Australas J. Dermatol 1992; 33: 45-48

SUPERFICIAL MYCOSES IN SAUDI ARABIA PANKAJALAKSHMI V. VENUGOPAL AND TARALAKSHMI V. VENUGOPAL

Saudi Arabia and India SUMMARY

Between June 1988 and December 1990, 1018 cases of superficial mycoses were investigated. Diagnosis was confirmed by microscopic examination in 503 cases and the causal agent was isolated in 490 cases. Tinea capitis accounted for 47.7% (92.5% in children below 10 years of age). The frequency of other clinical types in descending order was pityriasis versicolor 25.8%, tinea corporis 9%, onychomycosis 5.8%, tinea pedis 4%, intertrigo 3.9% and tinea cruris 2.8%. Erythrasma was encountered threee times and mixed piedra and trichomycosis axillaris once. Microsporum canis was the commonest aetiological agent, responsible for 46.9% of ringworm infections. Malassezia furftir was the next most common agent (26.5%) followed by Candida albicans (8.6%) a/7c? Trichophyton violaceum (8.2%). Other species were found less frequently. T.simii was isolated from four cases of tinea cruris and one each of" tinea capitis and tinea corporis, and Piedraia hortae and Trichosporon beigelii from a case of mixed piedra infection. The samples were studied directly in 10% potassium hydroxide and by culture on Sabouraud's dextrose agar with gentamycin at 26°C. Fungi were identified on the basis of microscopical morphology and cultural characteristics of the colonies. Whenever necessary, slide-cultures and cultures on additional media such as polished rice grains, corn meal agar with 1% dextrose, urease agar were performed and nutritional tests were used. In cases of pityriasis versicolor, scrapings were inoculated on to Sabouraud's dextrose agar with gentamycin and covered with a layer of corn oil and incubated at SVC. Candida albicans was identified on the basis of production of chlamydospores on corn meal agar and germ tubes in serum within two hours at 37°C.

INTRODUCTION

Superficial mycoses are among the most common human infectious diseases, and their incidence and distribution have been studied extensively in various parts of the world. However there are few reports on superficial mycoses from Saudi Arabia.'' The present study investigated the incidence and causal agents of superficial mycoses during 31 months in Saudi Arabia. MATERIALS AND METHODS

Material was obtained from clinically suspected cases of superficial mycoses attending the Dermatology clinics of two hospitals in the Eastern Province of Saudi Arabia - Qatif Central Hospital, Qatif between June 1988 and March 1989 and King Fahad Hofuf Hosital, Hofuf between April 1989 and December 1990. Data regarding age, sex, nationality and the anatomical site and clinical type of the lesion were recorded. Specimens of hair, skin and nail were collected according to recommended procedures.

RESULTS

Of 1018 caes investigated, 503 showed the presence of fungi by direct microscopy, and the causaf agents were isolated in 490 cases. Dermatophytes were cultured from 296 cases whereas yeasts were isolated from 19. Table 1 shows the frequency with which the species were isolated from different clinical types of infection. M.canis was mainly responsible for tinea capitis and tinea corporis. T.violaceum was the next most common agent in these infections. Candida albicans constituted the dominant organism in cases of tinea pedis and Calbicans or other Candida spp. were found in all but three

Prof P.V. Venugopal, MD, MNAMS, FIMSA. Dr. T.V. Venugopal. Laboratories, Qatif Central Hospital, and King Fahad Hofuf Hospital, Saudi Arabia. Institutes of Microbiology and Pathology, Madras Medical College, India. Address for correspondence: Prof Pankajalakshmi V. Venugopal, Director Upgraded Institute of Microbiology, Madurai Medical College "Malan Mangai", A2 1st Ave, Ashok Nagar, Madras 600 083, India.

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PANKAJALAKSHMI V. VENUGOPAL AND TARALAKSHMI V. VENUGOPAL

TABLE 1 Species from different clinical types Tinea capitis

Organisms Direct Microscopy & culture +ve M.canis M.furfur (pitydasis versicolor) C.albicans T.violaceum Candida spp. M.audovinii T.simii T.mentagrophytes T.rubrum E.floccosum G.candidum T.verrucosum Cladosporium spp. Scopulariopsis spp. P.hortae Xbeigelli

Tinea Onychocorporis mycosis

Tinea pedis

Intertrigo

Tinea cruris

Superficial infectons

31

195

130 15

16



33

12

5 1 1 1

2 1 1

3





4



2



2



2

Total

230 130 42

46.9 26.5

40 16 7

8.2 13.4

6 6 4

1.2 1.2 0.8

2 2 1 1 1

0.4 0.4 0.2 0.2 0.2

8.6

1.4

0.2 0.2

(Mixed piedra)

Erythrasma Trichomycosis Axillaris Direct Microscopy 4-ve culture -ve TOTAL

45 9

240 47.7

29 5.8

19 3.9

20 4

14 2.8

135 26.8

503 100

100

TABLE 2 Clinical types in relation to age and sex Age (years)

Tinea capitis

M

F

0-10 11-20 21 - 30 31 - 40 41 - 50 51 - 60 61 -70

135 10 —

87 4 1 — — 1

TOTAL

147

1 -— 1

Tinea corporis F M

5 3 8 5

I —

5 4 6 5 1 —

Onychomycosis

M

F

Tinea pedia F M

4 — 3 2 _ 1

3 7

— —

1 2

2 2 2 —

2 93

22

23

10

3 — 3 19

— — 5 5

2 1

M

F

Tinea cruris M F

8 — 2 — — —

5 — —

— 4 2

2 1 —

2

Intertrigo

1 14

cases of onychomycosis. T.simii was isolated from four cases of tinea cruris and one each of tinea capitis and tinea corporis. Two of the isolates have been confirmed and deposited at the American Type Culture Collection (ATCC 66341).

1 2

Tinea versicolor M F



4

— 2 2 — —

22 33 9

2 2

2 18 25

9 1 3

9

F

156 102 39 33 49 40 20 25

7 6 _

1 10

Total

M

10

72

58

277

8 5

7 220

Table 2 shows the distribution of the clinical condition related to age and sex. Tinea capitis was primarily seen in children in the prepubertal age, whereas pityriasis versicolor was found to occur more commonly in the age group 11-30. Infection of the glabrous skin was common in 46

SUPERFICIAL MYCOSES IN SAUDI ARABIA

species which are most prevalent can change as new species are introduced. In India, tinea corporis and tinea cruris are the commonest type of infections and T.rubrum is the predominant Reference pathogen, followed by T.mentagrophytes." The Al-Khobar Damman Hofuf & Qatif Koleman, Al-Sogair, Present series incidence of tinea capitis is low. We have et al, 1984 et al 1989 encountered only 2.6% of cases of tinea capitis in our previous study from Madras' whereas 1018 550 Total no. 143 Kamalam and Thambiah' reported a gradual Number+ 442 490 67 increase in the incidence from 0.46% in 1970-1972 M.Canis 47.8 56.6 46.9 to 6.25% in 1973-1976. However, an higher inciM.audouinii 1.4 1.5 8.5 dence has been reported from the rural areas of M.gypseum 1.5 — — South India.' The main aetiologic agent of tinea — M.ferrugineum 3 0.2 capitis is T.violaceum followed by T.tonsurans and T.violaceum 7.5 30.7 8.2 infections with M.canis are extremely rare," T.mentagrophytes 17.9 4 1.2 whereas in Saudi Arabia the major pathogen — T.verrucosum 10.4 0.2 reported is M.canis. — — T.simii 1.2 — Once favus due to T.schoenleinii was reported T.rubrum 4.5 0.8 to be widely prevalent in the Middle East (Iraq,* E.floccosum 6 0.4 — Iran,"" Turkey" and Libya'^) and infection with microsporum species was unrecognised in adults and involvement of the face was often Iraq*"'" and Lebanon." However, Sharquie and found in children. Males were more frequently Al-Zubaidi in 1985 encountered only M.canis affected than females. However, in tinea pedis and infection in Iraq." Favus due to Tschoenleinii has onychomycosis more females were encountered. not been reported in Saudi Arabia. We have M.canis and T.violaceum were responsible for encountered a single case of favus-type Hofuf the majority of dermatophyte infections in where the causative agent was T.violaceum. The Saudis, whereas T.mentagrophytes, T.rubrum and improvement in socio-economic conditions might E.floccosum were found mainly in non-Saudis: explain the disappearance of T.schoenleinii Kuwaitis, Egyptians, Indonesians, Indians and Sri infection. The emergence of M.canis as the preLankans. Trychomycosis axillaris and piedra were dominent pathogen may be due either to its recent encountered in a Sudanese male and Kuwaiti introduction by foreign workers, or the infection female. which has already been established in cats and The organisms isolated in the present study and dogs may now for some reason transfer more those identified by other workers from the readily to humans.'" Eastern Province of Saudi Arabia are shown in Although most of the patients denied having table 3. pet cats and dogs, the presence of cats in their neighbourhood might explain the high incidence DISCUSSION of M.canis infection. T.simii infection is reported for the first time The majority of the isolates came from cases in Saudis. Superficial infection of the axillary hair of tinea capitis and our results agree with the reports from the Eastern Province of Saudi (trichomycosis axillaris) was encountered in a Arabia'^ as to the most frequent species in the Sudanese doctor, and diagnosis was made by scalp (M.canis); to the predominance of M.canis direct microscopic examination of the nodules. in early childdhood and in boys and also to the The mixed piedra infection in a Kuwaiti housewife yielded both P.hortae and T.beigelii in sudden decrease of scalp infection at puberty. The incidence of pityriasis versicolor was culture. These infections are reported for the first greater in adolescents and adults. We have time from Saudi Arabia. encountered only six cases below the age of ten. ACKNOWLEDGEMENTS Al-Sogair et aP have reported an incidence of 9.6% in children under 12 years. We are grateful to Drs A.N. Tiwari, A. Toulabi The frequency of isolation of the different and Mushtaq Ali, Dermatologists, King Fahad fungi differs in different geographic regions, and Hofuf Hospital and Qatif Central Hospital for TABLE 3 Dermatophytes reported from the Eastern Province of Saudi Arabia.

47

PANKAJALAKSHMI V. VENUGOPAL AND TARALAKSHMI V. VENUGOPAL

providing clinical material. We are greatly indebted to Drs A. Yaneza and Ali M. El-Bashier, Directors of the Laboratories for their kind cooperation and encouragement.

Gumar AWS, Guirges S. Survey of aetiological agents of fungus infections of skin. J Faculty Med Baghdad 1978; 20: 19. Ansari N, Faghih M. Dermination de dermatophytes agents de teighes due cuir chevelu a Teheran. Ann Parasitol 1951; 26: 245. Petit JHS. Griseofulvin and favus. Br J Dermatol 1960; 72: 179. Ekmen H. A survey of dermatomycoses in Turkey. TUrk HiJ Tecr Biyol Dery 1958; 18: 275. Malhotra YK, Garg MP, Kanwar AJ, Nagarajan S. A study of tinea capitis in Libya (Benghazi). Sabouraudia 1979; 17: 181. Akrawi N, Raesam KH. Species of fungi which cause ringworm of the scalp in Iraq with a study of the action of griseofulvin on them in vitro. J Faculty Med Baghdad 1976; 4: 1. Rahim GF. A survey of fungi causing tinea capitis in Iraq. Br J Dermatol 1966; 78: 213. Farah FS, Kurban AK, Chaylession HT, Alami SY. Survey of the pathogenic dermatophytes in Lebanon. Lebanese Med Jour 1962; 15: 75.79. Sharquie KE, Al-Zubaidi KA. Microsporum canis in Iraq. Saudi Med J 1985; 6:248.

REFERENCES ' Koleman F, Gawad AA, Anter S, Kubba R. Dermatophytic flora of the Eastern Province in Saudi Arabia. King Faisal Specialist Hosp Med J 1984; 4: 313. ' Al-Sogair SM, Al-Humaidan YM, Moawad MK. Scalp fungus infections in the Eastern Province of Saudi Arabia. Ann Saud Med 1989; 9: 259. ' Al-Sogaii'SM, Al-Humaidan YM, Moawad MK. Tinea versicolor in the Eatern Province of Saudi Arabia. Ann Saud Med 1989; 4: 349. '' Mohapatra LN. Study of Medical Mycology in India - an overview. Indian J Med Res 1989; 89: 351. ' Pankajalakshmi V Venugopal, Subramanian S. Mycoses in Madras (superficial). Indian J Derm Vener 1974; 40: 228. ' Kamalam A, Thambiah AS. Tinea capitis an endemic disease in Madras. Mycopalhologia 1980; 71: 45. ' Klokke AH, Durairaj P. The causal agents of superficial mycoses isolated in rural areas of South India. Sabouraudia 1967; 5: 153.

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Superficial mycoses in Saudi Arabia.

Between June 1988 and December 1990, 1018 cases of superficial mycoses were investigated. Diagnosis was confirmed by microscopic examination in 503 ca...
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