

Maltose + w + + w + + + + + + w w + w + + + +

a, a-trehalose + + + + + + + + + + + + w + w + +

Methyl-a-D-glucoside + + + + + + + + + + w + + + + +

Cellobiose + + + + + w w + + + + +

Salicin + + w w + + + w + + + +

Arbutin + * w + + + + + + + +

Lactose + + + +

Raffinose + + + + + + +

Melezitose + + + + + + + + + w + + + +

Inulin + + + + + + + + + + + + + + + + + + +

Soluble starch + W + + + + +

Glycerol + + + + + + + + + + + + + + + + + + +

Meso-erythritol + + w + w + + +

Ribitol + + + + + + + + + + + + + + + + + + +

Xylitol + w + + + + + + + + + + + + w + +

D-glucitol + + + + + + + + + + + + + + + + + w

D-mannitol + + + + + + + + + + + + + + + + + +

Galactitol + +

Myo-inositol + +

Glucono-d-lactone + + + + + + + + + + + + w + + +

2-keto-D-gluconate + + + + + + + + + + + + + + + + + +

D-gluconate + + + + + + + + + + + w + + + + + +

D-glucuronate + + + + +

D-galacturonate w + w + + + w

DL-lactate + + + + + + w w w + + + + + + + w + +

Succinate + + + + + + + + + + + + + + + + + + +

Citrate + + + + + + + + + + + + + + + + + +

Methanol w

Ethanol + + + + + + + + + + + + + + + + + + w

Propane 1,2 diol + w w +

Butane 2,3 diol + w w w w + + + + + + + +

Quinic acid w +

Nitrogen compound

Nitrate w

Nitrite + +

Ethylamine + + + + + + + + + + + + + + + + + + +

L-lysine + + + + + + + + + + + + + + + w + + +

Creatine

Creatinine

D-glucosamine w w w + + + + + + + + + w w + w + + w

Imidazole

D-tryptophane + + + + + + + w w w + + + + + w + + +

Miscellaneous

0.01% cycloheximide + + + + + + + + + + + w

0.1% cycloheximide + + + + + + + + + + +

50% D-glucose + + + + + + + + + + + + + + +

174 A.H. Moubasher et al.

Table 3 (Continued )

Test/Species strain number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

60% D-glucose + + + + + + + +

10% NaCl + + + + + + +

16% NaCl

Starch formation

Species: 1 Candida albicans AUMC10216, 2 C. deformans (teleomorph: Yarrowia deformans M. Groenewald & M.T. Smith) AUMC8796, 3

C. fermentati (Saito) Bai (teleomorph: Meyerozyma caribbica) AUMC10214, 4 C. galli AUMC8769, 5 C. krusei (Castellani) Berkhout

(teleomorph: Pichia kudriavzevii) AUMC10190, 6 C. lusitaniae van Uden & do Carmo-Sousa (teleomorph: Clavispora lusitaniae) AUMC10210,

7 C. metapsilosis Tavanti AUMC10208, 8 C. orthopsilosis Tavanti, Davidson, Gow, Maiden & Odds (teleomorph: Lodderomyces elongisporus)

AUMC10194, 9 C. parapsilosis AUMC10209, 10 C. parapsilosis AUMC10219, 11 C. sphaerica (B.W. Hammer & Cordes) S.A. Mey. & Yarrow

(teleomorph: Kluyveromyces lactis) AUMC8993, 12 C. sphaerica AUMC9870, 13 Geotrichum australiensis (teleomorph: Dipodascus

australiensis Von Arx and Barker) AUMC9871, 14 G. candidum (Tel.: Galactomyces candidus de Hoog & Smith) AUMC8995, 15

G. candidum AUMC10304, 16 Rhodotorula mucilaginosa AUMC9296, 17 Saccharomycopsis fibuligera AUMC10213, 18 Trichosporon asahii

AUMC10195, and 19 T. dohaense AUMC10212.

+: growth; w: weak growth; : no growth.

(2 species), emerging each from 3.54%. Pichia and Trichos- tinea corporis. Madura foot was less frequently diagnosed

poron (2 species each), Clavispora lusitaniae and Kluyvero- while tinea amiantacea, oral candidiasis, tinea cruris, tinea

myces lactis affected each 1.76% of total cases. Other yeast incognito and tinea pedis were rarely encountered. Superfi-

species were responsible each for only one case of onycho- cial infections were more frequently encountered in females

mycosis (Candida deformans, C. galli, Pichia kudriavzevii, than males (61.73% versus 38.27%). This trend was markedly

P. sporocurirosa, Trichosporon ashii and T. dohaense), tinea observed in cases of tinea capitis and onychomycosis, while

capitis (Candida carpophila, Geotrichum australiensis), in tinea amiantacea the numbers of females and males were

tinea corporis (Meyerozyma caribbica) and tinea cruris (Lod- almost equal. In agreement with the current results, females

deromyces elongisporus) (Table 2). were more commonly affected than males (65.6% versus

Non-dermatophytic fungi were isolated from skin and nail 34.4%) in studies on onychomycosis in Guatemala City [25]

mycosis in the present work (38.05% of patients), appearing and in tropical climate [26] (50.2% versus 49.8%), and in

in most cases of onychomycosis (37 cases), tinea capitis (3), cutaneous fungal infections (60.9% versus 39.1%) in Iran [27].

tinea corporis (3) and only one case of each tinea incognita However, males outnumbered females in onychomycosis in

and madura foot. Among the non-dermatophytic fungi, Rajasthan, India (63.63% versus 36.37%) [9] and Singapore

Aspergillus was recovered from 19.47% of total cases; most (53.7% versus 46.3%) [28] and in superficial infections in Peru

of them were onychmycosis but only one case of tinea capitis (64% versus 36%) [29], Serbia (57% versus 43%) [30] and India

and one case of Madura foot. A. niger was the most common (62% versus 38%) [31].

Aspergillus species affecting 7.08% of the patients, followed The majority of cases of onychomycosis were observed in

by A. flavus (5.31%), and A. terreus (2.65%). Species of adults with ages from 21 to 30 years while tinea capitis were

Alternaria (A. alternata), Exophiala (E. dermatitidis, common in children under the age of 10 years, and those of

E. spinifera), Scopulariopsis (S. candida, S. brevicaulis and tinea corporis in children under the age of 10 years and adults

Scopulariopsis near to S. chartarum) and Fusarium (F. solani) over 50 years. However, the majority of onychomycosis cases

were responsible for 1.76, 1.76%, 2.65 and 1.76% of the total were between ages 50—69 years (51.9%, n = 120) in the study

cases, respectively. The remaining fungal species listed in of Leelavathi et al. [26] and between 41 to 65 years (46.9%) in

Table 2 were isolated each from one case. Guatemala City [25]. Dermatomycoses were most seen in the

Dermatophytic fungi appeared in 15.93% of cases studied, age group of 20—40 years in India [31].

most of them were suffering from tinea capitis, followed by Fifty-one fungal species and 1 variety belonging to 30

tinea corporis and onychomycosis. They were represented by genera (6 species and one unidentified dermatophytic, 27

two genera Trichophyton (5 species) and Microsporum species and 1 variety of non-dermatophytic and 18 species of

(1 species). Trichophyton violaceum (isolated from 6.19% yeasts) were recovered. Candida species and other yeast

of total cases) followed by T. schoenleinii (2.65%) were species gave same results with some physiological tests,

involved in cases of tinea capitis and tinea corporis, while however many tests could be species-specific. It is interest-

T. rubrum, T. terrestre were isolated each from only one ing to report that assimilation of nitrite is diagnostic for both

onychomycosis case. Microsporum canis was recovered only Trichosporon species from all other yeasts. In addition, some

from cases with tinea capitis, representing 3.54% of total tests are diagnostic such as D-xylose (for S. fibuligera),

cases (Table 4). xylitol (D. australiensis and G. candidus), galactitol

(T. asahii), myo-inositol (S. fibuligera and T. dohaense)

and 50% D-glucose (G. candidus and T. asahii).

Discussion

Yeasts were the most commonly isolated from superficial

mycosis followed by non-dermatophytic and dermatophytic

One hundred and twenty-five cases suggestive to have myco- species. They mostly affected nails then tinea capitis, tinea

tic skin diseases were studied of which onychomycosis was corporis and Madura foot. Candida was the leading yeast

the most common disease, followed by tinea capitis and affecting 23.01% of patients. Candida parapsilosis was the Diversity Table 4 Assiut University Mycological Centre accession numbers (AUMC) of yeast strains isolated from superficial infections with accession GenBank numbers given together with the closest match in the GenBank database and sequence similarity in percent to the match as inferred from Blastn searches of ITS sequences. Assiut University Mycological Centre (AUMC) nombre d’accession de souches de levure isole´es` a partir d’infections superficielles avec adhe´sion, ainsi que la correspondance la plus proche dans la base de donne´es GenBank et la similarite´ de se´quence en pourcentage` a la correspondance, comme le de´duit la recherche Blastn des se´quences ITS. of

mycobiota AUMC number Clinical finding Patient Accession Length (bp) Closest Sequencing Species Age/sex GenBank Genbank similarity (%) number match # ITS

in

Dematiaceous hyphomycetes 8807 Fingernail onychomycosis 28/F KU095856 661 CBS 139110 = KP658832 655/658 (99.54) Exophiala dermatitidis superficial CBS207.35 = NR_121268 638/639 (99.84) 9369 Tinea corporis 51/M KU052791 606 R68E3 = KC445294 604/607 (99.51) E. spinifera (chromoblastomycosis)

CBS899.68T = NR_111131 536/539 (99.44) infections Ascomycetous yeasts 8996 Tinea capitis 10/F KU095863 541 ZA046 = FJ662406 539/541 (99.63) Candida albicans

10189 Oral (tongue) candidiasis 20/F KU095860 543 ZB081 = JN606308 540/542 (99.63) Candida albicans 10216 Fingernail onychomycosis 6/F KU200444 542 ZB080 = JN606307 539/539 (100) Candida albicans 8881 Tinea capitis (favus) 35/F KU095858 610 PMM10-1535N2-L = KP131683 505/507 (99.61) Candida carpophila 8796 Fingernail onychomycosis 28/F KU052793 359 SM21 = FJ515168 351/359 (97.77) Candida deformans (Yarrowia deformans) 10214 Tinea corporis 2 days/M KU200440 614 UFLA CWFY11 = KM402049 608/614 (99.02) Candida fermentati (Meyerozyma caribbica) PMM08-431L = KP132411 597/599 (99.67) 8769 Fingernail onychomycosis 31/F KU200447 354 WM 07.4 = FM178330 352/353 (99.72) Candida galli CBS9722T = NR_077078 340/341 (99.71) 10190 Fingernail onychomcosis 58/F KU095862 513 KDLYL17-1 = JX174414 510/513 (99.42) Candida krusei (Pichia kudriavzevii) ATCC 24210 = AY939808 508/511 (99.41) 10210 Fingernail onychomycosis 29/F KU200437 387 LMICRO133 = KJ451657 385/386 (99.74) Candida lusitaniae (Clavispora lusitaniae) 10208 Fingernail onychomycosis 42/F KU200445 535 LEMI8448 = JQ585714 527/533 (98.87) Candida metapsilosis CBS 10907 = FJ872019 526/532 (98.87) 10194 Tinea cruris 28/F KU095861 558 ZA013a = JN606251 556/558 (99.64) Candida orthopsilosis (Lodderomyces elongisporus) CBS 2605T = AY391848 555/558 (99.46) 8880 Fingernail onychomycosis 20/M KU176112 527 ZA044 = FJ662417 525/527 (99.62) Candida parapsilosis 8904 Fingernail onychomycosis 20/F KU095857 523 CBS 604T = AY391843 521/522 (99.81) Candida parapsilosis 9171 Madura foot 52/M KU200441 528 CBS 604T = AY391843 523/525 (99.62) Candida parapsilosis 9295 Fingernail onychomycosis 59/M KU052789 524 CBS 604T = AY391843 520/523 (99.43) Candida. parapsilosis 10197 Foot ulcer 59/M KU176110 526 CBS 604T = AY391843 524/525 (99.81) Candida parapsilosis 10209 Tinea capitis 7 month/F KU200436 525 AUMC9295 = KU052789 520/521 (99.81) Candida parapsilosis CBS 604T = AY391843 519/521 (99.24) T 10215 Tinea corporis 2 days/M KU200443 526 CBS 604 = AY391843 524/525 (99.81) Candida parapsilosis 175 10217 Tinea capitis 44/M KU200449 524 AUMC9295 = KU052789 522/524 (99.62) Candida. parapsilosis 176

Table 4 (Continued ) AUMC number Clinical finding Patient Accession Length (bp) Closest Sequencing Species Age/sex GenBank Genbank similarity (%) number match # ITS CBS 604T = AY391843 521/523 (99.62) 10219 Fingernail onychomycosis 29/F KU255845 525 CBS 604T = AY391843 522/524 (99.62) Candida parapsilosis 10220 Toenail onychomycosis 19/F KU255846 526 AUMC9295 = KU052789 522/525 (99.43) Candida parapsilosis CBS 604T = AY391843 522/525 (99.43) 8993 Fingernail onychomycosis 20/F KU176113 725 PMM10/410L = KP132318 708/710 (99.72) Kluyveromyces lactis (Candida sphaerica) 9870 Tinea capitis 6/F KU193761 723 Y3-3 = KF646180 707/709 (99.72) Kluyveromyces lactis (Candida sphaerica) PMM10/410L = KP132318 706/709 (99.58) 9871 Tinea capitis 6/F KU132331 374 V/2/08 = HQ115737 363/364 (99.73) Geotrichum australiensis 8995 Fingernail onychomycosis 20/F KU176111 379 CBS 11176 = JN974290 374/375 (99.73) Geotrichum candidum 10304 Fingernail onychomycosis 6/M KU252879 380 CBS 11176 = JN974290 365/380 (96.05) G. candidum (Galactomyces candidus) CBS 557.83T = JN974288 352/381 (92.39) 10359 Toenail onychomycosis 14/M KU255847 478 G5 = EU315763 409/438 (93.38) Pichia sporocuriosa 8882 Fingernail onychomycosis 4/M KU200442 657 3-1Y = KF717373 654/658 (99.39) Saccharomycopsis fibuligera AUMC 9092 = KU052788 644/645 (99.85) 9092 Fingernail onychomycosis 27/M KU052788 662 3-1Y = KF717373 655/660 (99.24) Saccharomycopsis fibuligera 10213 Tinea capitis 38/F KU200439 646 AUMC 9092 = KU052788 645/646 (99.85) Saccharomycopsis fibuligera 3-1Y = KF717373 644/646 (99.69) 10218 Tinea amiantacea 11/M KU255844 660 3-1Y = KF717373 642/643 (99.84) Saccharomycopsis fibuligera Basidiomycetous yeasts 8770 Fingernail onychomycosis 31/F KU200448 622 CBS 316T = NR_073296 615/618 (99.52) Rhodotorula mucilaginosa 8795 Fingernail onychomycosis 28/F KU052792 620 CBS 316T = NR_073296 612/618 (99.03) Rhodotorula mucilaginosa 9296 Fingernail onychomycosis 59/M KU052790 615 CBS 316T = NR_073296 605/609 (99.34) Rhodotorula mucilaginosa 9298 Fingernail onychomycosis 24/F KU200446 620 CBS 316T = NR_073296 615/618 (99.52) Rhodotorula mucilaginosa 10195 Fingernail onychomycosis 20/F KU095859 548 CBS 2479T = NR_073341 540/542 (99.63) Trichosporon asahii T 10212 Fingernail onychomycosis 40/F KU200438 548 CBS10761 = HQ263355 516/516 (100) Trichosporon dohaense A.H.

F: female; M: male. Moubasher

et

al.

Diversity of mycobiota in superficial infections 177

main yeast species affecting 14.16% of the patients, followed (by E. spinifera) confirming earlier reports on onychomycosis

by Rhodotorula mucilaginosa (5.31%), C. albicans (4.42%) and phaeohyphomycosis [20,43,44]. Species of Aspergillus

and Saccharomycopsis (represented by S. fibuligera) and (mainly A. niger, A. flavus, A. candidus), Scopulariopsis

Geotrichum (2 species) (3.54% each). Of these, 3 species (mainly S. brevicaulis), Alternaria (mainly A. alternata),

were reported for the first (Saccharomycopsis fibuligera Fusarium (mainly F. solani, F. verticillioides,

from two onychomycosis cases, one tinea capitis and one F. oxysporum), Acremonium (mainly A. strictum), Syncepha-

tinea amiantacea) or second time from clinical specimens lastrum (S. racemosum) or Ulocladium (U. tuberculatum,

[32], Trichosporon dohaensis from a case with onychomyco- U. chartarum) were reported earlier frequently from finger-

sis after its original description in 2009 by Taj-Aldeen et al. nail or toenail onychomycosis [7—9,25,26,30,31,35,45—59].

[33]; and Candida galli as the second case of onychomycosis New and emerging fungal opportunists are being encountered

after its isolation from tinea ungunium in 2014 by Galan- commonly in many reports [2,20,36,45,54,55,59,60]. Inter-

Snchez et al. [34]. estingly, a case of onychomycosis of 19-year-old girl due to

Yeasts came in intermediate between non-dermatophytic Aspergillus clavatus is reported here for the second time

and dermatophytic fungi in their incidence as agents of worldwide after Falahati et al. [61]. In addition, a case of

onychomycosis in tropical climate and in Portugal in studies tinea corporis of 21-year-old woman due to Aspergillus cam-

of Leelavathi et al. [26] and Viegas et al. [35] with species of pestris with Thermoascus aurantiacus, both species are repor-

Candida (74.3% and 71.2% of total yeast cases) followed by ted here for the first time worldwide and probably both are

Rhodotorula (5.8%, 16.9%), Trichosporon (8.3% and 0%), and involved in infection.

Cryptococcus (0% and 6.8%, respectively) being the most Dermatophytic fungi appeared in 15.93% of cases studied,

common. However, in their review on onychomycosis, Wes- most of them were suffering from tinea capitis, followed by

terberg and Voyack [7] demonstrated that dermatophytes tinea corporis and onychomycosis. Trichophyton (5 species)

represented 80—90%, non-dermatophytes 2—10% and yeasts and Microsporum (1 species) were representatives of this

2—11% of onychomycosis cases. In studies in Peru [29] and group. Trichophyton violaceum followed by T. schoenleinii

Iran [27], yeasts affected 27.1% and 52.87% of the cases and Microsporum canis were involved in cases of tinea capitis

suffering from tinea pedis, onychomycosis and tinea versi- and or tinea corporis, while T. rubrum, T. terrestre were

color with species of Malassezia and Candida were the most isolated each from only one onychomycosis case. Trichophy-

common, while 72.41% and 35.63% of the cases were due to ton violaceum was mostly isolated from cases suffering from

species of Trichophyton or Epidermophyton. Despite its tinea capitis in Minia Governorate, Egypt [62], tinea capitis,

seldom report as an agent of onychomycosis in the past then tinea faciei, tinea corporis and tinea cruris in Ismailia,

3 decades, C. parapsilosis was considered thereafter as an Egypt [63,64]; Microsporun canis, M. gypseum, M. audouinii

emerging fungal pathogen [36] and ranked second after and T. verrucosum came next from tinea capitis in children

C. albicans in several reports [37—39]. In agreement with [64]. T. schoenleinii that was reported in the current work

the current observation that C. parapsilosis outranked from 2 cases of tinea capitis and one of tinea corporis was

C. albicans in onychomycosis, it was the most common also reported from a case of tinea capitis favosa from Tunisia

candidal species causing onychomycosis in Argentina and [65]. However, Bennasser and Grimalt [66] reported

Paraguay (37.7%), versus 22.0% for C. albicans [40], in Brazil T. tonsurans, followed by M. canis as the most common

(40.5% versus 31.5%) [41], and in Germany it was the leading causes of tinea capitis in childhood worldwide, but

yeast pathogen infecting fingernails (50%) and toenails (39%) T. mentagrophytes and T. violaceum were also involved.

and the second most common overall causative agent of Species of Trichophyton and/or Epidermophyton were

onychomycosis (12%), following the Tricho- also reported from cases of onychomycosis from Portugal

phyton rubrum [42]. However, in a study in Singapore, [35], Rajasthan, India [9]. T. rubrum followed by

C. albicans (78.7% of all Candida species isolated and T. mentagrophytes, and rarely T. tonsourans were identified

37.9% of all onychomycosis cases and most likely from from tinea pedis, onychomycosis and in Peru

fingernails) preceded T. rubrum (isolated from 44% of all [29]. Also, T. rubrum was the most predominant agent while

cases), and the non-dermatophytic Fusarium was encounte- other Trichophyton and Microsporum species were less

red from 5.6% of the cases [28]. However, species of Tri- common from various tinea infections in Gwalior, India

chophyton (50.9%) were the major agents of onychomycosis [67] or superficial infection in Singapore [28]. In a study

followed by species of non-dermatophytic (30.9%) then Can- between 1990 and 2001 involving 5077 nail samples in Ger-

dida (18.18%) in Rajisthan, India [9] with C. albicans being many, fungi were detected in 54% of the examined nail

the most prevalent (65% of the total Candida) followed by samples, and the causative agents of onychomycosis inclu-

C. glabrata (23%), and less commonly C. tropicalis (7%) and ded dermatophytes (68%), yeasts (29%), and moulds (3%)

C. parapsilosis (5%). [42], with the dermatophytic Trichophyton rubrum being

The present work revealed that non-dermatophytic fungi the leading pathogen infecting fingernails and toenails fol-

were isolated as the second group of fungi from skin and nail lowed by C. parapsilosis as the second most common cau-

mycosis. Aspergillus was isolated from 19.47% of total cases; sative agent of onychomycosis.

most of them were onychomycosis, with A. niger followed by

A. flavus and A. terreus being the most commonly isolated.

Conclusion

Species of Alternaria, Exophiala, Scopulariopsis and Fusarium

came after Aspergillus in infecting patients, while others

were responsible each for one case. Exophiala was involved Onychomycoses represented about two-third of the cases of

here in 2 cases, one of onychomycosis (by E. dermatiditis) the superficial infection studied followed by tinea capitis

and the other tinea corporis showing chromoblastomycosis (17.6%). Infections were more frequent in females than

178 A.H. Moubasher et al.

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and culturing are recommended for mycological evaluation

pathogens Trichosporon asahii and Trichosporon asteroides

of clinical specimens from superficial infections. Also in

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addition to the conventional methods, sequence analysis

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Netherlands/Universitat Rovira i Virgili, Reus, Spain; 2000.

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The authors declare that they have no competing interest. Doha: The Scientific and Applied Research Center, University of

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