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Itraconazole in varying doses and duration is being frequently used for the management of dermatophytosis. There is a scarcity of studies on the bioavailability of various itraconazole brands available in the market.The aim of this study was to determine the plasma concentration of itraconazole of various brands and its correlation with clinical efficacy in chronic dermatophytosis.One hundred patients with chronic dermatophytosis with age18 years were studied at the outpatient clinic of our tertiary care hospital. Plasma itraconazole level was estimated on Week 2 and Week 4 after randomly dividing the patients into Groups A, B and C who received cap itraconazole 100 mg twice a day of innovator, multinational and local generic brands, respectively, for 4 weeks. Both efficacy (cure, partial cure or no cure), safety and recurrence were compared between the three groups.At 4 weeks, number of patients classified as 'cured' were 10/26 (38.4%) in Group A, 5/22 in Group B (22.7%) and 3/21 (14.2%) in Group C (p = .002). Mycological cure rates at Week 4 in Groups A, B and C were 21 (80.8%), 17 (81.0%) and 5 (26.3%), respectively (p = .006). Plasma levels of itraconazole were comparable between the three groups at Week 2 and Week 4. No statistically significant correlation was found between itraconazole levels and treatment response in any of the groups at 4 weeks. Incidence of adverse effects and recurrence rates was also similar among the three groups.Cure rates for chronic dermatophytosis were poor with all three itraconazole brands at 4 weeks of treatment. Higher cure rates were obtained with innovator drug as compared to multinational and local generic brands at 4 weeks. Plasma levels of the three drugs were however similar, indicating that factors other than serum bioavailability are at play in determining response of chronic dermatophyte infections to oral itraconazole.

Human Coronaviruses (hCoVs) belongs to the enormous and dissimilar family of positive-sense, non-segmented, single-stranded RNA viruses. The RNA viruses are prone to high rates of mutational recombination resulting in emergence of evolutionary variant to alter various features including transmissibility and severity. The evolutionary changes affect the immune escape and reduce effectiveness of diagnostic and therapeutic measures by becoming undetectable by the currently available diagnostics and refractory to therapeutics and vaccines. Whole genome sequencing studies from various countries have adequately reported mosaic recombination between different lineage strain of SARS-CoV-2 whereby RNA dependent RNA polymerase (RdRp) gene reconnects with a homologous RNA strand at diverse position. This all lead to evolutionary emergence of new variant/ lineage as evident with the emergence of XBB in India at the time of writing this review. The continuous periodical genomic surveillance is utmost required for understanding the various lineages involved in recombination to emerge into hybrid variant. This may further help in assessing virus transmission dynamics, virulence and severity factor to help health authorities take appropriate timely action for prevention and control of any future COVID-19 outbreak.

S5.1 Antifungal resistance, September 22, 2022, 3:00 PM - 4:30 PM Objectives In tropical countries, the azole resistance in Candida tropicalis is on the rise. There are limited studies available regarding the azole resistance mechanisms in C. tropicalis. This study was designed to understand the molecular mechanisms of azole resistance in C. tropicalis by using genetic and bioinformatics approaches. Methods A total of 32 azole-resistant (R) and 10 azole-susceptible (S) clinical isolates of C. tropicalis were included in this study. All the isolates were subjected to complete gene sequencing of azole target genes including ERG11 to analyze the mutations which could lead the azole resistance. Four fragments were amplified, sequenced, and aligned to get full-length ERG11 gene. Inducible expression analysis of 17 other genes potentially associated with azole resistance was also evaluated. Homology modeling and molecular docking analysis were performed to study the effect of amino acid alterations in mediating azole resistance. Results Of the 32 resistant isolates, 12 (37.5%) showed A395T and C461T mutations in the ERG11 gene. The mean overexpression of CDR1, CDR3, TAC1, ERG1, ERG2, ERG3, ERG11, UPC2, and MKC1 in resistant isolates without mutation (R-WTM) was significantly higher (P Conclusions Nonsynonymous mutations in the ERG11 gene and coordinated overexpression of various genes including different transporters, ergosterol biosynthesis pathway, transcription factors, and stress-responsive genes are associated with azole resistance in clinical isolates of C. tropicalis.

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM Objectives The alarming situation of treatment failure cases in dermatophytosis and resistance to the first-line drug (terbinafine) is a worrisome condition for the management of tinea cases. However, studies also reported non-responders to terbinafine treatment even when the isolates are susceptible to this drug in vitro. Thus, evaluating the pharmacokinetic profile of terbinafine might help better manage dermatophytosis. This study was conducted to standardize and validate a rapid and simple reversed-phase high-performance liquid chromatography (HPLC)-based protocol for terbinafine in serum/plasma of dermatophytosis cases. Methods HPLC analysis was standardized for terbinafine drug on an Agilent 1290 infinity system (Agilent Technologies InC., USA). Chromatographic parameters including mobile phase [acetonitrile (A), methanol (M), and water (W)], flow rate (0.7-1.5 ml/min), injection volume (20 μl), and various wavelengths ranging from 220 to 265 nm under isocratic conditions were assessed and optimized. The mobile phase consisted of a filtered and degassed mix of A: W and M: W with various ratios of 85:15, 60:40, 50:50, and M-100%, respectively. Quality control samples were prepared in drug-free serum by spiking with the terbinafine at 0.0312-100 μg/mL concentrations. An equal volume of serum and acetonitrile (A) were mixed. The mixture was vigorously vortexed for 30 s, followed by high-speed centrifugation at 13 000 rpm at 40°C for 10 min. The supernatant was transferred into the chromatographic vials and placed in the autosampler of HPLC for injection. The standardized method was tested in 6 dermatophytosis patients’ serum/plasma samples collected at 3-time points (first, second, and third week of start of antifungal). Results Linearity of calibration standard for terbinafine was optimized at 250C at a flow rate of 1.0 ml/min, injection volume 20 μl, 8 minutes run time with the standardized wavelength at 245 nm under isocratic conditions. The best suitable graph was determined by plotting the area under the curve (AUC) and peak height separately against the drug concentrations measured by reversed-phase- HPLC for terbinafine drugs (Fig. 1a and b). The standardized mobile phase consisted of filtered and degassed Methanol (100, v/v). The chromatographic separation was achieved on an Agilent C18 column, and 4.3 ± 1 time represents the peak for terbinafine drug. Based on the standardized protocol, six tinea cases were included for validation, and the therapeutic range achieved for terbinafine in clinical samples was 0.6 to 1.13 μg/ml. Conclusions The standardization of HPLC method was successfully applied to quantify terbinafine in spiked samples with terbinafine drug and showed no observable interferences at the standardized parameter. Further evaluation with larger number of samples is warranted.

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM Objectives Taxonomic delineation of etiologic agents responsible for recalcitrant dermatophytosis causing epidemic in India is still debated. The organism responsible for this epidemic was previously designated as Trichophyton indotineae, a clonal offshoot of T. mentagrophytes. To evaluate the accurate identity of the agent causing the epidemic, we performed multigene sequence analysis of Trichophyton species isolated from human and animal origin. Methods The clinical isolates of T. mentagrophytes/interdigitale complex (n = 213) from PGIMER, and six isolates of animal origin (canine) from IVRI were included in the study. Seven genomic loci including internal transcribed spacer (ITS) region (n = 219), translational elongation factor (TEF 1-α) (n = 40), partial beta tubulin (BT) (n = 40), large ribosomal subunit (LSU) (n = 34), calmodulin (CAL) (n = 29), high mobility group transcription factor (HMG) (n = 17), and α-box (n = 17) were amplified by polymerase chain reaction (PCR). Phylogenetic tree was constructed by neighbor-joining method using ours and sequences retrieved from NCBI database. Trichophyton quinckeanum was used as the outgroup due to its high divergence. The identity labeling was validated as per the phylogenetic analysis of ITS gene in the present study [ITS gene (n = 374), TEF1-α (n = 184), BT (n = 52), LSU (n = 50), CAL (n = 69) and HMG transcription factor (n = 102)]. Results Phylogenetic analysis of ITS, TEF 1-α, LSU gene revealed that except for one isolate (PGI-IVRI B24-A) of animal origin belonged to ITS genotype III and rest all isolates [human (n = 213) and animal origin (n = 5)] belonged to the same cluster, i.e., T. mentagrophytes ITS genotype VIII. The phylogenetic tree constructed based on the BT gene (n = 39) also clustered all our isolates together and isolates belonging to T. mentagrophytes ITS genotype IV, VIII, and T. interdigitale and one isolate (PGI-IVRI B24-A) formed a separate cluster and did not coalesce with other genotypes. Whereas CAL gene clustered all our isolates (n = 28) together except PGI-IVRI B24-A isolate which grouped with T. mentagrophytes type VII. Further HMG analysis reveals that all the isolated Trichophyton species from humans (n = 11) and animals (n = 5) contained HMG transcription factors but lacked α-box genes. One animal isolate (PGI-IVRI B24-A) consisted of both HMG transcription factor and α-box genes. The accurate identity of the isolates was based on our phylogenetic analysis (ITS gene). Based on the analysis of the 374 ITS sequences deposited in the GenBank database, 107 sequences were mislabeled, ie, T. mentagrophytes was named T. interdigitale or vice versa. Similarly, 184, 52, 50, 69, and 102 sequences of TEF1-α, BT, LSU, CAL, and HMG transcription factor deposited in the GenBank have 6, 23, 25, 3, and 7 sequences were mislabeled, respectively. Further, for the identical isolates (n = 6), we found multiple accession numbers with different labels. Conclusion In this study, for the first time we isolated ‘Indian ITS genotype VIII’ from animal. Isolation of T. mentagrophytes type III from animal but none among humans indicates its niche among animals. Adding to the confusion, outdated/inaccurate naming for these dermatophytes in the public database has created confusion in using appropriate species designation.

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM Objectives There is an increasing incidence of recalcitrant dermatophytosis in India due to irrational use of antifungals, inappropriate treatment, and also in vitro resistance of the organism by itself. This study is done to determine the clinic-mycological profile, antifungal susceptibility, and outcome of patients with dermatophytosis in our institute. Methods All patients with culture-proven dermatophytosis attending the outpatient department of our hospital from January 2019 to December 2019 were included in the study. Detailed clinical data of all the patients were collected. Morphological Identification of the dermatophytes was done by conventional mycological methods. The isolates were sent to PGIMER Chandigarh for further identification by MALDI-TOF and antifungal susceptibility testing. Antifungal susceptibility testing was done for 47 isolates of Trichophyton species. Results Of the 155 clinical suspected cases, growth of dermatophytes was observed in 55 (35.4%) of the cases. Tinea corporis 39/55(70.9%) was the predominant clinical type The duration of infection was less than 6 months in 22/55(40%) of cases and >6 months in 33(60%) of the cases. Majority of the patients were in the age group of 20-30 years and were male. A total of 36/55 (65.4%) of the patients belong to middle socio-economic status and 19/55 to lower socioeconomic status (34.5%). In all, 10/55(19.2%) of the patients were students and 10/55 (19.2%) housewives; others include auto drivers, mechanics, teachers, cashiers, etc. All except 4 patients were from urban areas. Comorbid conditions noted were diabetes mellitus in 7/55 (12.7%), hypertension in 6/55 (10.9%), systemic steroid usage in 3/55 (5.4%), post-renal transplant status in 1/55 (1.8%), and SLE in 1/55 (1.8%). Sharing of personal use items was found in 12/55 (21.8%) of the patients and 9/55 (16.3%) of patients complained of excessive sweating. Previous therapy with topical and systemic antifungals was given in 32/55 (58.8%) of the patients, other modes of treatment like homeopathy, and ayurveda in 4/55 (7.2%). Topical steroids were given to 4 patients and 19/55 (34.5%) of the patients were not treated for the infection. Trichophyton mentagrophytes complex (69%) was the predominant species complex isolated followed by T. rubrum, M. gypseum, M.canis, and T. tonsurans. Of the 47 Trichophyton isolates subjected to AFST, all the isolates showed MIC >1ug/ml for fluconazole and griseofulvin. Majority of the isolates showed MIC of 1) were exhibited by 5 isolates for terbinafine and naftifine, 2 isolates for sertoconazole, and 1 isolate for voriconazole. Molecular detection of terbinafine resistance done in 15/55 isolates showed mutation in the squalene epoxidase (SE) gene leading to F397L substitutions in 2 isolates. In the present study, the patients were treated with both oral and topical antifungals Of the 55 cases, complete cure was observed in 21 (38%), partial cure in 9 (16.3%), and relapse in 5 (9%) on 2 years follow-up. However, 20/55 (36.3%) of the cases were lost to follow-up. Conclusion Trichophyton mentagrophytes complex was the predominant species isolated and Tinea corporis was the commonest clinical presentation. Resistance to terbinafine, griseofulvin, and fluconazole has been noted. Dermatophytosis has become a difficult to treat disease due to antifungal resistance, and chronicity/recurrence of the lesions. Early diagnosis followed by rational antifungal therapy are essential for improved outcome.

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM Objectives To determine the minimum inhibitory concentrations (MICs) of a novel antifungal lipopeptide against clinical isolates of dermatophytes of human origin. Methods To perform antifungal susceptibility testing (AFST) by CLSI microbroth dilution method, a reversed-phase high-performance liquid chromatography (RP-HPLC) purified lipopeptide of 1071.4 Da from a wild-type soil isolate Bacillus subtilis was used and compared with the standard allylamine terbinafine MICs. Briefly, 1200 ml of cell-free culture supernatant was extracted using a solvent mixture and silica gel (230-400 mesh size)-based adsorption chromatography. The semi-preparative RP-HPLC system consisted of an Agilent quaternary pump and a variable wavelength detector equipped with a Phenomenex Luna C18 column (10 mm × 250 mm, 5 μm). The solvent system for RP- HPLC was (A) water with 0.1% trifluoroacetic acid (TFA) and (B) acetonitrile containing 0.1% TFA. The gradient of solvent B used for purification was as follows: 0%-54% for 0-20 min at the flow rate of 1 ml/min, 54%-60% from 20-48 min at 0.5 ml/min, 60%-100% from 48-58 min at 0.5 ml/min, 100%-0% from 58-65 min at 1 ml/min and monitored at 210 nm. Results Superficial skin infections are caused by dermatophytes including Trichophyton spp. Nowadays, resistance to terbinafine in Trichophyton spp. isolates with higher MICs have been documented in India. We report here the antifungal prowess of a novel small antifungal lipopeptide against 20 clinical isolates of Trichophyton spp. of human origins (from human skin scrapings and nails) with the clinical diagnosis of tinea corporis/cruris and tinea unguium. The representative photographs of T. tonsurans, T. rubrum, and T. mentagrophytes complex are provided below. A total of 6 isolates of T. mentagrophytes and T. rubrum carry point mutations at F397L of squalene epoxidase (SQLE) protein. The in vitro antifungal efficacies determined by AFST revealed that the lipopeptide showed less or equivalent MICs (100% inhibition) in the case of five dermatophytes. The lipopeptide drug has exhibited improved MICs against two T. mentagrophytes complex and two T. rubrum isolates with amino acid substitution F397L in SQLE protein. Trichophyton mentagrophytes complex and T. rubrum with F397L mutations were inhibited at MICs 4-32 μg/mL of terbinafine. In comparison, the lipopeptide showed 4-16 μg/ml (100% inhibition). In the case of all four Trichophyton tonsurans, the MICs ranged between 2-4 μg/ml for the lipopeptide. Conclusions The broad-spectrum lipopeptide showed promising antifungal activity against dermatophytes and may be considered for nano-emulsion formulation and tested for topical application in a mice model.

COVID-19 pandemic has inflicted a painful unforgettable number of deaths throughout the world. Hematological inflammatory and organ-specific biomarkers are universally practiced in helping clinical decisions in various infectious diseases. Accordingly, their role in predicting progression and severity, and fatal outcome of COVID-19 was investigated to take initial appropriate treatment measures to reduce associated mortality.MethodsThe retrospective analysis of a total of 126 COVID-19 cases representing mild, moderate, severe, and succumbed cases were assessed for the pattern of hematological, inflammatory, and organ-specific biomarkers.ResultsA total of 126 proven cases of SARS-CoV-2 infection were retrospectively analyzed for the association of various biomarkers with the COVID-19 disease progression. The CBC analysis showed that the median TLC was high for the severe group of both males (12.49 × 103/μl) and females (14.23 x103/μl). Similarly, the neutrophil count was also found high in the severe group, whereas the monocytes count showed low median values in severe cases, but both these parameters had no significant difference among the males and the females. The platelet count showed a significant difference (p=0.018) among the non-severe and severe groups between males and females. Among inflammatory markers, D-dimer, CRP, LDH, and APTT showed a higher median value in severe cases among both the males and females while ESR value was higher in non-severe cases and ferritin showed similar values in both severe and non-severe cases. The liver and kidney function parameters were also analyzed and a significant P-value was found for ALP (p=0.004), ALT (p=0.032), and AST (p=0.009) in the non-severe vs. severe category of COVID-19 patients.DiscussionHigh TLC, neutrophilia, lymphopenia, thrombocytopenia, and eosinopenia are the potential risk factor for the progression of COVID-19 disease for severe and fatal outcomes. Inflammatory markers of D-dimer, CRP, LDH, APTT, and ferritin above normal range also carries the potential risk of severe and fatal outcome in COVID-19 disease. Higher ALT, AST, and serum creatinine may also carry a poor prognosis.

BACKGROUND Accurate and early identification of dermatophytes enables prompt antifungal therapy. However, phenotypic and molecular identification methods are time-consuming. MALDI-TOF MS-based identification is rapid, but an optimum protocol is not available. OBJECTIVES To develop and validate an optimum protein extraction protocol for the efficient and accurate identification of dermatophytes by MALDI-TOF MS. MATERIALS/METHODS Trichophyton mentagrophytes complex (n = 4), T. rubrum (n = 4) and Microsporum gypseum (n = 4) were used for the optimisation of protein extraction protocols. Thirteen different methods were evaluated. A total of 125 DNA sequence confirmed clinical isolates of dermatophytes were used to create and expand the existing database. The accuracy of the created database was checked by visual inspection of MALDI spectra, MSP dendrogram and composite correlation index matrix analysis. The protocol was validated further using 234 isolates. RESULT Among 13 protein extraction methods, six correctly identified dermatophytes but with a low log score (≤1.0). The modified extraction protocol developed provided an elevated log score of 1.6. Significant log score difference was observed between the modified protocol and other existing protocols (T. mentagrophytes complex: 1.6 vs. 0.2-1.0, p

Trichophyton(T.)mentagrophytesnow accounts for an overwhelming majority of clinical cases in India, a new “Indian genotype” (T. mentagrophytes ITS genotype VIII)having been isolated from skin samples obtained from cases across a wide geographical distribution in this country. The conventional diagnostic methods, like fungal culture, are, however, inadequate for diagnosing this agent. Thus, molecular methods of diagnosis are necessary for proper characterization of the causative agent. The shift in the predominant agent of dermatophytosis fromT. rubrumtoT. mentagrophytes, within a relatively short span of time, is without historic parallel. The apparent ease of transmission of a zoophilic fungus among human hosts can also be explained by means of mycological phenomena, like anthropization.

Dermatophytosis has attained unprecedented dimensions in recent years in India. Its clinical presentation is now multifarious, often with atypical morphology, severe forms and unusually extensive disease in all age groups. We hesitate to call it an epidemic owing to the lack of population-based prevalence surveys. In this part of the review, we discuss the epidemiology and clinical features of this contemporary problem. While the epidemiology is marked by a stark increase in the number of chronic, relapsing and recurrent cases, the clinical distribution is marked by a disproportionate rise in the number of cases with tinea corporis and cruris, cases presenting with the involvement of extensive areas, and tinea faciei.

Dermatophytosis has gained interest in India due to rise in terbinafine resistance and difficulty in management of recalcitrant disease. The terbinafine resistance in dermatophytes is attributed to single nucleotide polymorphisms (SNPs) in squalene epoxidase (SE) gene. We evaluated the utility of amplified refractory mutation system polymerase chain reaction (ARMS PCR) for detection of previously reported point mutations, including a mutation C1191A in the SE gene in Trichophyton species. ARMS PCR was standardized using nine non-wild type isolates and two wild type isolates of Trichophyton species. Study included 214 patients with dermatophyte infection from March through December 2017. Antifungal susceptibility testing of isolated dermatophytes was performed according to CLSI-M38A2 guidelines. Among dermatophytes isolated in 68.2% (146/214) patients, Trichophyton species were predominant (66.4%). High (>2 mg/L, cut off) minimum inhibitory concentrations to terbinafine were noted in 15 (15.4%) Trichophyton mentagrophytes complex isolates. A complete agreement was noted between ARMS PCR assay and DNA sequencing. C to A transversion was responsible for amino acid substitution in 397th position of SE gene in terbinafine resistant isolates. Thus, the ARMS PCR assay is a simple and reliable method to detect terbinafine-resistant Trichophyton isolates.

Increasing reports of azole resistance inCandida tropicalis, highlight the development of rapid resistance detection techniques. Nonsynonymous mutations in the lanosterol C14 alpha-demethylase (ERG11) gene is one of the predominant mechanisms of azole resistance inC.tropicalis. We evaluated the tetra primer-amplification refractory mutation system-PCR (T-ARMS-PCR), restriction site mutation (RSM), and high-resolution melt (HRM) analysis methods for rapid resistance detection based onERG11polymorphism inC.tropicalis. Twelve azole-resistant and 19 susceptible isolates ofC.tropicaliswere included. DNA sequencing of the isolates was performed to check theERG11polymorphism status among resistant and susceptible isolates. Three approaches T-ARMS-PCR, RSM, and HRM were evaluated and validated for the rapid detection ofERG11mutation. The fluconazole MICs for the 12 resistant and 19 susceptible isolates were 32–256 mg/L and 0.5–1 mg/L, respectively. The resistant isolates showed A339T and C461T mutations in theERG11gene. The T-ARMS-PCR and RSM approaches discriminated all the resistant and susceptible isolates, whereas HRM analysis differentiated all except one susceptible isolate. The sensitivity, specificity, analytical sensitivity, time, and cost of analysis suggests that these three methods can be utilized for the rapid detection ofERG11mutations inC.tropicalis. Additionally, an excellent concordance with DNA sequencing was noted for all three methods. The rapid, sensitive, and inexpensive T-ARMS-PCR, RSM, and HRM approaches are suitable for the detection of azole resistance based onERG11polymorphism inC.tropicalisand can be implemented in clinical setups for batter patient management.

Dermatophytosis due to the Trichophyton mentagrophytes-Trichophyton interdigitale complex is being increasingly reported across India. Reports of therapeutic failure have surfaced recently, but there are no clinical break points (CBP) or epidemiological cutoffs (ECVs) available to guide the treatment of dermatophytosis. In this study, a total of 498 isolates of the T. mentagrophytes -interdigitale complex were collected from six medical centers over a period of five years (2014 to 2018). Antifungal susceptibility testing of the isolates was carried out for itraconazole, fluconazole, ketoconazole, voriconazole, luliconazole, sertaconazole, miconazole, clotrimazole, terbinafine, amorolfine, naftifine, ciclopirox olamine, and griseofulvin. The MICs (in mg/liter) comprising >95% of the modeled populations were as follows: 0.06 for miconazole, luliconazole, and amorolfine; 0.25 for voriconazole; 0.5 for itraconazole, ketoconazole, and ciclopirox olamine; 1 for clotrimazole and sertaconazole; 8 for terbinafine; 16 for naftifine; 32 for fluconazole; and 64 for griseofulvin. A high percentage of isolates above the upper limit of the wild-type MIC (UL-WT) were observed for miconazole (29%), luliconazole (13.9%), terbinafine (11.4%), naftifine (5.2%), and voriconazole (4.8%), while they were low for itraconazole (0.2%). Since the MICs of itraconazole were low against the T. mentagrophytes -interdigitale complex, this could be considered the choice of first-line treatment. The F397L mutation in the squalene epoxidase (SE) gene was observed in 77.1% of isolates with a terbinafine MIC of ≥1 mg/liter, but no mutation was detected in isolates with a terbinafine MIC of

One of the canonical features of the current outbreak of dermatophytosis in India is its unresponsiveness to treatment in majority of cases. Though there appears to be discordance betweenin vivoandin vitroresistance, demonstration ofin vitroresistance of dermatophytes to antifungals by antifungal susceptibility testing is essential as it may help in appropriate management. The practical problem in the interpretation of antifungal susceptibility testing is the absence of clinical breakpoints and epidemiologic cutoff values. In their absence, evaluation of the upper limit of a minimal inhibitory concentration of wild type isolates may be beneficial for managing dermatophytosis and monitoring the emergence of isolates with reduced susceptibility. In the current scenario, most of the cases are unresponsive to standard dosages and duration of treatment recommended until now. This has resulted in many ex-cathedra modalities of treatment that are being pursued without any evidence. There is an urgent need to carry out methodical research to develop an evidence base to formulate a rational management approach in the current scenario.

Superficial fungal infections (SFIs) affect millions of people worldwide. The major causes of these infections include dermatophytes, non-dermatophyte molds (NDM), and yeasts. The etiological agents are restricted to stratum corneum. SFIs of importance include dermatophytosis, Malassezia associated infection, keratitis, and rare superficial fungal infection (tinea nigra and piedra). All the etiological agents have varied geographical distribution occurring in tropics where high humidity and hot climatic condition predominate. SFIs are also reported as epidemic infections in area of overcrowding and poor hygienic conditions. From the past two decades, the cases are increasingly being reported in patients undergoing transplants, chemotherapy and in immunocompromised patients. The epidemiology of SFIs in Asia is interesting as most of these regions have the climatic condition that supports the fungi to survive and proliferate.

Lasiodiplodia theobromae is a dematiaceous non-dermatophyte mold (NDM), rarely reported to cause onychomycosis. Here, we report three cases of toenail onychomycosis caused by L. theobromae in agricultural workers. Two patients presented with total dystrophic onychomycosis and one with distal and lateral subungual onychomycosis. These cases have unique importance that besides traumatized nail infection, its rarity has adversely affected the agricultural workers livelihood as L. theobromae sporulates poorly, resistant to commonly used antifungal therapy. From the literature search, we assume that this is the first case series of onychomycosis caused by L. theobromae from a tropical country like India.

We report invasive candidiasis caused by Candida viswanathii over 2 time periods during 2013–2015 in a tertiary care hospital in Chandigarh, India. Molecular typing revealed multiple clusters of the isolates. We detected high MICs for fluconazole in the second time period.

Background: An alarming increase in number of patients with chronic and recurrent dermatophytosis has invoked the need to study immunological parameters of the host in addition to traditional pathogens studies. This study was done to evaluate delayed type of hypersensitivity (DTH) response by estimating TH1 cells along with TH17 cells and immediate hypersensitivity (IH) response by estimating TH2 cells population in peripheral blood along with intradermal trichophytin skin test in patients with recurrent dermatophytosis. Methods: In this case-control study, 100 patients with recurrent dermatophytosis and 50 controls were included. Flow-cytometric evaluation of TH1, TH17 and TH2 cells in peripheral blood along with intradermal trichophytin extract test was done. Dermatophytes pathogens were isolated on culture and antifungal drug susceptibility test was done. Relevant risk factors for recurrent disease were analysed and serum IgE levels were estimated. Findings: TH1 cells were reduced in 72.6 % cases vs 52 % controls (p=0.01) and TH17 cells were reduced in 49.4% cases vs 26 % controls (p=0.006). Intradermal trichophytin test demonstrated negative DTH response in 100 % of cases (p=0.0001). Positive IH response was observed in 91% cases vs 68% controls (p=0.0001). T.mentagrophytes complex (95.8%) was the most common species isolated followed by T.rubrum (4.16%). The risk factors associated were family history of tinea, sharing of towels and clothes and corticosteroids use in recent past (p= 0.007, p=0.009, p=0.0001). Serum IgE was elevated in 83.15 % cases (p=0.01). Interpretations:Our study demonstrated impaired DTH response and reduced TH1 and TH17 cell population in patients with recurrent dermatophytosis. Funding Statement: The authors declare: "None ." Declaration of Interests: The authors declare: "None." Ethics Approval Statement: The study protocol was approved by the Institutional Ethics Committee (Intramural) of the Postgraduate Institute of Medical Education and Research, Chandigarh.

Opportunistic fungal infections of the skin and nail are frequently encountered in human. Recent years have shown increased incidence of fungal infections especially in immunocompromised patients. Onychomycosis in HIV-infected patients is reported to occur in 15-40%, four times more than in the general population. Here, we report a case of fingernail proximal subungual onychomycosis with associated skin infection caused by an opportunistic mold, Aspergillus sydowii, in a HIV positive individual. Isolation of A. sydowii from nail and skin of an immunocompromised person needs accurate identification for successful treatment.

Mucormycosis is an angio-invasive infection, predominantly acquired by inhalation of sporangiospores from the environment. However, the burden of Mucormycetes sporangiospores in the air is not well studied. We aimed to estimate the burden of Mucormycetes spores in the outdoor and indoor (hospital) environment across different seasons in north India. A total of 380 air samples from outdoor (n = 180) and indoor (n = 200) environment were included in the study. Air samples were suctioned using air sampler (100 l/min) and cultured on Dichloran Rose Bengal Chloramphenicol (DRBC) with benomyl for selective isolation of Mucormycetes. The isolates were identified by phenotypic and genotypic methods. The mean spore count (±SD) of Mucormycetes (cfu/m3) in outdoor samples varied from 0.73 (±0.96) to 8.60 (±5.70) across different seasons. In hospital, the mean spore count varied from 0.68 (±1.07) to 1.12 (±1.07) and 0.88 (±1.01) to 1.72 (±2.17) for air-conditioned wards and non-air-conditioned wards, respectively. Rhizopus arrhizus was the predominant agent isolated from both indoor and outdoor environment followed by Cunninghamella species. We also report a single isolate of the rare mucormycete agent, Apophysomyces variabilis from outdoor environment. The present study highlights the presence of low spore burden of Mucormycetes in outdoor and hospital settings in north India. This study also reports the first isolation of A. variabilis from air samples in the Indian subcontinent.

Dermatophytosis, the commonest superficial fungal infection, has gained recent attention due to its change of epidemiology and treatment failures. Despite the availability of several agents effective against dermatophytes, the incidences of chronic infection, reinfection, and treatment failures are on the rise. Trichophyton rubrum and Trichophyton interdigitale are the two species most frequently identified among clinical isolates in India. Consecutive patients ( n = 195) with suspected dermatophytosis during the second half of 2014 were included in this study. Patients were categorized into relapse and new cases according to standard definitions. Antifungal susceptibility testing of the isolated Trichophyton species ( n = 127) was carried out with 12 antifungal agents: fluconazole, voriconazole, itraconazole, ketoconazole, sertaconazole, clotrimazole, terbinafine, naftifine, amorolfine, ciclopirox olamine, griseofulvin, and luliconazole. The squalene epoxidase gene was evaluated for mutation (if any) in 15 T. interdigitale and 5 T. rubrum isolates exhibiting high MICs for terbinafine. A T1189C mutation was observed in four T. interdigitale and two T. rubrum isolates. This transition leads to the change of phenylalanine to leucine in the 397th position of the squalene epoxidase enzyme. In homology modeling the mutant residue was smaller than the wild type and positioned in the dominant site of squalene epoxidase during drug interaction, which may lead to a failure to block the ergosterol biosynthesis pathway by the antifungal drug.

Introduction: Haemophilus influenzae is responsible for wide range of localized and invasive lower respiratory tract infections (LRTI) with the highest burden of disease in low and middle income countries. Aim: The aim of the present study was to characterize the H.influenzae isolates from suspected LRTI. Materials and Methods: A prospective study was conducted over a period of one and half years (December 2012 to May 2014) including patients with LRTI. H.influenzae was isolated from lower respiratory specimens following standard procedures. Complete characterization of the isolates was performed by bio typing, capsular serotyping, molecular genotyping and antibiotic susceptibility testing. The predisposing factors and clinical presentation were studied in the infected patients. Results: A total of 8995 samples were received during the study period, out of which growth was significantly observed in 2848 (31.7%) samples. Among the various respiratory pathogens, H.influenzae was isolated from 175 (6.14%) patients. Majority (78.9%) of the patients presented with acute exacerbations of chronic obstructive pulmonary disease. The isolates most frequently were of Biotype II (35.42%). Only four of the 50 isolates subjected to capsular serotyping were typeable and were of type b, e and f. All the 50 isolates tested were found to be non-typeable by PCR for capsular genotyping. Maximum resistance was found against ampicillin (9.71%). Conclusion: H.influenzae was found to be a significant cause of LRTI. Majority of the isolates were found to be non typeable strains. Non typeable H. influenzae isolates should not be neglected as they can colonize the respiratory tract in COPD patients and can lead to biofilm formation and treatment failure.