Dermatophytosis pathophysiology: Difference between revisions

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{{Dermatophytosis}}
{{Dermatophytosis}}
{{CMG}};{{AE}}{{HK}}
{{CMG}}; {{AE}} {{HK}}
==Overview==
==Overview==
Dermatophytes mode of transmission is direct (or)indirect contact with skin (or) scalp lesions of infected people,animals (or) fomites. Following transmission, the dermatophytes use [[proteases]] to adhere to the [[stratum corneum]] of the [[skin]]. Penetration by dermatophytes is achieved by secreting multiple [[serine]]-[[Subtilisin|subtilisins]] and metallo-endoproteases (fungalysins) formerly called keratinases that are found only in the dermatophytes. Acutely, the [[Host (biology)|host]] responds to [[fungal]] invasion by [[Hypersensitivity reactions|Type IV delayed type hypersensitivity reaction]] (also known as "Trichophytin reaction") leading to a [[Cell-mediated immunity|cell mediated]] response. [[Fungus]] secreted [[proteases]] are one of the most important virulence factors of dermatophytes and are thought to be responsible for evasion from [[Host (biology)|host]] defense mechanisms. Secreted [[subtilisin]] [[proteases]] expressed in the dermatophytes could play a role in [[keratin]] degradation. Dermatophyte [[infections]] of the skin surface        ([[tinea corporis]] and [[tinea faciei]]) mostly present as [[erythematous]], scaly [[papules]] that gradually progress to annular or circular red patches or [[Plaque|plaques]], with central clearing and [[Scaling skin|scaling]] at the periphery. On microscopic examination of the skin, there may be [[Neutrophil|neutrophils]] retained in the [[stratum corneum]], parakeratosis, spongiosis and [[dermal]] [[edema]].


==Pathophysiology==
==Pathophysiology==
===Pathogenesis===
*Dermatophytes survive on the outer layer of [[skin]] called [[stratum corneum]].  
*Dermatophytes survive on the outer layer of skin called stratum corneum.  
*[[Stratum corneum]] has been known to be not only source of [[nutrition]] for the dermatophytes, but also the growing [[fungal]] [[Mycelium|mycelia]].<ref name="pmid16599028">{{cite journal |vauthors=Samdani AJ |title=Dermatophyte growth and degradation of human stratum corneum in vitro (pathogenesis of dermatophytosis) |journal=J Ayub Med Coll Abbottabad |volume=17 |issue=4 |pages=19–21 |year=2005 |pmid=16599028 |doi= |url=}}</ref>
*Stratum corneum has been known to be not only source of nutrition for the dermatophytes, but also the growing fungal mycelia.<ref name="pmid16599028">{{cite journal |vauthors=Samdani AJ |title=Dermatophyte growth and degradation of human stratum corneum in vitro (pathogenesis of dermatophytosis) |journal=J Ayub Med Coll Abbottabad |volume=17 |issue=4 |pages=19–21 |year=2005 |pmid=16599028 |doi= |url=}}</ref>
 
*After the inoculation in the host skin, suitable conditions favor the infection to progress through the following stages:
==Pathogenesis==
After the [[inoculation]] in the [[Host (biology)|host]] [[skin]], suitable conditions favor the infection to progress through the following stages:
 
====Adherence====
====Adherence====
*Dermatophyte-secreted proteases not only are mediate adherence to the host skin but also help in germination of arthroconidia and hyphal growth leading to growth of the fungi in multiple directions.<ref name="pmid8348716">{{cite journal |vauthors=Aljabre SH, Richardson MD, Scott EM, Rashid A, Shankland GS |title=Adherence of arthroconidia and germlings of anthropophilic and zoophilic varieties of Trichophyton mentagrophytes to human corneocytes as an early event in the pathogenesis of dermatophytosis |journal=Clin. Exp. Dermatol. |volume=18 |issue=3 |pages=231–5 |year=1993 |pmid=8348716 |doi= |url=}}</ref><ref name="pmid18478361">{{cite journal |vauthors=Vermout S, Tabart J, Baldo A, Mathy A, Losson B, Mignon B |title=Pathogenesis of dermatophytosis |journal=Mycopathologia |volume=166 |issue=5-6 |pages=267–75 |year=2008 |pmid=18478361 |doi=10.1007/s11046-008-9104-5 |url=}}</ref>
*Dermatophyte-secreted [[proteases]] not only mediate adherence to the [[Host (biology)|host]] [[skin]] but also help in germination of [[arthroconidia]] and [[Hyphae|hyphal]] growth leading to growth of the [[fungi]] in multiple directions.<ref name="pmid8348716">{{cite journal |vauthors=Aljabre SH, Richardson MD, Scott EM, Rashid A, Shankland GS |title=Adherence of arthroconidia and germlings of anthropophilic and zoophilic varieties of Trichophyton mentagrophytes to human corneocytes as an early event in the pathogenesis of dermatophytosis |journal=Clin. Exp. Dermatol. |volume=18 |issue=3 |pages=231–5 |year=1993 |pmid=8348716 |doi= |url=}}</ref><ref name="pmid18478361">{{cite journal |vauthors=Vermout S, Tabart J, Baldo A, Mathy A, Losson B, Mignon B |title=Pathogenesis of dermatophytosis |journal=Mycopathologia |volume=166 |issue=5-6 |pages=267–75 |year=2008 |pmid=18478361 |doi=10.1007/s11046-008-9104-5 |url=}}</ref>
*Fungal arthroconidia attach to keratinocytes via long and sparse microprojections (fibrils).<ref name="pmid18478361">{{cite journal |vauthors=Vermout S, Tabart J, Baldo A, Mathy A, Losson B, Mignon B |title=Pathogenesis of dermatophytosis |journal=Mycopathologia |volume=166 |issue=5-6 |pages=267–75 |year=2008 |pmid=18478361 |doi=10.1007/s11046-008-9104-5 |url=}}</ref>
*[[Fungal]] [[arthroconidia]] attach to [[keratinocytes]] via long and sparse microprojections (fibrils).<ref name="pmid18478361">{{cite journal |vauthors=Vermout S, Tabart J, Baldo A, Mathy A, Losson B, Mignon B |title=Pathogenesis of dermatophytosis |journal=Mycopathologia |volume=166 |issue=5-6 |pages=267–75 |year=2008 |pmid=18478361 |doi=10.1007/s11046-008-9104-5 |url=}}</ref>
 
====Penetration====
====Penetration====
*Penetration by dermatophytes is achieved by secreting multiple [[serine]]-[[Subtilisin|subtilisins]] and metallo-endoproteases (fungalysins) formerly called keratinases that are found only in the dermatophytes.<ref name="pmid8077506">{{cite journal |vauthors=Dahl MV |title=Dermatophytosis and the immune response |journal=J. Am. Acad. Dermatol. |volume=31 |issue=3 Pt 2 |pages=S34–41 |year=1994 |pmid=8077506 |doi= |url=}}</ref>
*[[Fungal|Funga]]<nowiki/>l [[Mannan|mannans]] in the dermatophyte [[cell wall]] have [[Immunosupression|immunosupressive]] ability and inhibit the action of [[T cells]]. [[Trichophyton rubrum|T. rubrum]] [[cell wall]] [[Mannan|mannans]] (TRM) may lead to inhibition of [[Lymphoproliferation|lymphoproliferative]] response of [[Mononuclear cells|mononuclear]] [[leukocytes]]. This leads to [[fungal]] growth and [[proliferation]] on the [[Host (biology)|host]] [[skin]].
====Host response====
*[[Fungal]] metabolic products diffuse through the [[stratum basale]] and [[stratum spinosum]] to cause [[erythema]], [[vesicle]] or even [[Pustules|pustule]] formation and [[pruritus]].
*Acutely, the [[Host (biology)|host]] responds to [[fungal]] [[invasion]] by [[Cell-mediated immunity|Type IV delayed type hypersensitivity]] reaction (also known as "Trichophytin" reaction) leading to a [[Cell-mediated immunity|cell mediated response]].<ref name="pmid18478362">{{cite journal |vauthors=Almeida SR |title=Immunology of dermatophytosis |journal=Mycopathologia |volume=166 |issue=5-6 |pages=277–83 |year=2008 |pmid=18478362 |doi=10.1007/s11046-008-9103-6 |url=}}</ref>
*[[Interferon-α]] secretion from [[T helper cells|type 1 T-helper lymphocytes]], [[cytokines]] like [[Interferon-gamma|interferon-γ]] ([[Interferon-gamma|IFN-γ]]), [[IL-8]] and [[macrophages]] are the effector mechanisms involved in defense against dermatophytes acutely.<ref name="pmid19207841">{{cite journal |vauthors=Brasch J |title=Current knowledge of host response in human tinea |journal=Mycoses |volume=52 |issue=4 |pages=304–12 |year=2009 |pmid=19207841 |doi=10.1111/j.1439-0507.2008.01667.x |url=}}</ref>
*Dermatophyte species have [[cell wall]] [[carbohydrate]] molecules ([[Glucan|β-glucan]]) that are recognized by the [[Innate immune response|innate]] immune mechanisms, such as Dectin-1 and Dectin-2, which consequently stimulate toll-like receptor 2 and 4 (TLR-2 and TLR-4). Dectin-1 augments the production of tumor necrosis factor-α and IL-17, IL-6, and IL-10, all of which activate the [[adaptive immunity]].
*[[Interleukin 8|IL-8]] mediated [[chemotaxis]] allows [[polymorphonuclear leukocytes]] adhere to [[opsonized]] and unopsonized [[hyphae]] to inhibit growth of the dermatophyte.<ref name="pmid8077506">{{cite journal |vauthors=Dahl MV |title=Dermatophytosis and the immune response |journal=J. Am. Acad. Dermatol. |volume=31 |issue=3 Pt 2 |pages=S34–41 |year=1994 |pmid=8077506 |doi= |url=}}</ref>
*The dermatophyte [[antigen]] is thought to be processed by [[Epidermis (skin)|epidermal]] [[Langerhans cells]] and presented in local [[lymph nodes]] to [[T lymphocytes]] which [[proliferate]], migrate to the infected site, and produce [[inflammation]].<ref name="pmid21772583">{{cite journal |vauthors=Tainwala R, Sharma Y |title=Pathogenesis of dermatophytoses |journal=Indian J Dermatol |volume=56 |issue=3 |pages=259–61 |year=2011 |pmid=21772583 |pmc=3132899 |doi=10.4103/0019-5154.82476 |url=}}</ref>
*The [[immune response]], and especially the level of [[inflammation]], is different for various dermatophyte species, the [[Host (biology)|host]] [[species]] and the pathophysiological status of the [[Host (biology)|host]]. In general, the [[zoophilic]] [[Species (biology)|species]] cause more [[Inflammation|inflammatory]] infections, which may heal spontaneously and result in relative resistance to re-infection. The anthropophilic [[Species (biology)|species]] usually cause more chronic, less circumscribed infections, which consequently lead to a poor resistance to re-infection.
*Cell-associated as well as secreted factors contribute to the dermatophyte's ability to exaggerate or suppress an [[Inflammation|inflammatory]] response.
*Many host factors for example, number and activity of [[sebaceous glands]] (due to inhibitory effect of [[sebum]] on dermatophytes) in a particular body region, breaks in the integrity of [[Skin|skin barrier]], moisturized and [[Maceration|macerated]] [[skin]] can promote invasion of dermatophytes.
*[[Fungus]] secreted [[proteases]] are one of the most important [[Virulence factor|virulence factors]] of dermatophytes and are thought to be responsible for evasion from [[Host (biology)|host]] defense mechanisms.<ref name="pmid21772583">{{cite journal |vauthors=Tainwala R, Sharma Y |title=Pathogenesis of dermatophytoses |journal=Indian J Dermatol |volume=56 |issue=3 |pages=259–61 |year=2011 |pmid=21772583 |pmc=3132899 |doi=10.4103/0019-5154.82476 |url=}}</ref>
==Genetics==
*The [[Genome|genomes]] of the dermatophytes are similar in size, ranging from 22.5 Mb for [[T. rubrum]] to 24.1 Mb for T. equinum.
* The LysM domains are implicated in evasion of the [[Host (biology)|host]] [[innate immune response]] (14) by securing fragments of [[chitin]], so that the [[chitin]] cannot stimulate the immune response.<ref name="pmid19299132">{{cite journal |vauthors=de Jonge R, Thomma BP |title=Fungal LysM effectors: extinguishers of host immunity? |journal=Trends Microbiol. |volume=17 |issue=4 |pages=151–7 |year=2009 |pmid=19299132 |doi=10.1016/j.tim.2009.01.002 |url=}}</ref>
*Secreted [[subtilisin]] [[proteases]] expressed in the dermatophytes could play a role in [[keratin]] degradation.<ref name="pmid21247460">{{cite journal |vauthors=Burmester A, Shelest E, Glöckner G, Heddergott C, Schindler S, Staib P, Heidel A, Felder M, Petzold A, Szafranski K, Feuermann M, Pedruzzi I, Priebe S, Groth M, Winkler R, Li W, Kniemeyer O, Schroeckh V, Hertweck C, Hube B, White TC, Platzer M, Guthke R, Heitman J, Wöstemeyer J, Zipfel PF, Monod M, Brakhage AA |title=Comparative and functional genomics provide insights into the pathogenicity of dermatophytic fungi |journal=Genome Biol. |volume=12 |issue=1 |pages=R7 |year=2011 |pmid=21247460 |pmc=3091305 |doi=10.1186/gb-2011-12-1-r7 |url=}}</ref>
*Dermatophytes have a large number of [[genes]] connected to secondary-metabolite production.
*[[Genes]] for [[protein]] [[kinases]] activate [[mitogen-activated protein kinase]] (MAPK) pathways and produce [[cytokines]].
*T. equinum infection of [[Epidermis (skin)|epidermal]] [[Tissue (biology)|tissue]] increase the expression of other human [[genes]] associated with [[inflammation]], including the [[Tissue (biology)|tissue]] remodeling matrix [[metalloprotease]], its regulatory [[gene]] Timp1, and the [[proinflammatory]] mediator [[gene]] [[COX2]].<ref name="pmid22951933">{{cite journal |vauthors=Martinez DA, Oliver BG, Gräser Y, Goldberg JM, Li W, Martinez-Rossi NM, Monod M, Shelest E, Barton RC, Birch E, Brakhage AA, Chen Z, Gurr SJ, Heiman D, Heitman J, Kosti I, Rossi A, Saif S, Samalova M, Saunders CW, Shea T, Summerbell RC, Xu J, Young S, Zeng Q, Birren BW, Cuomo CA, White TC |title=Comparative genome analysis of Trichophyton rubrum and related dermatophytes reveals candidate genes involved in infection |journal=MBio |volume=3 |issue=5 |pages=e00259–12 |year=2012 |pmid=22951933 |pmc=3445971 |doi=10.1128/mBio.00259-12 |url=}}</ref>
== Gross Pathology ==
* Dermatophyte infections of the [[skin]] surface ([[tinea corporis]] and [[tinea faciei]]) mostly present as [[erythematous]], [[Scaling skin|scaly]] [[papules]] that gradually progress to annular or circular red patches or [[plaques]], with central clearing and [[Scaling skin|scaling]] at the periphery.<ref name="pmid9805462">{{cite journal |vauthors=Stein DH |title=Tineas--superficial dermatophyte infections |journal=Pediatr Rev |volume=19 |issue=11 |pages=368–72 |year=1998 |pmid=9805462 |doi= |url=}}</ref>
* [[Pustules]], [[vesicles]], or large [[blisters]] may be infrequently seen grossly.
[[File:Tinea_arm.jpg|300px|Tinea corporis, source: wikiwand.com]]
<br style="clear:left>
== Microscopic Pathology ==
The following features may be seen on microscopic examination of the [[skin]] in dermatophytosis:<ref name="pmid98054622">{{cite journal |vauthors=Stein DH |title=Tineas--superficial dermatophyte infections |journal=Pediatr Rev |volume=19 |issue=11 |pages=368–72 |year=1998 |pmid=9805462 |doi= |url=}}</ref>
* Parakeratosis
* Spongiosis
* [[Neutrophil|Neutrophils]] in the [[stratum corneum]]
* Compact orthokeratosis
* Papillary [[dermal]] [[edema]]
* [[Fungal]] [[hyphae]] between 2 zones of cornified [[Cells (biology)|cells]] (called the 'sandwich' sign)
[[File:Tinea_micr.jpg|300px|left|'''H&E section on skin showing the sandwich sign''', source: ucsf.edu]]
[[Image:KOHtineacapitus.jpg|300px|left|'''KOH prep of Tinea capitis infecting hair''', source: ucsf.edu]]
<br style="clear:left>




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==References==
==References==
{{Reflist|2}}
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Latest revision as of 21:18, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Overview

Dermatophytes mode of transmission is direct (or)indirect contact with skin (or) scalp lesions of infected people,animals (or) fomites. Following transmission, the dermatophytes use proteases to adhere to the stratum corneum of the skin. Penetration by dermatophytes is achieved by secreting multiple serine-subtilisins and metallo-endoproteases (fungalysins) formerly called keratinases that are found only in the dermatophytes. Acutely, the host responds to fungal invasion by Type IV delayed type hypersensitivity reaction (also known as "Trichophytin reaction") leading to a cell mediated response. Fungus secreted proteases are one of the most important virulence factors of dermatophytes and are thought to be responsible for evasion from host defense mechanisms. Secreted subtilisin proteases expressed in the dermatophytes could play a role in keratin degradation. Dermatophyte infections of the skin surface (tinea corporis and tinea faciei) mostly present as erythematous, scaly papules that gradually progress to annular or circular red patches or plaques, with central clearing and scaling at the periphery. On microscopic examination of the skin, there may be neutrophils retained in the stratum corneum, parakeratosis, spongiosis and dermal edema.

Pathophysiology

Pathogenesis

After the inoculation in the host skin, suitable conditions favor the infection to progress through the following stages:

Adherence

Penetration

Host response

Genetics

Gross Pathology

Tinea corporis, source: wikiwand.com

Microscopic Pathology

The following features may be seen on microscopic examination of the skin in dermatophytosis:[12]

H&E section on skin showing the sandwich sign, source: ucsf.edu
H&E section on skin showing the sandwich sign, source: ucsf.edu
KOH prep of Tinea capitis infecting hair, source: ucsf.edu
KOH prep of Tinea capitis infecting hair, source: ucsf.edu



References

  1. ↑ Samdani AJ (2005). "Dermatophyte growth and degradation of human stratum corneum in vitro (pathogenesis of dermatophytosis)". J Ayub Med Coll Abbottabad. 17 (4): 19–21. PMID 16599028.
  2. ↑ Aljabre SH, Richardson MD, Scott EM, Rashid A, Shankland GS (1993). "Adherence of arthroconidia and germlings of anthropophilic and zoophilic varieties of Trichophyton mentagrophytes to human corneocytes as an early event in the pathogenesis of dermatophytosis". Clin. Exp. Dermatol. 18 (3): 231–5. PMID 8348716.
  3. ↑ 3.0 3.1 Vermout S, Tabart J, Baldo A, Mathy A, Losson B, Mignon B (2008). "Pathogenesis of dermatophytosis". Mycopathologia. 166 (5–6): 267–75. doi:10.1007/s11046-008-9104-5. PMID 18478361.
  4. ↑ 4.0 4.1 Dahl MV (1994). "Dermatophytosis and the immune response". J. Am. Acad. Dermatol. 31 (3 Pt 2): S34–41. PMID 8077506.
  5. ↑ Almeida SR (2008). "Immunology of dermatophytosis". Mycopathologia. 166 (5–6): 277–83. doi:10.1007/s11046-008-9103-6. PMID 18478362.
  6. ↑ Brasch J (2009). "Current knowledge of host response in human tinea". Mycoses. 52 (4): 304–12. doi:10.1111/j.1439-0507.2008.01667.x. PMID 19207841.
  7. ↑ 7.0 7.1 Tainwala R, Sharma Y (2011). "Pathogenesis of dermatophytoses". Indian J Dermatol. 56 (3): 259–61. doi:10.4103/0019-5154.82476. PMC 3132899. PMID 21772583.
  8. ↑ de Jonge R, Thomma BP (2009). "Fungal LysM effectors: extinguishers of host immunity?". Trends Microbiol. 17 (4): 151–7. doi:10.1016/j.tim.2009.01.002. PMID 19299132.
  9. ↑ Burmester A, Shelest E, Glöckner G, Heddergott C, Schindler S, Staib P, Heidel A, Felder M, Petzold A, Szafranski K, Feuermann M, Pedruzzi I, Priebe S, Groth M, Winkler R, Li W, Kniemeyer O, Schroeckh V, Hertweck C, Hube B, White TC, Platzer M, Guthke R, Heitman J, Wöstemeyer J, Zipfel PF, Monod M, Brakhage AA (2011). "Comparative and functional genomics provide insights into the pathogenicity of dermatophytic fungi". Genome Biol. 12 (1): R7. doi:10.1186/gb-2011-12-1-r7. PMC 3091305. PMID 21247460.
  10. ↑ Martinez DA, Oliver BG, Gräser Y, Goldberg JM, Li W, Martinez-Rossi NM, Monod M, Shelest E, Barton RC, Birch E, Brakhage AA, Chen Z, Gurr SJ, Heiman D, Heitman J, Kosti I, Rossi A, Saif S, Samalova M, Saunders CW, Shea T, Summerbell RC, Xu J, Young S, Zeng Q, Birren BW, Cuomo CA, White TC (2012). "Comparative genome analysis of Trichophyton rubrum and related dermatophytes reveals candidate genes involved in infection". MBio. 3 (5): e00259–12. doi:10.1128/mBio.00259-12. PMC 3445971. PMID 22951933.
  11. ↑ Stein DH (1998). "Tineas--superficial dermatophyte infections". Pediatr Rev. 19 (11): 368–72. PMID 9805462.
  12. ↑ Stein DH (1998). "Tineas--superficial dermatophyte infections". Pediatr Rev. 19 (11): 368–72. PMID 9805462.

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