Research Article (Open access)

SSR Inst. Int. J. Life Sci., 7(2): 2788-2793, March 2021

Changing Trend of Dermatophyte Infections: A Five Year Study

 

Sunita Gajbhiye1*, Nirmal Channe2, Sunanda Shrikhande3

1Associate Professor, Department of Microbiology, Government Medical College, Nagpur, Maharashtra, India

2Assistant Professor, Department of Microbiology, Government Medical College, Nagpur, Maharashtra, India

3Professor and Head, Department of Microbiology, Government Medical College, Nagpur, Maharashtra, India

 

*Address for Correspondence: Dr. Sunita Gajbhiye, Associate Professor, Department of Microbiology, Government Medical College, Nagpur, Maharashtra, India

E-mail: sunitarajgaj@yahoo.com

 

ABSTRACT- Background- Dermatophytosis is a common infection affecting humans globally. According to WHO, the prevalence rate of superficial mycotic infections worldwide is 20-25%. The fungal infections of the skin and its appendages are more common in tropical countries like India, due to environmental factors like heat and humidity. In the recent past, there has been an increase in dermatophytic infections, which are caused by non-dermatophytic species of fungi. This study was undertaken to note the changing trend of dermatophytic infection for five years.

Methods- A total of 459 skin, hair and nail samples from clinically diagnosed cases of dermatophytoses attending Dermatology clinics were included in the study. Out of 459 samples, 116 (25.27%) fungi were isolated, which included dermatophytic and non-dermatophytic fungi.

Results- Amongst dermatophytes, the most common isolate was Trichophyton mentagrophytes (28.57%) followed by Trichophyton rubrum (21.42%) and Epidermophyton floccossum (21.42%). The most common non-dermatophyte isolated was Aspergillus species (50.93%) followed by Candida (15.68%) and Fusarium (9.80%).

Conclusion- In our study, non-dermatophytic isolates outnumbered dermatophytes and this reflects the changing trend of dermatophytic infections with a high isolation rate of non-dermatophytic fungi.

Key Words: Changing trend, Dermatophytosis, Dermatophytes, Non dermatophytes, Superficial mycotic infections


INTRODUCTION- Dermatophytes are a group of closely related fungi that tend to invade keratinized tissue, skin, hair and nails commonly referred to as ringworm [1]. The isolation of these agents from clinical specimens may pose a challenge to the clinicians unless there is proper identification of the organisms. Successful treatment of these infections requires a high index of clinical suspicion and knowledge of etiological agents [2]. The etiological agents of dermatophytoses are classified as Trichophyton, Epidermophyton and Microsporum and they are differentiated based on conidia formation [3]. According to WHO, the prevalence rate of superficial mycotic infections worldwide is 20-25% [1].

The fungal infections of the skin and its appendages are more common in tropical countries like India due to environmental factors like heat and humidity [4]. Although it does not cause mortality, it causes high morbidity and worsens the quality of patientsí life [4]. The prevalence of dermatophytic infections with different species of dermatophytes varies with geographical locations and conditions. In the recent past, there has been an increase in dermatophytic infections which are caused by non-dermatophytic species of fungi. In addition to the accepted pathogens, there are significant numbers of non-dermatophytic fungi, which have been implicated in superficial mycoses [5,6].

Dermatophytic and non-dermatophytic fungi implicated as a cause of dermatophytoses have been recorded all over the world but with variation in distribution, incidence, epidemiology, clinical manifestations and target hosts from one location to another [6]. Though several reports on dermatophyte infection are available from different parts of the country, there are only a few reports on non-dermatophytic fungi [1].

The present study was undertaken to study the fungal etiology of dermatophytic infections in patients attending Dermatology clinics and to study the rising trend of non-dermatophytic fungi causing dermatophytosis over five years.

 

MATERIALS AND METHODS- The present study was conducted in the Department of Microbiology, Government Medical College, Nagpur from January 2015 to November 2019. A total of 459 skins, hair and nail samples from clinically diagnosed cases of dermatophytoses attending Dermatology clinics were included in the study.


The skin, hair and nail samples were processed as per standard recommended procedures. The samples were collected in sterile petri dishes and direct microscopy using 10-20% KOH was done and was screened for fungal hyphae, spores or yeast cells. They were then inoculated on two sets of Sabouraudís Dextrose Agar containing Chloramphenicol and Cycloheximide and incubated at 25o C and 37oC. The cultures were examined once a week and were declared negative if no growth was obtained till 4 to 6 weeks. The isolates were further identified by studying the culture characteristics, pigment production and microscopic examination using Lactophenol Cotton Blue mount and slide culture were done wherever necessary for identification of species [8].

 


RESULTS- A total of 459 samples of skin, hair and nail were collected during the study period. The most common sample collected was of nail followed by skin and hair (Table 1).

Table 1: Specimen-wise distribution

Years

Nail

Skin

Hair

Total

2015

40

5

0

45

2016

84

2

0

86

2017

92

1

1

94

2018

100

2

0

102

2019

131

1

0

132

Total

447

11

1

459

 

Out of 459 samples, 116 (25.27%) fungi were isolated. It was observed that there is an increase in sample size over the years (Table 2).

 

Table 2: Fungi isolation rate from samples received

Years

No. of samples received

No. of fungi isolated

2015

45

12

2016

86

18

2017

94

24

2018

102

28

2019

132

34

Total

459

116 (25.27%)

††††††††††††††††††††††††††††

Table 3: Fungi isolation rate from dermatophytosis in various places

Study

Year

Place

Percentage (%)

Teklebirhan et al. [11]

2015

Ethiopia

73.40

Naglot et al. [12]

2015

Assam

59.66

Kannan et al. [13]

2016

Tamilnadu

66.30

Hazarika et al. [7]

2019

Assam

47.69

Angadi et al. [15]

2019

Pune

73.57

Present study

2019

Nagpur

25.27

††††††††††††††††††††††††††††

In our study, out of 116 fungi isolated 14 (12.06%) were dermatophytes and 102 (87.93%) were non dermatophytes (Table 4).

 

Table 4: Dermatophytic and Non Dermatophytic fungi isolated from dermatophytosis cases

Year

No. of fungi isolated

Dermatophytes

Non-dermatophytes

2015

12

4

8

2016

18

3

15

2017

24

3

21

2018

28

2

26

2019

34

2

32

Total

116

14 (12.06%)

102 (87.93%)

††††††††††††††††††††††††††††

Table 5: Dermatophytic and Non-dermatophytic fungi isolated from dermatophytosis cases in different studies

Author

Year

Dermatophytes (%)

Non-dermatophytes (%)

Teklebirhan et al. [11]

2015

58

42

Bitew [14]

2018

54.43

47.56

Hazarika et al. [7]

2019

43.54

56.46

Present study

2019

12.06

87.93

 

During the study period (2015-2019), out of 116 fungi isolated, 14 (12.06%) were dermatophytes. The year-wise identification of dermatophytes is shown in Table 6.

Table 6:Year wise Identification of Dermatophytes (n= 14)

Dermatophytes

No. of isolates

2015

2016

2017

2018

2019

Total

T. mentagrophytes

2

2

-

-

-

4

T. rubrum

-

1

-

1

1

3

T. violaceum

2

-

1

-

-

3

T. tonsurans

-

-

-

1

-

1

E. flocossum

-

-

2

-

1

3

Total

4

3

3

2

2

14

††††††††††††††††††††††††††††

In this present study, the commonest isolate among dermatophytes was T. vmentagrophytes (28.57%). Some studies have shown T. mentagrophytes as the common isolate while other workers have found T. rubrum as the common isolate (Table 7).

Table 7: Dermatophytic fungi isolated from Dermatophytosis cases in different studies

Authors

T.

mentagrophytes (%)

T.

rubrum (%)

T.

tonsurans (%)

T.

violaceum (%)

E. flocossum (%)

Sharma et al. [5]

40.33

6.6

-

-

-

Uma et al. [15]

30.58

37.64

-

-

-

Rathod et al. [16]

28.57

51.19

7.15

3.57

-

Kannan et al. [9]

16.7

70.83

-

-

8.33

Gunasekaran et al. [10]

30.69

39.2

-

3.2

3.2

Present study

28.57

21.42

7.14

21.42

21.42

 

A total of 102 (87.93%) non-dermatophytes were isolated in our study. The species wise distribution of non-dermatophytes is shown in Table 8.

 

Table 8: Species wise distribution of Non-dermatophytes (n= 102)

Non-dermatophytes

No. of isolates

Aspergillus sp.

52

Aspergillus niger

32

Aspergillus fumigatus

12

Aspergillus flavus

4

Aspergillus nidulans

2

Aspergillus glaucus

1

Aspergillus versicolor

1

Candida sp.

16

Candida albicans

10

Candida tropicalis

3

Candida krusei

2

Candida glabrata

1

Fusarium sp.

10

Fusarium solani

8

Fusarium oxysporum

2

Penicillium sp.

5

P. marneffi

5

Rhizopus sp.

6

R. arrihizus

6

Mucor sp.

6

M. racemosus

6

Curvularia sp.

2

C.geniculata

2

Alternaria sp.

1

A.alternata

1

Cladosporium sp.

2

C.bantiana

2

Exophiala sp.

1

E.werneckii

1

Fonsaeca pedrosii

1

Total

102

 

The most common non-dermatophyte isolated in our study was Aspergillus sp. (50.98%) followed by Candida sp. (15.68%) and Fusarium spp. (9.8%). In a study by Sharma et al. [5], the most common NDM isolated was Aspergillus sp. (64.51%). Kannan et al. [8] found a higher isolation rate of Candida (58.6%). The bar diagram is shown below shows increasing sample size over the years and increased isolation of non-dermatophytes (Fig. 1).

2019

 

Fig. 1: Dermatophytes v/s Non-dermatophytes

Dermatophytosis caused by non-dermatophytic fungi is not uncommon now. The myth that non-dermatophytes are to be considered as laboratory contaminants does not hold always. To consider non-dermatophytic fungi as a causative agent, it should be positive indirect microscopy and re-isolation.

 

DISCUSSION- A total of 459 samples of skin, hair and nail were collected during a five year study period. The most common sample collected was of nail infection followed by skin and hair. However, Kannan et al. [9] and Gunasekaran et al. [10] found skin samples to be the common sample collected.Out of 459 samples, 116 (25.27%) fungi were isolated in our study and there was an increase in sample size over the years. In our study in the year 2016, the isolation rate was 20.9%, which gradually increased to 25.75% in 2019. Other workers have shown different isolation rates of dermatophytosis from various places. Teklebirhan et al. [11] in the year 2015 in Ethiopia found an isolation rate of 73.40%. In a study by Kannan et al. [9] in 2016 in Tamil Nadu, they found an isolation rate of 66.30%. However, Angadi et al. [13] in 2019 in Pune found an isolation rate of 23.57%.

Further, in our study, the isolation rate of dermatophytes versus non-dermatophytes had an increasing trend over the years from 2015 to 2019 as shown in Table 4. Similarly, other workers have shown an increasing isolation rate of non-dermatophytes from various regions as shown in Table 5. Hazarika et al. [7], in 2019, isolated 43.54% dermatophytes and 56.46% non-dermatophytes. In our study, we isolated 12.06% dermatophytes and 87.93% non-dermatophytes, which clearly show an increasing trend of isolation of non-dermatophytic isolates from cases of dermatophytosis.

In the present study, the most common isolate among dermatophytes was T. mentagrophytes (28.57%) followed by T. rubrum (28.42%). Sharma et al. [5] isolated 40.33% of T. mentagrophytes and 6.6% of T. rubrum. However, Gunasekaran et al. [10] isolated 30.69% of T. mentagrophytes and 39.2% of T. rubrum as shown in Table 7.

The most common non-dermatophyte isolated in our study was Aspergillus species (50.98%) followed by Candida (15.68%) and other non-dermatophytic moulds isolated were 23.52%. This study done by Sharma et al. [5], the most common non-dermatophytic mould isolated was Aspergillus species (64.51%) and Kannan et al. [9] found higher isolation rate of Candida species (58.6%) among the non-dermatophytes.

 

CONCLUSIONS- In our study, nail infections were commonly found. Among dermatophytes, Trichophyton species were more common. Among non dermatophytes, Aspergillus species was the most common isolate. A rising trend of non-dermatophytic isolates from cases of dermatophytosis is seen in the study. Dermatophytosis caused by non-dermatophytic fungi is not uncommon now.

The myth that non-dermatophytes are to be considered as laboratory contaminants does not hold always. Accurate diagnosis is important for successful treatment, which requires laboratory confirmation.

 

CONTRIBUTION OF AUTHORS

Research concept- Sunita Gajbhiye, Nirmal Channe, Sunanda Shrikhande

Research design- Sunita Gajbhiye, Nirmal Channe

Supervision- Dr. Sunita Gajbhiye, Dr. Nirmal Channe, Dr. Sunanda Shrikhande

Materials- Sunita Gajbhiye, Nirmal Channe

Data collection- Sunita Gajbhiye, Nirmal Channe

Data analysis and interpretation- Sunita Gajbhiye, Nirmal Channe

Literature search- Sunita Gajbhiye, Nirmal Channe, Sunanda Shrikhande

Writing article- Sunita Gajbhiye, Nirmal Channe

Critical review- Sunita Gajbhiye, Nirmal Channe, Sunanda Shrikhande

Article editing- Sunita Gajbhiye, Nirmal Channe, Sunanda Shrikhande

Final approval- Sunita Gajbhiye, Nirmal Channe, Sunanda Shrikhande

 

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