MYCOSES 34,
4 19-422 ( 199 1)
ACCEPTED: AUGUST8, 1991
Cultural evidence for a bullous type of tinea pedis Kulturelle Sicherung einer bullosen Form der Tinea pedis H. C. Korting and Helga Zienicke Key words. Trichophyton rubrum, tinea pedis, bulla. ~
Schliisselworter. Trichophyton rubrum, Tinea pedis, Blase.
Summary. Maceration, hyperkeratosis and vesicles are well known as typical clinical correlates of dermatophyte infection of the feet. It seems, however, still to be controversial whether bullae also belong to the clinical spectrum. In a 48year-old female Trichophyton rubrurn could be cultured from the fluid obtained by aspiration of an interdigital bulla. In another case Trichophyton mentagrophytes could be isolated from the interdigital space but not from a bulla found on the sole, microscopic investigation, however, being positive. This emphasizes the hypothesis that blisters found on the foot can be due to dermatophytes. Zusammenfassung. Wahrend Mazeration, Hyperkeratose und Blaschen als typische klinische Korrelate der Dermatophyten-Infektion der FuBe gelten, scheint es bis heute umstritten, ob auch Blasen hierher gehoren. Bei einer 48 Jahre alten Frau konnte Trichophyton rubrum aus dem durch Aspiration gewonnenen Inhalt einer interdigitalen Blase angezuchtet werden. In einem weiteren Fall konnte Trichophyton rnentagrophytes aus dem Interdigitalraum kultiviert werden, aber nicht aus einer Blase an der FuBsohle, deren Inhalt sich freilich mikroskopisch als positiv erwies. Dies erhartet die Auffassung, wonach Blasen an der FuBsohle unmittelbar auf Dermatophyten zuruckgehen konnen.
Introduction As early as 1892 Djtlaleddin-Moukhtar [ 13 described the fungal origin of vesiculous lesions of the feet, naming “trichophyton ordinaire” as the causative organism, i.e. a dermatophyte. A bullous lesion on a foot obviously due to a fungus was described in 1922 by Alexander [2]. Unfortunately, however, he did not precisely specify whether only microscopy or also culture were positive in the particular clinical case which belonged to a series of patients suffering from dermatophytosis of hands and feet. In 1952 Costello [3] described a case of a female middleaged patient suffering from a “generalized, extremely pruritic vesiculo-bullous, roughly symmetrical eruption of the extremities and torso’’ in whom a specimen of vesicular fluid was found positive for Trichophyton rubrum by culture. The precise location of the lesion investigated, however, remained unclear. Thus there is no clearcut evidence from original communications whether bullous lesions of the feet can be directly attributed to dermatophyte infection. The opinions offered in recent textbooks differ widely according to the nationality of the authors. European mycologists tend not to mention bullae in the context of dermatophytosis of the feet, while the opposite is true of mycologists from North America (Table 1). Case reports
Case I
Department of Dermatology and Venereology, LudwigMaximilians-University, Munich, Germany.
History. A 48-year-old female had been repeat-
Correspondence: PD Dr Hans C. Korting, Dermatologische Klinik der Universitat, Frauenlobstr. 9, D-W-8000 Munchen 2, Germany.
edly suffering from maceration of the interdigital spaces and dyshidrosiform eruptions of the feet due to Trichophyton rubrum for the past two years.
420
H. C.KORTINC & H. ZIENICKE
____
Table 1. Clinical manifestations of tinea pedis and causative organisms Author, year
Types of lesions
Derrnatophyte
Europe: Kalkoff, J a d e , 1958 [4]
dyshidrosiforrn, occasionally purulent bullae intertriginous, occasionally vesicles squarnous-hyperkeratotic vesicular, dyshidrotic, occasionally Gotz, 1962 [5] larger bullae in tertriginous squamous-hyperkeratotic in tertriginous Fejtr, 1966 [6] dyshidrosiform, occasionally bullous squamous-hyperkerato tic combined in tertriginous Meinhof, 1980 [7] vesicular squarnous-hyperkeratotic combined squarnous-hyperkeratotic, fissuring Male, 1981 [8] vesicular, occasionally dyshidrosiform macerated with erosions dyshidrotic, occasionally bullous Grigoriu el al., 1984 [9] squamous-hyperkeratotic intertriginous squamous-hyperkeratotic, fissuring Nolting, Fegeler, 1984 [ 101 macerated with erosions vesicular Roberts, Mackenzie, 1986 [ 1 1 intertriginous
T. mentagrophytes, T. rubrum (often T. rubrum)
T. mentagrophytes var. interdigitalis
7.rubrum, 1.mentagmphytes var. interdigitalis, E.floccosum
Braun-Falco el al., 1991 [12]
North America: Rippon, 1982 [ 131 Allen, Rippon, 1985 [ 141
squarnous-hyperkeratotic vesiculobullous, occasionally pustules dyshidrotic, occasionally bullous squarnous-hyperkeratotic dyshidrosiforrn, often with cloudy blisters intertriginous papulosquamous hyperkeratotic vesicular, sometimes bullae intertriginous vesicular, frequently bullae or blisters
Goslen, Kobayashi, 1987 [I51
sq u arnous in tertriginous papulosquarnous vesicular or vesiculobullous ulcerative
Patch testing at the time of the onset of disease had turned out entirely negative.
Clinical Jindings. This time the patient presented again because of heavily itching and burning sensations of her feFt. Clinical inspection gave evidence of whitish maceration in particular of the first interdigital space of the right foot, as well as several small vesicles and one bulla (Fig. 1). Laboratoryjndings. Material for mycological investigation, including microscopy and culture, was obtained both from the macerative type of lesion
7.rubrum T. mcntagrophytes var. interdigitalis, E. floccosum
7.rubrum, T. mentagrophytes var. interdigitalis T. mentagrophytes T. mentagrophytes 7.rubrum, E. floccasum 1.mentagrophytes, T. rubrum E. Joccosum T. rubrum
T. rubrum, T. mcntagrophytes, E. joccosum T. mentagrophytes var. ‘interdigitalis, E. Joccosum
and from the interior of the bulla. To guarantee sterile conditions and to exclude contamination from the outer parts of the lesion, the surface was disinfected first and fluid from the interior obtained by puncture with a sterile syringe. Trichophyton rubrum could be grown from the bullous fluid, but no dermatophyte was detected upon culture with the other type of material which, however, proved positive by microscopy. Here, as in the following, laboratory diagnosis was based on the procedures described by Seeliger & Heymer [16]. In the liquid obtained no bacteria could be detected. The roof of the blister was fixed, cut and PAS-stained, and the following mycoses 34, 419-422 (1991)
BULLOUSTYPE
OF TINEA PEDIS
421
Laboratoryjndings. Material for mycological investigation was taken both from an interdigital space and from the bullous lesion. Both types of material were positive upon microscopic inspection. A fungus, however, could only be grown from the interdigital space, not from the blister fluid. The fungus grown was Trichophyton mentagrophytes. Treatment. For treatment, 1yo ciclopiroxolamine cream was used and proved successful. Figure 1. Solitary bullous lesion of an interdigital space of the foot due to Trichophyfon rubrum (Case 1 ) .
microscopic findings could then be made: orthohyperkeratosis, spongiosis of the partially necrotic epidermis, inflammatory infiltrates consisting of lymphocytes, histiocytes and many neutrophils. They could be seen in the strata of the cutis attached to the epidermis as well as oedema. Typical hyphae were not observed.
Treatment and course of disease. The patient was put on 1.0% ciclopiroxolamine cream and solution, which had to be applied at least once daily each at the start together with povidone iodine solution. No further readmission to the hospital was required thereafter. Case 2 History. The 14-year-old male had presented himself twice already over the past three years for tinea pedis diagnosed clinically. Clinical jindings. This time the patient showed maceration and fissuring of interdigital spaces of his left foot. Moreover, a group of vesicles as well as one small bulla were seen on the sole (Fig. 2).
Figure 2. Bullous lesion close to several vesicles on the sole associated with tinea pedis of the intertriginous type due to Trichophyfon rnentugrophytes (Case 2).
mycoses 34,419-422
(1991)
Discussion As may be concluded from the two cases presented here, bullous lesions due directly to dermatophytes can either be the result of vesicles which become confluent as described by Goetz [5] or develop de novo. The latter phenomenon, found in case 1, seems to be less frequent. In this case the fungal origin of the lesion could be definitely proven by culture. In cases 1 and 2 there was additional evidence of fungal infection at other sites of the foot. This might help clinically as a reference to dermatophytosis when it comes to differential diagnosis. I t might, however, also divert the clinician from the proper diagnosis if he takes the view that the bullous lesions represent an allergic type of reaction i.e. a dermatophytid reaction. Bullae are said to belong to the clinical spectrum of this type of disease insofar as the pompholyx-like id-reaction is involved [ 1 11. Since a dermatophytid reaction is defined as a “noninfective cutaneous eruption representing an allergic response to a distant focus of dermatophyte infection”, the detection of fungal material either on microscopy or culture excludes this type of genesis of the lesions in our cases. Bullous lesions are not always considered as a typical manifestation of dermatophytosis. This might be due in part to rare mycological analysis. Although culture seems not to give positive results in every case, it should always be performed. This would contribute to our knowledge of the various species of dermatophytes able to cause this particular type of disease. So far one has to presume that there is no remarkable difference with respect to the causative species between tinea of the bullous type and other types. The species found here, as well as those described in the literature (compare Table l ) , might primarily reflect the general frequency of the various dermatophytes.
422
H. C. KORTING & H. ZIENICKE
References 1 DjClaleddin-Moukhtar, M. (1892) De la trichophytie des
2 3 4
5
6 7
rkgions palmaire et plantaire. Annales de Derm., 885-9 15. Alexander, A. (1922) Die Trichophytie der Hande und FiiBe. Med. Klinik 18, 1550-1553. Costello, M. J. (1952) Vesicular Trichophyton mbrum (purpurcum) infection simulating dermatitis herpetiformis. Arch. Derm. Syph. 66, 653-654. Kalkoff, K.-W. & Janke, D. (1958) Mykosen der Haut. In: Gottron, H. A. & Schonfeld, W. (eds) Dermatologie und Venerologic, Volume II, Part 2. Stuttgart: Thieme, pp. 1038-1061. Glitz, H. (1962) Die Pilzkrankheiten der Haut durch Dermatophyten. In: Marchionini, A. et al. (eds) Handbuch der Haut- und Ceschlechtskrankheiten,3.Jadassohn Erganzungswerk, Vol. 4, Part 3. Berlin: Springer, pp. 298-340. FejCr, E. (1966) Die FuBmykosen. In: Fejkr, E. et al. (eds) Medizinische Mykologie und Pilzkrankheiten. Budapest Akademiai Kiad6, pp. 420-480. Meinhof, W. (1989) Dermatornykosen ohne Hefemykosen. In: Korting, G. W. (ed.) Dermatologic in Praxis und Klinik, Vol. II. Stuttgart: Thieme, pp. 19.119.23.
8 Male, 0. (1981) Medizinische Mykologie fir die Praxis. Stuttgart: Thieme, pp. 17-59. 9 Grigoriu, D., Delacrttaz, J. & Borelli, D. (1984) Lehrbuch der medizinischm Mykologie. Bern: Huber, pp. 87- 106. 10 Nolting, S. & Fegeler, K. (1984) Medizinische Mykologie. Berlin: Springer, pp. 41-48. 11 Roberts, S. 0.B. & MacKenzie, D. W. R. (1986) Mycology. In: Rook, A. et al. (eds) Textbook of Dermatology, Vol. 2. Oxford: Blackwell Scientific Publications, pp. 885-986. 12 Braun-Falco, 0. et al. (1991) Dermalology. Berlin: Springer, pp. 217-232. 13 Rippon, J. W. (1982) Medical Mycology. Philadelphia: Saunders Company, pp. 197-203. 14 Allen, H. B. & Rippon, J. W. (1985) Superficial and deep mycoses. In: Moschella, S. L. & Hurley, H. J. (eds) Dermatology, Vol. 1. Philadelphia: Saunders Company, pp. 739-773. 15 Goslen, J. B. & Kobayashi, G. S. (1987) Mycologic infections. In: Fitzpatrick, Th. B. et al. (eds) Dermatology in General Medicine. Textbook and Atlas, Vol. 2. New York: McGraw-Hill Book Company, pp. 2 193-2248. 16 Seeliger, H. P. R. and Heymer, Th. (1981) Diagnostik pathogener Pilze des Menschen und seiner Umwelt. Lehrbuch und Atlas. Stuttgart: Thieme.
mycoses 34, 4 19-422 ( 199 1)
4 19-422 ( 199 1)
ACCEPTED: AUGUST8, 1991
Cultural evidence for a bullous type of tinea pedis Kulturelle Sicherung einer bullosen Form der Tinea pedis H. C. Korting and Helga Zienicke Key words. Trichophyton rubrum, tinea pedis, bulla. ~
Schliisselworter. Trichophyton rubrum, Tinea pedis, Blase.
Summary. Maceration, hyperkeratosis and vesicles are well known as typical clinical correlates of dermatophyte infection of the feet. It seems, however, still to be controversial whether bullae also belong to the clinical spectrum. In a 48year-old female Trichophyton rubrurn could be cultured from the fluid obtained by aspiration of an interdigital bulla. In another case Trichophyton mentagrophytes could be isolated from the interdigital space but not from a bulla found on the sole, microscopic investigation, however, being positive. This emphasizes the hypothesis that blisters found on the foot can be due to dermatophytes. Zusammenfassung. Wahrend Mazeration, Hyperkeratose und Blaschen als typische klinische Korrelate der Dermatophyten-Infektion der FuBe gelten, scheint es bis heute umstritten, ob auch Blasen hierher gehoren. Bei einer 48 Jahre alten Frau konnte Trichophyton rubrum aus dem durch Aspiration gewonnenen Inhalt einer interdigitalen Blase angezuchtet werden. In einem weiteren Fall konnte Trichophyton rnentagrophytes aus dem Interdigitalraum kultiviert werden, aber nicht aus einer Blase an der FuBsohle, deren Inhalt sich freilich mikroskopisch als positiv erwies. Dies erhartet die Auffassung, wonach Blasen an der FuBsohle unmittelbar auf Dermatophyten zuruckgehen konnen.
Introduction As early as 1892 Djtlaleddin-Moukhtar [ 13 described the fungal origin of vesiculous lesions of the feet, naming “trichophyton ordinaire” as the causative organism, i.e. a dermatophyte. A bullous lesion on a foot obviously due to a fungus was described in 1922 by Alexander [2]. Unfortunately, however, he did not precisely specify whether only microscopy or also culture were positive in the particular clinical case which belonged to a series of patients suffering from dermatophytosis of hands and feet. In 1952 Costello [3] described a case of a female middleaged patient suffering from a “generalized, extremely pruritic vesiculo-bullous, roughly symmetrical eruption of the extremities and torso’’ in whom a specimen of vesicular fluid was found positive for Trichophyton rubrum by culture. The precise location of the lesion investigated, however, remained unclear. Thus there is no clearcut evidence from original communications whether bullous lesions of the feet can be directly attributed to dermatophyte infection. The opinions offered in recent textbooks differ widely according to the nationality of the authors. European mycologists tend not to mention bullae in the context of dermatophytosis of the feet, while the opposite is true of mycologists from North America (Table 1). Case reports
Case I
Department of Dermatology and Venereology, LudwigMaximilians-University, Munich, Germany.
History. A 48-year-old female had been repeat-
Correspondence: PD Dr Hans C. Korting, Dermatologische Klinik der Universitat, Frauenlobstr. 9, D-W-8000 Munchen 2, Germany.
edly suffering from maceration of the interdigital spaces and dyshidrosiform eruptions of the feet due to Trichophyton rubrum for the past two years.
420
H. C.KORTINC & H. ZIENICKE
____
Table 1. Clinical manifestations of tinea pedis and causative organisms Author, year
Types of lesions
Derrnatophyte
Europe: Kalkoff, J a d e , 1958 [4]
dyshidrosiforrn, occasionally purulent bullae intertriginous, occasionally vesicles squarnous-hyperkeratotic vesicular, dyshidrotic, occasionally Gotz, 1962 [5] larger bullae in tertriginous squamous-hyperkeratotic in tertriginous Fejtr, 1966 [6] dyshidrosiform, occasionally bullous squamous-hyperkerato tic combined in tertriginous Meinhof, 1980 [7] vesicular squarnous-hyperkeratotic combined squarnous-hyperkeratotic, fissuring Male, 1981 [8] vesicular, occasionally dyshidrosiform macerated with erosions dyshidrotic, occasionally bullous Grigoriu el al., 1984 [9] squamous-hyperkeratotic intertriginous squamous-hyperkeratotic, fissuring Nolting, Fegeler, 1984 [ 101 macerated with erosions vesicular Roberts, Mackenzie, 1986 [ 1 1 intertriginous
T. mentagrophytes, T. rubrum (often T. rubrum)
T. mentagrophytes var. interdigitalis
7.rubrum, 1.mentagmphytes var. interdigitalis, E.floccosum
Braun-Falco el al., 1991 [12]
North America: Rippon, 1982 [ 131 Allen, Rippon, 1985 [ 141
squarnous-hyperkeratotic vesiculobullous, occasionally pustules dyshidrotic, occasionally bullous squarnous-hyperkeratotic dyshidrosiforrn, often with cloudy blisters intertriginous papulosquamous hyperkeratotic vesicular, sometimes bullae intertriginous vesicular, frequently bullae or blisters
Goslen, Kobayashi, 1987 [I51
sq u arnous in tertriginous papulosquarnous vesicular or vesiculobullous ulcerative
Patch testing at the time of the onset of disease had turned out entirely negative.
Clinical Jindings. This time the patient presented again because of heavily itching and burning sensations of her feFt. Clinical inspection gave evidence of whitish maceration in particular of the first interdigital space of the right foot, as well as several small vesicles and one bulla (Fig. 1). Laboratoryjndings. Material for mycological investigation, including microscopy and culture, was obtained both from the macerative type of lesion
7.rubrum T. mcntagrophytes var. interdigitalis, E. floccosum
7.rubrum, T. mentagrophytes var. interdigitalis T. mentagrophytes T. mentagrophytes 7.rubrum, E. floccasum 1.mentagrophytes, T. rubrum E. Joccosum T. rubrum
T. rubrum, T. mcntagrophytes, E. joccosum T. mentagrophytes var. ‘interdigitalis, E. Joccosum
and from the interior of the bulla. To guarantee sterile conditions and to exclude contamination from the outer parts of the lesion, the surface was disinfected first and fluid from the interior obtained by puncture with a sterile syringe. Trichophyton rubrum could be grown from the bullous fluid, but no dermatophyte was detected upon culture with the other type of material which, however, proved positive by microscopy. Here, as in the following, laboratory diagnosis was based on the procedures described by Seeliger & Heymer [16]. In the liquid obtained no bacteria could be detected. The roof of the blister was fixed, cut and PAS-stained, and the following mycoses 34, 419-422 (1991)
BULLOUSTYPE
OF TINEA PEDIS
421
Laboratoryjndings. Material for mycological investigation was taken both from an interdigital space and from the bullous lesion. Both types of material were positive upon microscopic inspection. A fungus, however, could only be grown from the interdigital space, not from the blister fluid. The fungus grown was Trichophyton mentagrophytes. Treatment. For treatment, 1yo ciclopiroxolamine cream was used and proved successful. Figure 1. Solitary bullous lesion of an interdigital space of the foot due to Trichophyfon rubrum (Case 1 ) .
microscopic findings could then be made: orthohyperkeratosis, spongiosis of the partially necrotic epidermis, inflammatory infiltrates consisting of lymphocytes, histiocytes and many neutrophils. They could be seen in the strata of the cutis attached to the epidermis as well as oedema. Typical hyphae were not observed.
Treatment and course of disease. The patient was put on 1.0% ciclopiroxolamine cream and solution, which had to be applied at least once daily each at the start together with povidone iodine solution. No further readmission to the hospital was required thereafter. Case 2 History. The 14-year-old male had presented himself twice already over the past three years for tinea pedis diagnosed clinically. Clinical jindings. This time the patient showed maceration and fissuring of interdigital spaces of his left foot. Moreover, a group of vesicles as well as one small bulla were seen on the sole (Fig. 2).
Figure 2. Bullous lesion close to several vesicles on the sole associated with tinea pedis of the intertriginous type due to Trichophyfon rnentugrophytes (Case 2).
mycoses 34,419-422
(1991)
Discussion As may be concluded from the two cases presented here, bullous lesions due directly to dermatophytes can either be the result of vesicles which become confluent as described by Goetz [5] or develop de novo. The latter phenomenon, found in case 1, seems to be less frequent. In this case the fungal origin of the lesion could be definitely proven by culture. In cases 1 and 2 there was additional evidence of fungal infection at other sites of the foot. This might help clinically as a reference to dermatophytosis when it comes to differential diagnosis. I t might, however, also divert the clinician from the proper diagnosis if he takes the view that the bullous lesions represent an allergic type of reaction i.e. a dermatophytid reaction. Bullae are said to belong to the clinical spectrum of this type of disease insofar as the pompholyx-like id-reaction is involved [ 1 11. Since a dermatophytid reaction is defined as a “noninfective cutaneous eruption representing an allergic response to a distant focus of dermatophyte infection”, the detection of fungal material either on microscopy or culture excludes this type of genesis of the lesions in our cases. Bullous lesions are not always considered as a typical manifestation of dermatophytosis. This might be due in part to rare mycological analysis. Although culture seems not to give positive results in every case, it should always be performed. This would contribute to our knowledge of the various species of dermatophytes able to cause this particular type of disease. So far one has to presume that there is no remarkable difference with respect to the causative species between tinea of the bullous type and other types. The species found here, as well as those described in the literature (compare Table l ) , might primarily reflect the general frequency of the various dermatophytes.
422
H. C. KORTING & H. ZIENICKE
References 1 DjClaleddin-Moukhtar, M. (1892) De la trichophytie des
2 3 4
5
6 7
rkgions palmaire et plantaire. Annales de Derm., 885-9 15. Alexander, A. (1922) Die Trichophytie der Hande und FiiBe. Med. Klinik 18, 1550-1553. Costello, M. J. (1952) Vesicular Trichophyton mbrum (purpurcum) infection simulating dermatitis herpetiformis. Arch. Derm. Syph. 66, 653-654. Kalkoff, K.-W. & Janke, D. (1958) Mykosen der Haut. In: Gottron, H. A. & Schonfeld, W. (eds) Dermatologie und Venerologic, Volume II, Part 2. Stuttgart: Thieme, pp. 1038-1061. Glitz, H. (1962) Die Pilzkrankheiten der Haut durch Dermatophyten. In: Marchionini, A. et al. (eds) Handbuch der Haut- und Ceschlechtskrankheiten,3.Jadassohn Erganzungswerk, Vol. 4, Part 3. Berlin: Springer, pp. 298-340. FejCr, E. (1966) Die FuBmykosen. In: Fejkr, E. et al. (eds) Medizinische Mykologie und Pilzkrankheiten. Budapest Akademiai Kiad6, pp. 420-480. Meinhof, W. (1989) Dermatornykosen ohne Hefemykosen. In: Korting, G. W. (ed.) Dermatologic in Praxis und Klinik, Vol. II. Stuttgart: Thieme, pp. 19.119.23.
8 Male, 0. (1981) Medizinische Mykologie fir die Praxis. Stuttgart: Thieme, pp. 17-59. 9 Grigoriu, D., Delacrttaz, J. & Borelli, D. (1984) Lehrbuch der medizinischm Mykologie. Bern: Huber, pp. 87- 106. 10 Nolting, S. & Fegeler, K. (1984) Medizinische Mykologie. Berlin: Springer, pp. 41-48. 11 Roberts, S. 0.B. & MacKenzie, D. W. R. (1986) Mycology. In: Rook, A. et al. (eds) Textbook of Dermatology, Vol. 2. Oxford: Blackwell Scientific Publications, pp. 885-986. 12 Braun-Falco, 0. et al. (1991) Dermalology. Berlin: Springer, pp. 217-232. 13 Rippon, J. W. (1982) Medical Mycology. Philadelphia: Saunders Company, pp. 197-203. 14 Allen, H. B. & Rippon, J. W. (1985) Superficial and deep mycoses. In: Moschella, S. L. & Hurley, H. J. (eds) Dermatology, Vol. 1. Philadelphia: Saunders Company, pp. 739-773. 15 Goslen, J. B. & Kobayashi, G. S. (1987) Mycologic infections. In: Fitzpatrick, Th. B. et al. (eds) Dermatology in General Medicine. Textbook and Atlas, Vol. 2. New York: McGraw-Hill Book Company, pp. 2 193-2248. 16 Seeliger, H. P. R. and Heymer, Th. (1981) Diagnostik pathogener Pilze des Menschen und seiner Umwelt. Lehrbuch und Atlas. Stuttgart: Thieme.
mycoses 34, 4 19-422 ( 199 1)
