Dermatophytosis

SUMMARY

Dermatophytosis are superficial mycoses caused by fungi that can invade stratum corneum and keratinized tissues. In order to study the frequency of dermatophytes species and the clinical manifestations caused by these fungi, in Sao Paulo, SP, Brazil, the authors analyzed cultures isolated at the Mycology Laboratory from a selected population (15,300 out-patients of the Hospital das Clinicas, Department of Dermatology, Faculty of Medicine of University of Sao Paulo) from January 1992 to June 2002.

The most prevalent dcrmatophyte was Trichophyton rubrum (48.7%), followed by Microsporum canis (20.9%), Trichophyton tonsurans (13.8%), Trichophyton mentagrophytes (9.7%), Epidermophyton floccosum (4.1%), and Microsporum gypseum (2.5%). These agents determined more than one clinical manifestation, i.e., tinea corporis (31.5%), tinea capitis (27.5%), tinea unguium (14.8%), tinea cruris (13.9%), tineapedis (9.9%), and tinea manuum( 1.9%). Clinical variants of dermatophytosis and their relationship to the etiologic agents were studied and the results were compared to those obtained in previous studies in other regions of Brazil and in other countries.

KEYWORDS: Dermatophytosis; Dermatophyte; Tinea; Selected population; Frequency.

INTRODUCTION

Dermatophytes are a group of fungi that, during their parasitic life, utilize keratin as a substrate, infecting the skin, hairs and nails and thereby cause superficial mycoses in humans and animals51. They are universally distributed and may be categorized as geophilic, zoophilic and anthropophilic depending on their natural habitat2,20,43. According to the morphological characteristics of the aleuriospores they are classified in three anamorphic genera: Trichophyton, Epidermophyton and Microsporum11. Telcomorphs of dermatophytes are classified in the genus Arthmderma16.

During the evolution of dermatophytes, more species have evolved a dependency on human infection than on any other species of animals. This probably is a result of our soft "naked" stratum corneum, the wearing of clothing and shoes and our gregarious behavior45.

Dermatophytosis are fungal infections commonly occurring in tropical countries, often representing a public health problem. The distribution and frequency of dermatophytosis and their etiologic agents vary according to the geographic region studied, the socio-economic level of the population, the time of study, the climatic variations, the presence of domestic animals, and age45.

This study investigated the frequency of dermatophyte species and the clinical variants of dcrmatophytosis in Sao Paulo City, Sao Paulo, Brazil, during the period from 1992 to 2002.

MATERIALS AND METHODS

A total of 15,300 cases of superficial mycotic infections were diagnosed during the period from January 1992 to June 2002. Specimens were collected from ambulatory patients attended in the Mycology Laboratory of Department of Dermatology of Hospital das Clinicas. Skin, nail scrapings, and broken hairs were clarified in 10% potassium hydroxide plus dimethyl sulfoxide for microscopic examination. Cultures were performed only when asked by the clinician. The specimens were inoculated on slant tubes of Sabouraud-dextrose agar with chloramphenicol and cycloheximide (Mycobiotic agar, Difco), and incubated at room temperature for two weeks or more and discarded.

The identification of dermatophytes was based on the macro and microscopic characteristics of their colonies grown on routine medium or special medium for diagnosis.

Six clinical variants were considered: tinea capitis, tinea corporis, tinea cruris, tinea manuum, tinea pedis, and tinea unguium.

RESULTS

All the mycological exams carried out on 15,300 patients with clinically suspected dermatophytosis were positive, but only 655 dermatophyte strains were recovered. Reduced number of isolates may be explained by the small number of requisition for cultures, bacterial contamination of clinical specimens, cases of chronic dermatophytosis with a long time therapy or therapy control. In the study of bacterial contamination of primary isolates, it was found that the major species isolated with dermatophytes were Pseudomonas aeruginosa, which showed inhibitory properties on the growth of species of dermatophytes21.

Among the species isolated, T. rubrum was the most frequent (48.7%), followed by M. canis (20.9%), T. tonsurans (13.8%), T. mentagrophytes (9.7%), E. floccosum (4.1%), and M. gypseum (2.5%) (Table 1).

As shown in table 2, among the clinical variants, tinea corporis comprised 31.9% of cases, while tinea capitis was observed in 27.5% of cases, tinea ungueum was involved in 14.8%, tinea cruris in 13.9%, tinea pedis in 9.9% and tinea manuum in 1.9%. Regarding correlation of the clinical variant with the etiological agent, results indicated that the major agent of tinea capitis was M. canis (65.0%), followed by T. tonsurans (28.3%). Tinea corporis was predominantly caused by T. rubrum (69.4%), followed by T. tonsurans, M. canis, and T. mentagrophytes (8.6%, 7.2% and 6.2%). In tinea cruris cases, T. rubrum was the most prevalent (67.0%), followed by E. floccosum (18.7%). T. rubrum prevailed on the hands (61.5%), followed by T. tonsurans (15.3%). The main etiological agent of tinea pedis and tinea unguium was T. rubrum (56.9% and 67.0%, respectively), followed by T. mentagrophytes (30.7% and 18.5%, respectively).

Of the patients studied, 377 (57.5%) were male and 278 (42.4%) female, and in the majority of them the clinical features but not the age was recorded. As shown in the table 3, a correlation of frequency of clinical variants and sex, it was found a significant prevalence of tinea corporis (59.8%), tinea cruris (80.2%), tinea pedis (64.6%) and tinea manuum (69.2%) in male sex than in females. A frequency of tinea unguium, with 59.7% predominated in females but in tinea capitis the frequency is the same in both sexes.

DISCUSSION

In the last decade (1992 to 2002), six dermatophyte species were detected as dermatophytosis agents in Sao Paulo City: T. rubrum, T. mentagrophytes, M. canis, E. floccosum, T. tonsurans, and M. gypseum. The predominance of T. rubrum (48.7%) represents a worldwide trend and the present data are consistent with those reported in studies carried out in the South, Southeast, Center-West and Northeast regions of Brazil8,12,13,14,28,29,30,38,46,47.

Studies conducted in European countries, United States of America, Mexico and Argentina, also confirm the higher percentage of isolation of T. rubriim10,15,23,34,35. This is an anthropophilic fungus perfectly adapted to human keratinizcd tissues causing a mild chronic inflammation and rarely infects animals49. There have been only a few reports of its isolation from animals (cats, dogs, calves)22,37,43,50,52. Transmission of T. rubrum probably occurs directly from humans to animals26. The frequency of this agent increases with the process of urbanization, leading to its predominance as an agent causing dermatophytosis in large urban centers42.

Since 1965, T. rubrum has become the predominant species, being more frequent than M. cams and being isolated from as many as 65.5% of dermatophytosis cases in Sao Paulo14,29,46. In the present study, this percentage was decreased to 48.7%, but the species persists as the leading agent.

The prevalence of the zoophilic fungus M. canis has been decreased in developed countries and in most of the states of Brazil14,29,30,46. It is a species adapted to domestic animals such as dogs, cats, cattle or horses which can infect persons who have contact with these animals in the domestic environment24,42. It is responsible for most scalp infections, being the predominant agent detected at this region in most studies12,13,14,15,18. In the present study it was the second most frequent species, in agreement with the trend reported in a previous study conducted in SSo Paulo46 and in European studies conducted in Spain, Greece and Italy9,35,39. In other regions, the frequency of M. canis varies, with the species being the third most frequent one in Rio Grande do Sul and Goias (Brazil) and Argentina12,13,15,31, and being present at reduced percentages in Colombia and in the Amazon region6,40,41.

T. tonsurans is an anthropophilic dermatophyte brought to the American continent by Spanish and Portuguese colonizers, which causes epidemics in schools, day-care-centers and asylums. T. tonsurans is a cosmopolitan fungus that causes an endothrix infection of hair and its distribution is worldwide. In the present study, T. tonsurans was the third most frequent species, predominantly causing lesions on the scalp. In South region of Brazil, T. tonsurans was rarely isolated29,30,31,32,48, although it was responsible for microepidemics in Rio Grande do Sul33. In the North and Northeast regions, this agent is the most prevalent in scalp infections4,6,40,41. When it finds favorable environmental conditions it becomes settled as an endemic species. T. tonsurans is most commonly found in Central and Southern Europe, U.S.S.R. and Central and South America24. In the United States, the fungus predominates in scalp infections23,25,54. Infections in humans are often acquired from contact with animals, environment or person-to-person spread24.

T. mentagrophytes can be both anthropophilic and zoophilic. The fungus is cosmopolitan1 and is one of the most common dermatophytes infecting man and animals. Infections in humans are often acquired to contact with soil and domestic animals or others, such as cattle, horses and birds17.

T. mentagrophytes was the fourth species most frequently detected in the present study, mainly involving hands and nails. In other Brazilian studies carried out at different times, this species was the second most common8,12,13,31,32,36 and occasionally predominated in tinea pedis ("athlete's foot")8,12,13,31,32,36.

Epidermophyton floccosum is an anthropophilic fungus, ubiquitous1 which attacks the skin and nails of man. Infections are more common in the tropics affecting males and children7. Animal infections are rare2,51,53.

E. floccosum in our study was the fifth most frequent species of dcrmatophytes and was the predominant cause of tinea cruris. In Western Europe this species is a major cause of tinea cruris and tinea pedis. Its frequency has been decreasing unlike the increasing incidence of T. rubrum, although data from Italy showed that it is still a prevalent agent among the dermatophytosis9.

Microsporiun gypseum is a geophilic fungus found worldwide, frequently isolated from soil, and being seldom detected as an agent of superficial mycoses that commonly infect humans1. It is relatively rare in the United States, United Kingdom and Germany, but common in South America1.

M. gypseum frequency was the least and observed mainly in cases of tinea corporis. Tinea pedis and tinea manuum are seen commonly, but tinea unguium is rare.

In the present study, no other agents such as Trichophyton violaceum, Trichophyton verrucosum or Trichophyton schoenleinii were isolated, confirming a trend observed in the latest studies carried out in Sao Paulo14,40. Except for tinea capitis, T. rubrum was the dermatophyte most frequently isolated in all the variants of infection: tinea corporis (69.4%), tinea cruris and tinea unguium (67.0%), tinea manuum (61.5%), and tinea pcdis (56.9%). It is interesting to note that in regions of low urbanization the frequency of T. rubrum is lower and may even be nonexistent, as is the case for the Amazon region40,41, confirming once again the predominance of this anthropophilic fungus in urban centers.

About tinea corporis, the second most frequent agent is T. tonsurans (8.6%), followed by M. canis (7.2%) and T. mentagrophytes (6.2%).

Infection with M. canis is more frequent in the scalp (65.0%), followed by T. tonsurans (28.3%). This frequency is maintained in most regions of Brazil, except for the Amazon region and some Northeastern cities, where T tonsurans is the most common agent4,40,41. The frequency of tinea capitis increases with poverty, malnutrition, crowding, and large families with precarious hygiene habits, as found in developing countries5.

Ringworm of the nails is recorded worldwide, almost many species has been implicated in this infection, the common ones are T. rubrum, T. mentagrophytes, E. floccosum and to lesser extent, T. tonsurans and T. violaceum55.

In the present study T. rubrum (67%) prevailed, followed by T. mentagrophytes (18.5%). This same order was detected in tinea pedis, with respective frequencies of 56.9% and 30.7%. These values agree with those reported in the literature12,13,14,15,28,29,30,31,32,46,48.

T. rubrum predominated in the inguinal region (67.0%), followed by E. floccosum (18.7%), both being anthropophilic agents prevailing in the areas covered by clothing, a fact that makes environmental transmission more difficult.

In conclusion, our data show a predominance of T. rubrum over the remaining agents in all body regions, except for the scalp, where M. canis predominated. This may be explained by urbanization, which leads to a predominance of anthropophilic fungi as ctiologic agents of dermatophytosis because of their better adaptation to human keratinized tissues; the agents may also require a longer time before a cure can be obtained by treatment compared to other zoophilic and geophilic agents27.

Dermatophytosis occur more frequently in the genital area of males than in female patients due to the use of tight clothes that give rise a local maceration and obstruction by the scrotum45,53. Another site affected more frequently in males are feet and nails caused by the use of nylon stocking and shoes for a long time in a day.

Prevalence of dermatophyte infections may change as a result of many factors, including human migratory patterns, climatic alterations and new therapies1, but none of these can adequately explain the current increase of some species like T. rubrum and T. mentagrophytes.

ACKNOWLEDGEMENTS

The authors are grateful to the head of the Dermatology Department, and their staff for the collaboration in the study. We are especially grateful to Elisabeth Maria Heins-Vaccari and Natalina T. de MeIo from Instituto de Medicina Tropical de Sao Paulo, for review of the manuscript. We thank Claudia de Freilas Caetano for the secretarial work.

REFERENCES

1. AJELLO, L. - Geographic distributions and prevalence of the dermatophytes. Ann. N. Y. Acad. Sci., 89: 20-38, I960.

2. ALY, R. - Ecology and epidemiology of dermatophyte infections. J. Amer. Acad. Derm., 31: 521-525, 1994.

3. BORO, B.R.; CHACKRABARTY, A.K.; SARMA, G. & SARMAH, A.K. - Ringworm in animals due to Epidennophyton floccosum. Vet. Rec., 107: 491-492, 1980.

4. BRILHANTE, R.S.; PAIXAO, G.C.; SALVING, L.K. et al. - Epidemiology and ecology of dennatophytosis in the City of Fortaleza: Trichophyton tonsurans as important emerging pathogen of Tinea capitis. Rev. Soc. bras. Med. trop., 33: 417-425, 2000.

5. BUGINGO, G. - Dermatophytic infection of the scalp in the region of Butare (Rwanda). Int. J. Derm., 22: 107-108, 1983.

6. BUITRAGO, O.E. - Dermatomicosis en poblacion de Manizales. Biomedica, 14: 77-84, 1994.

7. CABRITA, J. & FIGUEIREDO, M.M. - Dermatophytes in Portugal. Sabouraudia, 11: 21-29, 1973.

8. CAMPBELL, I.; CAMPBELL, G.; AGUIRRE, L. & SANTOS, M.G. - Dermatofitos em Brasilia. An. bras. Derm., 59: 224-225, 1984.

9. CARETTA, G.; DEL FRATE, G.; PICCO, A. M. & MANGIAROTTI, A.M. - Superficial mycoses in Italy. Mycopathologia (Den Haag), 76: 27-32, 1981.

10. CHMEL, L. & BUCHVALD, L. - Ecology and transmission of Micimporum gypseum from soil to man. Sabouraudia, 8: 149-156, 1970.

11. CLAYTON, Y.M. & MIDGLEY, G. - Identification of agents of superficial mycoses. In: EVANS, E.G.V. & RICHARDSON, M.D., ed. Medical Mycology. A practical approach. Oxford, Oxford University Press, 1989.

12. COSTA, M.; PASSOS, X.S.; SOUZA, L.K.H. el al. - Epidemiologia e etiologia das dermatofitoses em Goiania, GO, Brasil. Rev. Soc. bras. Med. trop., 35: 19-22, 2002.

13. COSTA, T.R.; COSTA, M.R.; SILVA, M.V. et al. - Etiology and epidemiology in dennatophytosis in Goiania, State of Goias, Brazil. Rev. Soc. bras. Med. trop., 32: 367-371, 1999.

14. CUCE, L.C.; CASTRO, R.M.; DINATO, S.L.M. & SALEBIAN, A. - Flora dermatofitica em Sao Paulo (1964-1974). An. bras. Derm., 50: 141-146, 1975.

15. DAVEL, G.; PERROTA, D.; CANTEROS, C. et al. - Multicenter study of superficial mycoses in Argentina. EMMS Group. Rev. argent. Microbiol., 31: 173-181, 1999.

16. DAWSON, D.C. & GENTLES, J.C. - The perfect states of Keratinomyces ajelloi Vanbreuscghem, Trichophyton terrestre (Durie): Frey and Microsporum nanum Fuentes. Sabouraudia, 1: 49-57, 1961.

17. ENGLISH, M.R & MORRIS, P. - Trichophylon mentagrophytes var. erinacei in hedgehog nests. Sabouraudia, 7: 118-121, 1969.

18. FERNANDES, N.C.; AKITI, T. & BARREIROS, M.G.C.- Dematophytosis in children: study of 137 cases. Rev. Inst. Med. trop. S. Paulo, 43: 83-85, 2001.

19. GENTLES, J.C. & SCOTT, E. - Superficial mycoses in the West of Scotland. Scott, mcd. J., 26: 328-335, 1981.

20. GEORG, L.K. - Ecology and diagnostic problems of fungal zoonoses. Indian med. Surg., 33: 308-310, 1964.

21. KANE, J. - The biological aspects of the Kane/Fisher System for identification of dermatophytes. In: KANE, J.; SUMMERBELL, R.; KRAJDEN, S.; SIGLER, L. & LAND, G. Laboratory handbook of dermatophytes. A clinical guide and laboratory handbook of dermatophytes and other filamentous fungi from skin, hair, and nails. Belmont, Star Publishing Company, 1997. p. 95-100.

22. KANETO, C.N.; CALIL, E.M.B.; VILLALOBOS, E.M.C. et al. - Epizootia de "tinha" em bezerros devida a Trichophyton rubrum. Biologico, 58: 17-20, 1996.

23. KEMNA, M.E. & ELEWSKI, B.E. - A United States epidemiologic survey of superficial fungal diseases. J. Amer. Acad. Derm., 35: 539-542, 1996.

24. KRAJDEN, S. - Dermatophytes: epidemiology and clinical features. In: KANE, J.; SUMMERBELL, R.; KRAJDEN, S.; SIGLER, L. & LAND, G. Laboratory handbook of dermatophytes. A clinical guide and laboratory handbook of dermatophytes and other filamentous fungi from skin, hair, and nails. Belmont, Star Publishing Company, 1997. p. 5-32.

25. KROWCHUCK, D.P.; LUCKY, A.W.; PRIMMER, S.I. & McGUIRRE, J. - Current status of the identification and management of tinea capitis. Pediatrics, 72: 625-631, 1983.

26. KUSHIDA, T. & WATANABE, S. - Canine ringworm caused by Trichophyton rubrum; probable transmission from man to animal. Sabouraudia, 13: 30-32, 1975.

27. KWON-CHUNG, K.J. & BENNETT, I.E. - Medical Mycology. Philadelphia, Lea & Febiger, 1992. p. 121.

28. LIMA, E.G.; PONTES, Z.B.V.S.; OLIVEIRA, N.M.C. et al. - Frequencia de dermatofitoses cm Joao Pessoa, Paraiba, Brasil. An. bras. Derm., 74: 127-132, 1999.

29. LONDERO, A.T. & RAMOS, C.D. - Agentes de dermatofitoses humanas no interior do Estado do Rio Grande do Sul no periode 1960-1987. An. bras. Derm., 64: 161-164, 1989.

30. LOPES, J.O.; ALVES, S.H. & BENEVENGA, J.P. - Dermatofitoses humanas no interior do Rio Grande do Sul no periode 1988-1992. Rev. Inst. Med. trop. S. Paulo, 36: 115-119, 1994.

31. LOPES, J.O.; ALVES, S.H.; KREBS, R.C. & KREBS, A.M. - Epidemiologia das dermatofitoses nos usuarios da piscina do centra de educaceo fisica da Universidade Eederal de Santa Maria: nota preliminar. Rev. Ass. med. Rio Gr. Sul, 36: 120-121, 1992.

32. LOPES, J.O.; ALVES, S.H.; MARI, C.R.D. et al. - A ten-year survey of tinea pedis in the central region of the Rio Grande do Sul, Brazil. Rev. Inst. Med. trop. S. Paulo, 41: 75-77, 1999.

33. LOPES, J.O.; COSTENARO, C. & BENEVENGA, J.P. - Dermatofitoses por Trichophyton lonaurans no interior do Rio Grande do Sul. Rev. Ass. med. Rio Gr. Sul, 39: 255-257, 1995.

34. MANZANO-GAYOSSO, P.; MENDEZ-TOVAR, L.J.; HERNANDEZ-HERNANDEZ, F. & LOPEZ-MARTINEZ, R. - Dermatophytosis in Mexico City. Mycoses, 37: 49-52, 1994.

35. MARAKI, S. & TSELENTIS, Y. - Dermatophytosis in Crete, Greece, between 1992 and 1996. Mycoses, 41: 175-178, 1998.

36. MATTEDE, M.G.S.; COELHO, C.C.; MATTEDE, A.F.; PERIN, FC. & PALHANO Jr., L. - Etiologia das dermatofitoses em Vitoria (ES). An. bras. Derm., 61: 177-182, 1986.

37. MORIELLO, K.A. & DeBOER, D.J. - Fungal flora of the coat of pet cats. Amer. J. vet. Res., 52: 602-606, 1991.

38. NASCIMENTO, A.M. - Caracterizacao morfologica, bioquimica e molecular de isolados patogenicos de Trichophyton. Ribeirao Preto, 1997. (Dissertacao de Mestrado - Departamento de Genetica da Eaculdade de Medicina de Ribeirao Preto da Universidade de Sao Paulo).

39. PALACIO, A.; CUETARA, M.S.; VALLE, A. et al. - Cambios epidemiologicos observados en un decenio en las dermatofitosis del hospital universitario "12 de Octubre" de Madrid: nuevas especies emergentes. Rev. iberoamer. Micol., 16: 101-100, 1999.

40. PECHER, S.A. & BORRAS, M.R.L. - Prevalencia de micoses superficiais na populacao adulta da fronteira Brasil-Colombia. Med. cut. ibero-lat.-amer., 14: 333-340, 1986.

41. PECHER, S.A.; CASTRO, G.B. & BORRAS, M.R.L. - Prevalencia de micoses superficiais em escolares de localidades da regiao amazonica ocidental (fronteira Brasil-Colombia). An. bras. Derm., 57: 13-18, 1982.

42. PROENCA, N.G.; MASSETI, J.H.; SALEBIAN, A. & CUCE, L.C. - Flora dermatofitica e condicoes socioeconomicas. An. bras. Derm., 50: 183-196, 1975.

43. RANGANATHAN, S.; BALAJEE, A.S. & RAJA, S.M. - A survey of dermatophytosis in animais in Madras, India. Mycopathologia (Den Haag), 140: 137-140, 1997-1998.

44. REBELL, G. & TAPLIN, D. - Dermatophytes. Their recognition and identification. Coral Gables, University of Miami Press, 1979. p. 1-62.

45. RIPPON, J.W. - The changing epidemiology and emerging patterns of dennatophyte species. In: McGINNIS, M.R., ed. Current topics in medical Mycology. New York, Springer-Verlag, 1985. v.1, p. 208-234.

46. RUIZ, L.R.B. & ZAITZ, C. - Dermatophytes and dermatophytosis in the city of Sao Paulo, from August 1996 to July 1998. An. bras. Derm., 76: 391-401, 2001.

47. SANTOS, J.I.; NEGRI, C.M.; WAGNER, D.C. et al. - Some aspects of dermatophytoses seen at University Hospital in Florianopolis, Santa Catarina, Brazil. Rev. Inst. Med, trop. S.Paulo, 39: 137-140, 1997.

48. SINSKI, J.T. & KELLEY, L.M. - A survey of dermatophytes isolated from human patients in the United States from 1982 to 1984. Mycopathologia (Den Haag), 98: 35-40, 1987.

49. SMITH, J.M.B., RUSH-MUNRO, F.M. & McCARTHY, M. - Animals as a reservoir of human ringworm in New Zealand. Aust. J. Derm., 10: 169-182, 1969.

50. STENWIG, H. & TAKSDAL, T. - Isolation of Epidermophyton floccosum from a dog in Norway. Sabouraudia, 22: 171-172, 1984.

51. TAPLIN, D. - Superficial mycoses. J. invest. Derm., 67: 177-181, 1976.

52. TERRENI, A.A.; GREGG Jr, W.B.; MORRIS, PR. & Di SALVO, A.E. - Epidermophyton floccosum infection in a dog from the United States. Sabouraudia, 23: 141-142, 1985.

53. WEITZMAN, I. & SUMMERBELL, R.C. - The dermatophytes. Clin. Microbiol. Rev., 8: 240-259, 1995.

54. WILMINGTON, M.; ALY, R. & FRIEDEN, I.J. - Trichophylon tonsurans tinea capitis in the San Francisco Bay area: increased infection demonstrated in a 20-year survey of fungal infection from 1974 to 1994. J. med. vet. Mycol., 34: 285-287, 1996.

55. ZAIAS, N. - Onychomycosis. Arch. Derm., 105: 263-274, 1972.

Received: 14 November 2002

Accepted: 18 September 2003

Patricia Augusta Vianna CHINELLI(I), Alexandre de Abreu SOFIATTI(1), Ricardo Spina NUNES(2) & Jose Eduardo da Costa MARTINS(2)

(1) Department of Dermatology of Hospital das Clinicas, Faculty of Medicine, University of Sao Paulo, Sao Paulo, SP, Brazil.

(2) Mycology Laboratory, Department of Dermatology of Hospital das Clinicas, Faculty of Medicine, University of Sao Paulo, Sao Paulo, SP, Brazil.

Correspondence to: Dra. Patricia A.V. Chinelli. Department of Dermatology, Hospital das Clinicas, Faculty of Medicine, University of Sao Paulo. Av. Dr. Eneas Carvalho de Aguiar 255,

3rd floor, 05403-900 Sao Paulo, SP, Brazil. Tel.: (55) (11) 30625069. E-mail patchinelli@ig.com.br,

Copyright Instituto de Medicina Tropical de Sao Paulo Sep/Oct 2003
Provided by ProQuest Information and Learning Company. All rights Reserved