Case and Research Letter
Photodynamic Therapy With Methyl-aminolevulinate can be Useful in the Management of Scytalidium Infections
La terapia fotodinámica con metilaminolevulinato puede ser útil en el manejo de las infecciones por Scytalidium
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"apellidos" => "Gilaberte" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Unidad de Microbiología, Hospital Royo Villanova, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Ciencias de la Salud de Aragón, Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital Universitario Miguel Servet, Zaragoza, Universidad de Zaragoza, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unidad de Dermatología, Hospital San Jorge, Huesca, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La terapia fotodinámica con metilaminolevulinato puede ser útil en el manejo de las infecciones por <span class="elsevierStyleItalic">Scytalidium</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 453 "Ancho" => 900 "Tamanyo" => 99925 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Onychomycosis of the first and second toes of right foot caused by <span class="elsevierStyleItalic">Scytalidium dimidiatum</span> infection, before photodynamic therapy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Scytalidium</span> spp., recently renamed <span class="elsevierStyleItalic">Neoscytalidium</span> spp., are keratinophilic molds that cause superficial disease (skin, nails) which is indistinguishable from and sometimes occurs concomitantly with dermatophyte infections.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> While infection with these fungi, and in particular <span class="elsevierStyleItalic">Scytalidium dimidiatum</span>, is fairly common in tropical climates, it is rare in Spain. The clinical and microbiological diagnosis of such an infection is a challenge, especially because the growth of these fungi is suppressed by the antimicrobial component of the media routinely used for the isolation of dermatophytes. There is, at present, no effective oral or topical treatment for skin and nail infections caused by <span class="elsevierStyleItalic">Scytalidium.</span><a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Antimicrobial photodynamic therapy (PDT) is an emerging treatment for infections. This process involves the application of a photosensitizer that binds to the microorganisms. When excited by an appropriate light source in the presence of oxygen the photosensitizer produces reactive oxygen species that induce cell death, either by apoptosis or necrosis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Our group had recently demonstrated the usefulness of methyl-aminolevulinate PDT in the treatment of onychomycosis caused by non-dermatophyte molds<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and yeasts.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A 61-year-old healthy woman from Cameroon, resident in Spain for more than 5 years, presented with a very long history of dystrophic toenails. She had been diagnosed with onychomycosis caused by <span class="elsevierStyleItalic">Aspergillus</span> spp. and treated with several topical antifungal agents with no improvement. On examination, she presented thickened, opaque nail plates with a yellow or brown discoloration and cracked surfaces (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Significant scaling was observed around the nails, between the toes, and on the soles. Her fingernails were unaffected.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Nail clippings and periungual skin swabs confirmed <span class="elsevierStyleItalic">S. dimidiatum</span> on microscopy and cycloheximide-free agar mycological culture. No dermatophytes were found, but colonies of <span class="elsevierStyleItalic">Aspergillus</span> spp. were seen on Sabouraud plates from 1 of the 2 affected toenails.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Bearing in mind the failure of previous antifungal treatments and the lack of any effective treatment for this infection, and encouraged by our good results in onychomycosis,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> proposed this treatment to the patient.</p><p id="par0030" class="elsevierStylePara elsevierViewall">For five days prior to PDT, a combination of 40% urea and 1% bifonazole (Mycospor Onicoset<span class="elsevierStyleSup">®</span>) ointment was applied every night in occlusion to the nail plates. On the day of treatment, methyl-aminolevulinate (Metvix<span class="elsevierStyleSup">®</span>) was applied to the nail plates and periungual skin, which were then covered with an occlusive dressing (Tegaderm<span class="elsevierStyleSup">®</span>) and protected from light for 3<span class="elsevierStyleHsp" style=""></span>h, as previously described.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> When the dressing was removed, the nails were cleaned with 70% ethanol and irradiated using a 635<span class="elsevierStyleHsp" style=""></span>nm light emitting diode lamp (Aktilite<span class="elsevierStyleSup">®</span>, 37<span class="elsevierStyleHsp" style=""></span>J/cm<span class="elsevierStyleSup">2</span>). No side effects were observed during or after treatment. The same procedure was repeated 1 week later and every 2 weeks thereafter. Microbiological cultures became negative after the third session. A total of 4 sessions were administered.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Clinical improvement was noticed after 2 months. Four months later, the patient was clinically and microbiologically cured according to the standard criteria (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). After 6 months of follow-up, cultures became positive in 1 of the 2 nails, but the nails remained clinically cured and there was no evidence under microscopy of nail penetration.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Infection with <span class="elsevierStyleItalic">S. dimidiatum</span> accounts for under 1% of cases of onychomycosis and seldom responds to amorolfine or terbinafine.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Recently, an intermittent posaconazole regimen has been proposed to treat superficial <span class="elsevierStyleItalic">S. dimidiatum</span> infection.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However, all of these drugs are expensive and can have significant adverse effects. Moreover, there is little or no evidence of their effectiveness in this setting.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Fewer than 50 cases of onychomycosis treated with aminolevulinic acid or methyl-aminolevulinate PDT have been reported and most of these were caused by dermatophytes.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–8</span></a> Our group obtained good results with methyl-aminolevulinate, using one protocol based on the one previously reported by Piraccini et al.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> In localized mycosis, the therapeutic effect of PDT is twofold: the treatment directly kills the fungus and also reinforces the fungicidal effect by stimulating host immune cells, especially neutrophils.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Although in previous cases<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> we have successfully used a protocol with a 2-week interval between sessions, in this case we made some modifications. We reduced the interval between the first and second sessions to 1 week in an attempt to reduce the recovery capacity of the fungus. The results of <span class="elsevierStyleItalic">in vitro</span> experiments with dermatophytes suggest that reducing the interval between PDT sessions will improve the fungicidal effect.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Microbiological diagnosis of onychomycosis is difficult; in fact up to 90% of the cases microbiologically diagnosed the first laboratory result may be negative.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In our case, however, it is unlikely that the culture results after PDT were false negatives because no antimicrobial substances were present in the medium used. Another problem associated with onychomycosis in general, and <span class="elsevierStyleItalic">Scytalidium</span> infection in particular, is that recurrence is frequent. In this patient we observed microbiological reappearance of the fungus without clinical recurrence. A possible solution for recalcitrant cases might be periodic administration of PDT or a combination of PDT with an antifungal drug over a period of time.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 453 "Ancho" => 900 "Tamanyo" => 99925 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Onychomycosis of the first and second toes of right foot caused by <span class="elsevierStyleItalic">Scytalidium dimidiatum</span> infection, before photodynamic therapy.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 669 "Ancho" => 900 "Tamanyo" => 172335 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Nail plates showing significant clinical improvement 4 months after 4 sessions of methyl-aminolevulinate photodynamic therapy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Development of murine models of disseminated infection by <span class="elsevierStyleItalic">Neoscytalidium dimidiatum</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 6 | 10 | 16 |
| 2024 Octubre | 52 | 41 | 93 |
| 2024 Septiembre | 45 | 20 | 65 |
| 2024 Agosto | 85 | 45 | 130 |
| 2024 Julio | 53 | 31 | 84 |
| 2024 Junio | 63 | 28 | 91 |
| 2024 Mayo | 58 | 29 | 87 |
| 2024 Abril | 59 | 21 | 80 |
| 2024 Marzo | 57 | 30 | 87 |
| 2024 Febrero | 50 | 22 | 72 |
| 2024 Enero | 43 | 22 | 65 |
| 2023 Diciembre | 48 | 21 | 69 |
| 2023 Noviembre | 53 | 27 | 80 |
| 2023 Octubre | 46 | 21 | 67 |
| 2023 Septiembre | 50 | 29 | 79 |
| 2023 Agosto | 45 | 16 | 61 |
| 2023 Julio | 76 | 31 | 107 |
| 2023 Junio | 50 | 24 | 74 |
| 2023 Mayo | 44 | 20 | 64 |
| 2023 Abril | 41 | 18 | 59 |
| 2023 Marzo | 37 | 23 | 60 |
| 2023 Febrero | 39 | 23 | 62 |
| 2023 Enero | 29 | 24 | 53 |
| 2022 Diciembre | 49 | 28 | 77 |
| 2022 Noviembre | 34 | 30 | 64 |
| 2022 Octubre | 55 | 36 | 91 |
| 2022 Septiembre | 44 | 65 | 109 |
| 2022 Agosto | 35 | 60 | 95 |
| 2022 Julio | 26 | 64 | 90 |
| 2022 Junio | 32 | 45 | 77 |
| 2022 Mayo | 38 | 49 | 87 |
| 2022 Abril | 30 | 35 | 65 |
| 2022 Marzo | 51 | 37 | 88 |
| 2022 Febrero | 32 | 25 | 57 |
| 2022 Enero | 27 | 42 | 69 |
| 2021 Diciembre | 36 | 49 | 85 |
| 2021 Noviembre | 30 | 34 | 64 |
| 2021 Octubre | 37 | 54 | 91 |
| 2021 Septiembre | 39 | 49 | 88 |
| 2021 Agosto | 13 | 36 | 49 |
| 2021 Julio | 22 | 35 | 57 |
| 2021 Junio | 28 | 29 | 57 |
| 2021 Mayo | 24 | 32 | 56 |
| 2021 Abril | 43 | 64 | 107 |
| 2021 Marzo | 57 | 32 | 89 |
| 2021 Febrero | 49 | 29 | 78 |
| 2021 Enero | 32 | 16 | 48 |
| 2020 Diciembre | 35 | 22 | 57 |
| 2020 Noviembre | 17 | 16 | 33 |
| 2020 Octubre | 18 | 12 | 30 |
| 2020 Septiembre | 39 | 11 | 50 |
| 2020 Agosto | 20 | 21 | 41 |
| 2020 Julio | 27 | 11 | 38 |
| 2020 Junio | 27 | 27 | 54 |
| 2020 Mayo | 20 | 23 | 43 |
| 2020 Abril | 23 | 22 | 45 |
| 2020 Marzo | 34 | 18 | 52 |
| 2020 Febrero | 6 | 0 | 6 |
| 2020 Enero | 0 | 1 | 1 |
| 2019 Diciembre | 4 | 3 | 7 |
| 2019 Noviembre | 0 | 2 | 2 |
| 2019 Octubre | 1 | 0 | 1 |
| 2019 Septiembre | 1 | 0 | 1 |
| 2019 Agosto | 0 | 3 | 3 |
| 2019 Julio | 3 | 7 | 10 |
| 2019 Junio | 0 | 8 | 8 |
| 2019 Mayo | 2 | 4 | 6 |
| 2019 Abril | 0 | 1 | 1 |
| 2019 Marzo | 0 | 4 | 4 |
| 2019 Febrero | 4 | 1 | 5 |
| 2018 Diciembre | 0 | 2 | 2 |
| 2018 Noviembre | 1 | 3 | 4 |
| 2018 Octubre | 1 | 1 | 2 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Febrero | 37 | 0 | 37 |
| 2018 Enero | 31 | 7 | 38 |
| 2017 Diciembre | 44 | 11 | 55 |
| 2017 Noviembre | 36 | 4 | 40 |
| 2017 Octubre | 28 | 4 | 32 |
| 2017 Septiembre | 25 | 12 | 37 |
| 2017 Agosto | 51 | 10 | 61 |
| 2017 Julio | 41 | 7 | 48 |
| 2017 Junio | 48 | 11 | 59 |
| 2017 Mayo | 37 | 10 | 47 |
| 2017 Abril | 34 | 13 | 47 |
| 2017 Marzo | 25 | 13 | 38 |
| 2017 Febrero | 73 | 5 | 78 |
| 2017 Enero | 27 | 5 | 32 |
| 2016 Diciembre | 35 | 6 | 41 |
| 2016 Noviembre | 48 | 11 | 59 |
| 2016 Octubre | 69 | 10 | 79 |
| 2016 Septiembre | 104 | 10 | 114 |
| 2016 Agosto | 44 | 10 | 54 |
| 2016 Julio | 33 | 13 | 46 |
| 2016 Junio | 6 | 16 | 22 |
| 2016 Mayo | 6 | 5 | 11 |
| 2016 Abril | 3 | 71 | 74 |
| 2016 Marzo | 2 | 0 | 2 |
| 2016 Febrero | 5 | 6 | 11 |
| 2016 Enero | 3 | 0 | 3 |
| 2015 Diciembre | 20 | 4 | 24 |
| 2015 Noviembre | 6 | 11 | 17 |
| 2015 Octubre | 2 | 2 | 4 |
| 2015 Septiembre | 2 | 1 | 3 |
| 2015 Agosto | 7 | 3 | 10 |
| 2015 Julio | 30 | 0 | 30 |
| 2015 Junio | 30 | 0 | 30 |
| 2015 Mayo | 57 | 0 | 57 |
| 2015 Abril | 32 | 1 | 33 |
| 2015 Marzo | 39 | 0 | 39 |
| 2015 Febrero | 38 | 1 | 39 |
| 2015 Enero | 35 | 0 | 35 |
| 2014 Diciembre | 52 | 0 | 52 |
| 2014 Noviembre | 50 | 0 | 50 |
| 2014 Octubre | 50 | 0 | 50 |
| 2014 Septiembre | 47 | 0 | 47 |
| 2014 Agosto | 32 | 0 | 32 |
| 2014 Julio | 23 | 0 | 23 |
| 2014 Junio | 42 | 0 | 42 |
| 2014 Mayo | 37 | 0 | 37 |
| 2014 Abril | 31 | 0 | 31 |
| 2014 Marzo | 40 | 6 | 46 |
| 2014 Febrero | 39 | 10 | 49 |
| 2014 Enero | 38 | 4 | 42 |
| 2013 Diciembre | 35 | 7 | 42 |
| 2013 Noviembre | 36 | 10 | 46 |
| 2013 Octubre | 16 | 18 | 34 |
| 2013 Septiembre | 2 | 5 | 7 |
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