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BACKGROUND Tinea gladiatorum as the major health concern among combat athletes and the most common cause of a decrease in the quality of their sports activities. OBJECTIVES This study aimed to determine the molecular epidemiology of tinea gladiatorum in contact sports in Mazandaran Province, Northern Iran. MATERIALS/METHODS In total, 631 suspected athletes out of 4240 ones were screened for tinea gladiatorum in this cross-sectional study from May 2018 to February 2019. The infection was confirmed by direct microscopy and culture tests. The causative agents were identified by polymerase chain reaction-restriction fragment length polymorphism method on ITS rDNA region. The indoor environmental factors were evaluated in 81 sports halls in terms of temperature (°C), humidity (%), density (m2 /athletes) and the number of ventilators. RESULTS Tinea gladiatorum was confirmed in 6.5% (278/4240) of the athletes. Tinea corporis was the most common type of tinea (192/278; 69.0%), and 175 cases (27.7%) had more than one type of tinea. Moreover, Trichophyton tonsurans (192/203; 94.5%) was the most aetiological agent in all athletes followed by Microsporum canis (6/203; 2.9%), Trichophyton rubrum (2/203; 0.9%) and Trichophyton interdigitale (1/203; 0.4%). There was no significant association between the prevalence of tinea gladiatorum and the indoor environmental factors. CONCLUSION T. tonsurans is the most common agent of tinea gladiatorum in Northern Iran. Since no positive culture of dermatophyte was obtained from mats, it seems that skin-to-skin contact would be the most probable mode of transmission among wrestlers. Accordingly, periodical checkups should be considered by health care providers.

Background Accurate diagnosis of mucormycosis, a life-threatening fungal infection, remains a challenge for physicians. Objectives To identify the causative Mucorales in fresh clinical samples and formalin-fixed paraffin-embedded (FFPE) samples of patients with proven mucormycosis by molecular method. Patients/methods Fresh clinical samples of patients with proven mucormycosis according to the EORTC/MSG criteria admitted between 2015 and 2017 and histopathologically proven FFPE archives collected during 2004-2007 and 2015-2017 from Mazandaran University-affiliated hospitals of northern Iran were included. Seminested PCR targeting the 18S rDNA of Mucorales and ITS region was performed, and PCR products were then sequenced. Results While culture was positive only in 5 of 9 (56%) of fresh specimen cases, PCR was positive in all 9 (100%) histologically proven mucormycosis. Ten of 18 (56%) FFPE samples were PCR-positive. Overall, Mucorales PCR was positive in 19 of 27 (70%) samples. Mucorales species were Rhizopus arrhizus in 16 (84%) cases, R. arrhizus/Amylomyces rouxii in 2 (10.5%) cases and Rhizopus stolonifer in one case (5.5%). Among 27 mucormycosis cases, 25 (93%) cases were rhinocerebral, and 2 (7%) cases were disseminated. Diabetes mellitus (74%) and neutropaenia (63%) were the main risk factors. Conclusions Seminested PCR targeting 18S rDNA region of Mucorales is useful for identification of the causative agents of mucormycosis.

Mucormycosis is a rare but fulminant opportunistic fungal infection, which occurs most often in diabetic and immunocompromised patients. Dental extractions may create a portal of entry for the fungal infection. The mucormycosis may be the original cause of the pain and can be misdiagnosed as dental pain. In this paper, two cases of mucormycosis are reported after dental extractions and successfully treated with amphotericin B (case #1) and combined with posaconazole (case #2). The two cases we describe exemplify the fulminant mucormycosis of maxillary sinuses after dental extraction inpatients with uncontrolled diabetic support the findings that this predisposing condition created a suitable environment for the Mucorales growth. These case reports emphasize early recognition and urgent treatment of mucormycosis is necessary to prevent the spread of infection Therefore, dental surgeons and healthcare practitioners should become familiar with mucormycosis.

Fungi of the genus Fusarium are well known as major plant pathogens but also cause a broad spectrum of human infections. Sixty-three clinical isolates, collected during 2014–2017, were identified using a part of the TEF1 gene as barcoding marker. Fusarium fujikuroi species complex (FFSC, n = 41, 65%) showed to be the dominant etiological agent, followed by F. solani species complex (FSSC, n = 14, 22%) and F. oxysporum species complex (FOSC, n = 7, 11%). There was one strain belonging to F. lateritium species complex (FLSC, n = 1, 1.5%). For final identification, a phylogenetic tree was constructed including the type strains of each species complex. Most cases of fusariosis were due to nail infection (n = 38, 60.3%), followed by keratitis (n = 22, 34%). Fusarium infections are difficult to be treated due to their intrinsic resistance to different azoles; however, accurate and fast identification of etiological agents may enhance management of the infection. We present the first phylogenetic study on clinical Fusarium spp. from Iran.

Background and Purpose: Rhinocerebral mucormycosis is a rare fatal fungal infection which is on a growing trend, particularly among immunocompromised patients. Immunosuppressive drugs, including corticosteroids and antimetabolites, increase the risk of this infection. Herein, we reported the case of fulminant rhinocerebral mucormycosis in a patient with ulcerative colitis receiving azathioprine and corticosteroid. Case report: A 58-year-old woman was admitted to the hospital in a state of coma with an extensive necrosis in her nose. She was afflicted with intestinal bleeding after 1 month of fasting and was treated with azathioprine and a high dose of prednisolone for ulcerative colitis 2 months prior to hospital admission. The direct microscopic examination of the necrotic tissues of the paranasal sinuses showed several non-septate hyphae consistent with Mucorales. Culture media yielded Rhizopus species, which was identified as Rhizopus oryzae by internal transcribed spacer polymerase chain reaction sequencing. Despite the implementation of surgical and pharmaceutical (liposomal amphotericin B) treatments, the patient expired after 2 weeks of admission. Conclusion: The gastroenterologists should be aware of the adverse effect of immunosuppressive drugs they prescribe for the treatment of inflammatory bowel disease.

The patients with hematologic malignancies and hematopoietic stem cell transplantation (HSCT) recipients are at high risk for invasive fungal diseases (IFDs) mainly due to the severe and prolonged neutropenia related to high-dose chemotherapy. Voriconazole prophylaxis is recommended for possible IFDs. Mucormycosis is a fulminant infection, which may occur after voriconazole prophylaxis for invasive aspergillosis in immunocompromised hosts. Here, we report mucormycosis after 4 months of voriconazole prophylaxis in a young patient with relapsed acute lymphoblastic leukemia and hematopoietic stem cell transplant failure and discuss the clinical manifestation, imaging, laboratory findings and therapeutic regimens. Clinician's awareness of this entity and timely diagnosis using conventional and molecular methods are the promising approach for the management of this devastating infection.

Objective The aim of the present study was to provide insight into the prevalence and susceptibility profiles of Candida species isolated from the dental plaque of Iranian immunocompetent patients. As a biofilm, Candida species are responsible for several disorders common to the oral cavity including gingivitis, dental caries, periodontitis, and the less common severe systemic infections specifically in immunosuppressed individuals. Method PCR-RFLP was performed to identify yeasts isolated from the dental plaques of 40 immunocompetent patients. Moreover, antifungal susceptibility testing was performed in according to CLSI guidelines (M27-A3). Results Among 40 yeasts isolated from the dental plaques of immunocompetent patients, Candida albicans was the most common species (92.5%), followed by P. kudriavzevii (7.5%). It is the first isolation of P. kudriavzevii from dental plaques and the first evaluation of antifungal effect of the new imidazole, luliconazole and echinocandins against these samples worldwide. Luliconazole, voriconazole, amphotericin B and anidulafungin showed the best activity with the lowest geometric mean (GM) 0.03, 0.06, 0.08 and 0.09 μg/ml, respectively, followed by miconazole (0.14 μg/mL), caspofungin (0.24 μg/mL) fluconazole (0.38 μg/mL) and itraconazole (0.5 μg/mL). Conclusion The current study demonstrated luliconazole and echinocandins displayed excellent activity against all Candida isolates from dental plaques, presenting promising and potent alternative for all oral Candidiasis.

Onychomycosis is a common nail problem, accounting for up to half of all nail diseases. Several nail disorders may mimic the onychomycosis clinically. Therefore, a sensitive, quick, and inexpensive test is essential for screening nail specimens for the administration of the proper drug. The aim of this study was to compare 4 different diagnostic methods in the evaluation of onychomycosis and to determine their sensitivity, specificity, positive predictive value, and negative predictive value. In a cross-sectional study, nail specimens were collected from 101 patients suspected to have onychomycosis during a 14-month period. The nail specimens were examined using potassium hydroxide (KOH) 20 %, KOH-treated nail clipping stained with periodic acid-Schiff (KONCPA), and calcofluor white (CFW) stain, and grew a fungal culture. The culture was chosen as the gold standard for statistical analysis using the McNemar and chi-square tests. Out of 101 patients, 100 (99 %) patients had at least 1 of the 4 diagnostic methods positive for the presence of organisms. The positive rates for the fungal culture, KOH preparation, CFW, and KONCPA were 74.2, 85.1, 91.09, and 99.01 %, respectively. The sensitivity and negative predictive value of KONCPA was 100 %. KONCPA was the most sensitive among the tests and was also superior to other methods in its negative predictive value. KONCPA was easy to perform, rapid, and gave significantly higher rates of detection of onychomycosis compared to the standard methods of KOH preparation and fungal culture. Therefore, KONCPA should be the single method of choice for the evaluation of onychomycosis.

Objective/background Tuberculosis (TB) continues to be a major public health problem worldwide. This is especially true in Northern Iran, which has high TB prevalence. The chronic nature of this disease is further exacerbated if it is accompanied by fungal infection, which usually remains undiagnosed and thus untreated. Thus, mycotic infections add fatal dimensions to pulmonary TB. Our objective was to determine the prevalence of invasive forms of fungal elements in sputum samples collected from patients with pulmonary TB at a reference laboratory in Ghaemshahr, Northern Iran, during the past 10 years. Methods In this retrospective study, sputum samples collected from 430 patients were examined. Pulmonary TB in patients was confirmed in our laboratory, and samples obtained during the period from March 2006 to February 2016 were analyzed. The sputum samples were subjected to biological (bacterial) staining (Ziehl–Neelsen and fluorochrome) and mycological investigation using KOH+ Calcofluor White (Sigma-Aldrich, India) by fluorescent microscopy and fungal culture on Sabouraud dextrose agar (Sigma-Aldrich, India) and CHROMagar (Paris, France). Results Invasive forms of fungal pathogens were observed as co-infection with Mycobacterium tuberculosis in 28/430 cases (6.51%). The frequency of Aspergillus, both branching and dichotomous infection, accounted for 3.72% (16/430): Aspergillus flavus, 1.63%; Aspergillus fumigatus, 1.16%; Aspergillus niger, 0.69%; and Aspergillus oryzae, 0.23%, respectively. Blastoconidia and pseudohyphae forms of yeast were observed as co-infection with M. tuberculosis in 2.79% (12/430) of the cases: Candida albicans, 1.86%; Candida krusei, 0.46%; and other Candida species, 0.46%, respectively. Conclusion Northern Iran is a critical region in the TB world and multidrug-resistant TB is a serious problem in this region. Although it is believed that there exists a commensal relationship between fungus and TB infections, the invasive forms of fungal pathogens and their co-infection can be caused by increasing disability and failure of treatment. Diagnosis of secondary or co-existing fungal infections in TB is most important for reducing the mortality and morbidity of these patients.

Introduction Aspergillus species as cosmopolitan fungi with remarkable virulence factors were found to be agents of pulmonary aspergillosis in patients with impaired immunity. The formed cavity of some previously treated lung diseases, such as tuberculosis, sarcoidosis and pneumoconiosis, is usually predisposed to the development of aspergillosis. Pulmonary aspergillosis (PA) is an uncommon disease which is characterized by hemoptysis, malaise, fever, cough, weight loss and nonspecific radiographic manifestations, including an oval or round mass with a radiolucent halo or crescent of air, a focal consolidation, and cavitary lesions. Case presentation This study presents the case of a 54-year-old woman with dyspnea alongside a history of treated pulmonary tuberculosis (PTB) by ATT 2 years ago. X-ray confirmed the presence of a rounded mass in a surrounding cavity in the lung. Tracheobronchial and chest CT images of the patient showed cavities with tuberculous nodules. Clinical symptoms of the patient were fever, malaise, anorexia, weight loss, chest pain, cough and dark mucus sputum. Aspergillus sp. was detected primarily as branching hyaline hyphae in direct examination of the sputum by calcofluor-white staining. The sample was positive with culture as well. Aspergillus flavus was identified in culture and confirmed by polymerase chain reaction (PCR) and sequencing of the ITS region of rDNA and β-tubulin of fungus. The patient signed an agreement for reporting her case as a medical document in journals or in conferences. Conclusion The importance of tuberculosis (TB) in the development of aspergillosis, even after treatment, has been highlighted by multiple studies. Microbiological and molecular evaluation are needed to detect PA quickly and accurately. The WHO reported about 8.8 million new cases of TB in 2010. Therefore, it is essential to focus more on monitoring of diagnosis and treatment of PA.

Introduction Opportunistic fungal organisms, such as Aspergillus and Candida species, tend to cause diseases in tuberculosis (TB) patients. Respiratory tract mycosis has clinical and radiological characteristics which are very similar to TB, thereby making the disease easily misdiagnosed. TB can be a predisposition to serious opportunistic fungal infections. Prolonged use of anti-TB drugs promotes the growth and reproduction of opportunistic fungi and, in turn, aggravates the course of the underlying process in the lung tissues. The study objective is to determine fungal coexistence with mycobacterium tuberculosis (MTB) in patients attending the Central Tuberculosis Reference Laboratory of the Health Center in Ghaemshahr city, Iran. Material and methods Twenty-five participants were recruited into the study during two months. For each patient, three successive morning samples during one month were collected into sterile wide-neck universal sputum mugs. Specimen collection was taken for analysis at the Laboratory. None of the participants in this study had been placed on anti-fungal therapy. Sputa samples were studied for fungal elements and MTB. Direct microscopy by three stainings – KOH + Calcofluor white, Gomori-methenamine-silver and Giemsa – and fungal culture were done on Sabouraud Dextrose agar. Analysis for acid-fast bacilli (AFB) was done by the Ziehl–Neelsen technique. Results A total of 75 fresh sputa samples were collected. Branching hyphae in 10 samples of 5 (20%) patients and pseudo-hyphae and blastoconidia in 12 samples of 5 (20%) patients were seen together with TB. Aspergillus flavus and Candida albicans were identified in the culture method and mycological exams. Discussion Mycotic disease is an important coexistence in patients with TB. Although active mycosis may be an independent marker of advanced immunosuppression, it may also act as a co-factor in accelerating and amplifying the clinical course of TB disease. It is necessary in TB patients to increase the cure rate considering coexistencing opportunistic infections.