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Rev. Inst. Med. trop. S. Paulo vol.50 no.5 São Paulo Sept./Oct. 2008
Surto de piedra branca afetando os cabelos do couro cabeludo de crianças em creche brasileira
Ana Maria RoselinoI; Ana Beatriz SeixasI; José A. ThomaziniII; Claudia M.L. MaffeiIII
IDivision of Dermatology, Department of Internal Medicine. Faculdade de Medicina de Ribeirão Preto/USP, Ribeirão Preto, SP, Brazil
IIDepartment of Surgery and Anatomy. Faculdade de Medicina de Ribeirão Preto/USP, Ribeirão Preto, SP, Brazil
IIIDepartment of Cellular and Molecular Biology and Pathogenic Bio-Agents, University of São Paulo, Faculty of Medicine of Ribeirão Preto, São Paulo State, Brazil
White piedra is a superficial mycosis caused by Trichosporon spp. that affects the hair shaft of any part of the body. It is presented an outbreak of scalp white piedra seen in 5.8% of the children frequenting a day care in Northeastern of São Paulo State, Brazil. Mycological exam and culture identified T. cutaneum in all five cases, and scanning electron microscopy of nodules around hair shaft infected by Trichosporon spp. is demonstrated comparing them with those of black piedra and with nits of Pediculous capitis.
Keywords: White piedra; Epidemiology; Outbreak; Trichosporon spp.; T. cutaneum; T. beigelii.
Piedra branca caracteriza-se por ser micose superficial, causada por Trichosporon spp., que compromete a haste dos pelos de qualquer região do corpo. Um surto de piedra branca, afetando os cabelos do couro cabeludo, foi registrado em 5,8% das crianças que freqüentavam uma creche na região nordeste do estado de São Paulo. Exame micológico direto e cultura identificaram T. cutaneum nas cinco crianças afetadas. Enfatiza-se a utilização da microscopia eletrônica de varredura, que mostrou nódulos circundando a haste dos cabelos infectada por Trichosporon spp., comparando-os com nódulos de Piedra nigra e com lêndeas de Pediculus capitis.
White piedra is a superficial mycosis characterized by nodules of Trichosporon spp. that encircle the hair shaft of any part of the body. It occurs mainly in South America. More recently, molecular studies have shown that the taxon Trichosporon beigelli was replaced by the following six human pathogens: T. cutaneum, T. asahii, T. asteroides, T. mucoides, T. inkin and T. ovoides3,6. The main reports in the literature show compromising of the hair on genital region2,5,10,16,18. Isolated cases and laboratorial results from mycological exams have been related1,13. There are some recent reports of scalp white piedra seen in children in Brazil4,8,9,15, Mexico17 and in North America11. This is the first report of an outbreak of scalp white piedra in children from Ribeirão Preto city, Northeastern of São Paulo State, Brazil.
PATIENTS AND METHODS
The first case of scalp white piedra was a 5 year-old female child, assisted at the University Hospital of Faculty of Medicine of Ribeirão Preto (São Paulo State, Brazil), in February of 1997, who had been frequenting a public children day care. In the end of 1997, the children of that day care and 10 workers were examined. Hair samples of suspicious cases of white piedra were collected for mycological exam, culture in Sabouraud's agar, and scanning electron microscopy. For the fungi identification, biochemical methods were accomplished.
Eighty-six children were examined (83.5%) from the total of 103, with age between one and five years, 44 female, with prevalence of the white race (69.8%). Included the first case, scalp white piedra was diagnosed in five children among those examined (5.8%), all female, with long curly brown hair, good hygiene and without any other lesions in their scalp (Table 1). On scanning electron microscopy, multiple nodules composed by arthrospores were surrounding the hair shaft, without compromising the cortex or the marrow hair (Fig. 1). In the culture colonies presented as paraffin-like aspect, which microscopy exam evidenced arthroconidia as well as blastoconidia (Fig. 2). The identification of T. cutaneum was confirmed by biochemical methods.
Several other pediatric dermatoses were diagnosed, such as pediculosis in 18.6% and chickenpox in 15.1%. Among the examined professionals white piedra was not diagnosed.
Trichosporon spp. (old denomination T. beigelii) is commonly found in nature (soil, water and vegetal matter) and it has been isolated from monkeys, horses and dogs3,6. The diagnosis of Trichosporon infection has became more important in the last few years, as it has been described as eczematous form mimicking dermatophytosis, as generalized papules and nodules in immunocompromised patients representing a trichosporonosis form, or as systemic infection in patient submitted to peritoneal dialysis or parenteral nutrition12,14.
White piedra can be clinically indistinguishable from pediculosis or trichobacteriosis, and association of white piedra with bacteria and nits has been observed7,15,16,19. In our casuistic, in one case there was association with pediculosis but we didn't observe association with bacteria by culture or scanning electron microscopy.
Most of the reports of scalp white piedra has demonstrated that it occurred predominantly among female children (2-6 years old at preschool age)4,8,11,15,17, according with our finding.
The first child diagnosed in this study had frequented the day care from 1994 to February 1997. As this fungal dermatosis is not common in Ribeirão Preto, Northeastern of São Paulo State, it was considered the possibility of one of the children, who was coming from Ilhéus (Bahia State, Brazil) being the contaminating source. However, this child had arrived in the city recently, and she started frequenting the day care after February 1997. Moreover, the parents of this child were examined and did not have their scalp or genital hair compromised.
The mode of transmission in human is not so far clear being more associated with high temperature and humidity11,15,16, and we didn't observe any relation with socioeconomic level like other reports4,8,9,11,15,17. Despite the fact that it was not possible to determine the focal source of contamination, the first cases of white piedra configuring an interpersonal contagion in an outbreak seen in the northeastern region of São Paulo State were registered.
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Ana Maria F. Roselino
Departamento de Clínica Médica
Faculdade de Medicina de Ribeirão Preto/USP
Av. Bandeirantes 3900, 14049-900
Ribeirão Preto, SP, Brasil
Received: 27 November 2007
Accepted: 11 September 2008