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Mycology in the Philippines, Revisited

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Mycology in the Philippines, Revisited Jpn. J. Med. Mycol. Vol. 46, 71－76, 2005 ISSN 0916－4804 Review Mycology in the Philippines, Revisited Evangeline B. Handog and Johannes F. Dayrit Consultant Dermatologist, Section of Dermatology, Department of Health-Research Institute for Tropical Medicine Filinvest Corporate City, Alabang, Muntinlupa City, 1708, Metro Manila Abstract The warm tropical climate of the Philippines and its interaction with cultural practices, occupation and immune responsiveness contribute to the increased susceptibility of Filipinos to fungal infections. An investigation to determine the prevalence of fungal infections in dermatology training institutions over a 4-year period was conducted. The results showed that fungal infections rank as the second leading cause of consultation with a prevalence of 12.98%. Pityriasis versicolor （25.34%）, tinea corporis （22.63%）, tinea cruris （16.7%） and tinea pedis （16.38%） were the most frequently encountered cases. Fungal culture yield is low and Candida sp. is the most common isolate, obtained predominantly from specimens taken from the oral mucosa and nails. Candidiasis is still the most common opportunistic infection followed by coccidioidomycosis, cryptococcosis and aspergillosis. Imidazoles are the most commonly prescribed systemic and topical treatment by Filipino dermatologists. Initial data collected would serve as reference for future research and may be used to compare with epidemiologic data obtained from other Asian countries. Key words: mycology, Philippines, prevalence, tinea RITM）. Questionnaires were distributed in five INTRODUCTION accredited government institutions, 1 private The Philippines has a tropical marine climate institution and private clinics to determine divided into a rainy and a dry season. Having incidence of superficial and deep mycoses from an average temperature of 27-33゜C and a year 2000 to 2003 to compare with data relative humidity of 77-83% makes the weather gathered from the DOH-RITM. Most common almost always hot and humid. These environ- diagnostic procedures done and modes of mental factors and their interplay with age, treatment were likewise identified. Published occupation, genetic susceptibilities and immune studies on the prevalence of skin infections in responsiveness contribute to the high preva- the Philippines were reviewed. lence of fungal infections among Filipinos. This Potassium hydroxide（ KOH） smear and fungal study aimed to determine the prevalence of culture results were retrieved from the laboratory fungal infections in dermatology training institu- record database of the Microbiology section of tions. Data which pertains to diagnosis and the DOH-RITM from years 1998 to 2004. treatment were also collected. Data collected were analyzed using indicators such as frequency distributions, rates and ratios. METHODS After assessing the data, significant interpreta- Data on the cases of superficial and deep fungal tion was provided. infections were retrieved from the medical RESULTS record database of the Department of Health- Research Institute for Tropical Medicine （DOH- Fungal infections rank second as the leading cause of consultation at the DOH-RITM Section Corresponding author: Evangeline B. Handog, MD of Dermatology outpatient clinic with a prevalence Filinvest Corporate City, Alabang, Muntinlupa City, 1708, Metro Manila, the Philippines of 12.98% （Table 1）. Fig. 1 shows the relative Consultant dermatologist, Section of Dermatology, distribution of cases seen where pityriasis Department of Health-Research Institute for Tropical versicolor（ 25.34%） is the most common, followed Medicine by tinea corporis（ 22.63%）, tinea cruris（ 16.7%） 72 真菌誌 第46巻 第 2 号 平成17年 Table 1. Ten leading causes of consultation January 2000 to December 2003 Disease No. of classification 2000 2001 2002 2003 cases seen % Dermatitis and eczema 6,447 6,173 7,491 8,082 28,193 29.52 Fungal infections 3,585 2,718 3,272 2,826 12,401 12.98 Disturbance of pigmentation 922 828 1,610 7,176 10,336 10.82 Papulosquamous d isorders 1,314 1,298 2,480 3,633 8,725 9.14 Mycobacterial infections 1,597 1,358 2,260 2,476 7,691 8.05 Disorders of skin appendages 911 1,532 2,512 2,594 7,549 7.9 Infections of skin and subcutaneous 1,312 959 1,178 1,229 4,678 4.9 tissue Parasitic infestations/bites 1,320 918 1,135 935 4,308 4.51 and stings Viral infections 234 816 1,037 1,348 3,453 3.6 Urticaria and hypersensitivity 849 561 909 956 3,275 3.43 reactions Other diseases 66 947 1,899 7,456 4,898 5.15 Total 18,557 18,108 25,783 33,059 95,507 100 Department of Health- Research Institute for Tropical Medicine Section of Dermatology outpatient clinic（ n=95,507） 㪚㪸㫅㪻㫀㪻㫀㪸㫊㫀㫊㪃㩷㪊㪐㪈 㪫㫀㫅㪼㪸㩷㪺㪸㫇㫀㫋㫀㫊㪃㩷㪉㪇㪎 㪦㫅㫐㪺㪿㫆㫄㫌㪺㫆㫊㫀㫊㪃㩷㪍㪐㪊 㪤㫀㫊㪺㪅㩷㩿㪫㪅 㪽㪸㪺㫀㪸㫃㪼㪃㩷㪻㪼㪼㫇㩷㫄㫐㪺㫆㫊㫀㫊㪀㪃㩷㪊㪊㪍 㪫㫀㫅㫀㪸㩷㫄㪸㫅㫌㫄㪃㩷㪎㪉㪊 㪫㫀㫅㪼㪸㩷㫇㪼㪻㫀㫊㪃㩷㪉㪃㪇㪊㪈 㪧㫀㫋㫐㫉㫀㪸㫊㫀㫊㩷㫍㪼㫉㫊㫀㫆㫃㫆㫉㪃㩷㪊㪃㪈㪋㪊 㪫㫀㫅㪼㪸㩷㪺㫉㫌㫉㫀㫊㪃㩷㪉㪃㪇㪎㪈 㪫㫀㫅㪼㪸㩷㪺㫆㫉㫇㫆㫉㫀㫊㪃㩷㪉㪃㪏㪇㪍 Fig. 1. Different fungal infections seen at DOH-RITM outpatient clinic（ n=12,401） Table 2. Seasonal distribution of fungal diseases in a period of 4 in less than 25% of cases in 4 institutions and years (2000 to 2003) done in all KOH positive cases in 1 institution. Year Jan-March Apr.-Jun. Jul.-Sept. Oct.-Dec. Total Nineteen percent of specimens obtained from the skin, hair, nails and mucous membranes 2000 973 1,207 1,119 431 3,585 2001 745 738 595 640 2,718 are sent for fungal culture at the RITM 2002 679 783 966 844 3,272 laboratory which is the national referral 2003 1,056 466 607 697 2,826 laboratory for mycology （Fig. 2）. Sources of specimen are from skin scrapings, oral mucosa, Total 3,453 3,194 3,287 2,612 12,401 tissue biopsy and nails, in descending order. Eighteen percent yielded growth in culture and tinea pedis （16.38%）. An identical distribu- whereas molds grew in 7.75% of cases. The tion is seen at the outpatient clinic of Jose R. majority of isolates were from the oral mucosa, Reyes Memorial Medical Center（ JRMMC） Depart- which yielded mostly Candida sp. （Table 3）. ment of Dermatology. More cases are seen Similar findings were observed in a private during early summer and early rainy season hospital where Candida sp. is the most common months （Table 2）. Fungal culture is performed isolate, obtained mostly from the oral mucosa Jpn. J. Med. Mycol. Vol. 46（ No. 2）, 2005 73 Table 3. Most commonly isolated species in fungal culture at Specimens for Fungal Culture the DOH-RITM Microbiology laboratory（ 1998 to 2003） No. of 㪏㪇㪇 Species isolated specimens with growth Candida albicans 11 㪍㪇㪇 Candida tropicalis 3 Cryptococcus neoformans 2 㪋㪇㪇 㪎㪊㪐 Candida parapsilosis 5 㪌㪏㪎 Candida guilliermondii 2 㪉㪇㪇 Candida non-albicans 1 㪈㪋㪉 Candida fomata 1 Trichosporon beigelli 1 㪇 Total number of Specimens from skin, Others (urine, organ specimens sent for hair, nails and oral aspirates, sputum, NG Total 26 fungal culture mucosa tube aspirates, etc.) Fig. 2 Breakdown of specimens for fungal culture at the Research Table 4. Most commonly isolated species in fungal culture at a Institute for Tropical Medicine micrbilogy laboratory（ 1998 to private hospital microbiology laboratory（ 2003） 2004） Fungal culture isolates from all specimens No. of collected（ including non-skin specimens） specimens with N=61 growth and nails （Table 4）. The incidence of subcutaneous mycoses is Candida spp.（ non-albicans） 29 rare in the Philippines with only 1 case of Aspergillus spp. 16 sporotrichosis, 1 case of chromoblastomycosis Candida albicans 14 and 3 cases of mycetoma reported in a 4-year Cryptococcus terreus 1 Microsporum spp. 1 period （2000-2003）. Candidiasis is still the most common opportunistic infection followed by coccidioidomycoses, cryptococcosis and aspergillosis. The imidazoles are still the most commonly A 4-year retrospective study from 1996 to prescribed topical treatment for dermatophyte 1999 in a tertiary hospital dermatology clinic in infections followed by terbinafine, and sulfur- Davao City shows that dermatophytoses, the salicylic acid creams. The use of ciclopirox most common of which are tinea pedis and shampoo is preferred. Most commonly prescribed cruris ranked fourth among the most frequently systemic therapy includes itraconazole, ketocona- seen dermatoses in the elderly 65 years old and zole, terbinafine, griseofulvin, and fluconazole above, occurring in 8.98% 2）. This type of in descending order of frequency. dermatophytosis is commonplace because of the warm and humid environment that favors its DISCUSSION growth 3）. In a survey conducted by Tianco, Our finding that dermatophytosis ranks second Teodosio and Alberto among 100 patients 60 among the most common causes for consulta- years and above, dermatophytosis also ranked tions in dermatology clinics is supported by a 5- in the top 4 common dermatologic conditions 4）. year study of common dermatoses seen at the A three-year retrospective study from 1996 to University of the Philippines-Philippine General 1998 done at the Davao Medical Center Hospital dermatology clinic from 1982-1986 where Department of Dermatology showed that fungal dermatophytosis ranked in the top 4 common infections rank 7 th among the most common dermatologic conditions 1）. The high prevalence dermatoses affecting the pediatric age group. of fungal infections among Filipinos can be Tinea corporis followed by tinea pedis were the attributed to both cultural and environmental most frequently seen dermatophytosis and were factors. A high relative humidity coupled with more pervasive in the pubertal age group （10- the Filipino penchant for the Caucasian style 14 years）5）. of dressing promotes sweating and increased The higher prevalence of tinea pedis in a incidence of pityriasis versicolor during hot country with a tropical climate has been summer months. The increased incidence of mentioned in retrospective studies done in tinea pedis from July to September is most Asian countries like Taiwan 6） and Thailand 7）. probably due to persistent soaking of feet In the Philippines, a higher prevalence of during floods. Other predisposing factors may tinea pedis is observed among military personnel. include age and occupation. A study conducted at Camp Catitipan, Davao 74 真菌誌 第46巻 第 2 号 平成17年 City in 1999 revealed that the prevalence of therapy, AIDS and depressed immunologic tinea pedis is higher among combatant （42%） responses 10）.
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