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25.10.2014 (vor 2167 Tagen)
TitelJournal of Investigative Dermatology
Startdatum16.10.2013 15:31 (vor 2540 Tagen)
Journal of Investigative Dermatology

William R. Denton, Post Surgeon, and to many medical and line officers at Fort Benning for providing facilities for these observations; and to Prof. Rhoda W. Benham, who served as consultant in this investigation, for advice and assistance in mycological work.

1 The work described in this paper was done under a contract recommended by the Committee on Medical Research between the Office of Scientific Research and Development and Columbia University.

Received 20 September 1946.

In developing measures for prophylaxis of dermatophytosis, it is of first importance to know whether primary attacks and recurrences are caused by exogenous infection or by activation of a latent infection. This fundamental question is unsolved. Although it is usually assumed by the patient that each attack results from a new infection, and many prophylactic measures are based on this hypothesis, there is little evidence to support this belief. Von Graf fenried (1) and Weidman (2) found inoculation of the toes possible only if measures were taken to macerate the skin. Williams and Barthel (3) presented strong evidence that latent infection of nails was a frequent source of recurrent attacks on the toes and soles. Sulzberger, Baer and Hecht (4) pointed to the rareness of conjugal cases as evidence against contagion. Nickerson, Irving and Mehmert (5) showed dramatically that removal of shoes without protection from contagion effectively prevented the disease.

In a study conducted at Fort Benning, Georgia, from September 1942 to September 1945, etiological data were collected in an effort to solve this question. While they do not permit a definite answer, they provide information which seems of sufficient interest to record. They also throw some light on the characteristics of the diseases produced by different species of dermatophytes.


Clinical inspection. Determination of the incidence of dermatophytosis by clinical examination is surprisingly difficult,michael kors handbags. The gradations from quite normal to severely infected feet are so even that it seems impossible by inspection to draw any sharp line between those who do and those who do not have dermatophytosis.

Slide examination. Microscopic demonstration of mycelium in hydroxide mounts of scrapings from the skin is a more objective method and would appear more reliable. It has limitations. Some cases will escape detection, as one negative examination obviously does not exclude the presence of fungi. Templeton et al. (6) report positive slides in 90 of their clinically positive cases, Hulsey and Jordan (7) 63 Phillips (8) 39 Muskatblit (9) 31 and Keeney et al. Many doubtless represent failures of the method; others are probably not cases of dermatophytosis.

On the other hand, fungi can sometimes be demonstrated in cases without clinical signs or symptoms. We saw few such cases but in one group of 30, slides were positive in 4, (13 Strickler and Friedman (11) reported the astonishing finding of 40.8 of positive slides in 157 normal cases. Kurotkin and Ch'en (12) found 3.3 positives in 150 cases, Keeney et al. (10) 1.7 in 359 cases. Considering the difficulty of obtaining adequate scrapings from normal skin, the actual occurrence of latent infection is doubtless higher. Moreover, pathogenic species have been identified by culture from normal cases by Kurotkin and Ch'en (12) in 2 of their 150 cases, by Andrews and Birkman (13) in 2 of 44 cases, by Williams (3) in 6 of 36 cases, by Cornbleet (14) in 3 of 100 cases and by Peck et al. (15) in 1.6 of 125 cases. Burgess, (16) on the other hand, obtained no pathogenic fungi in cultures from 100 normal feet.

Cultutes. Cultures from scrapings of skin are less satisfactory for statistical purposes than are direct slide examinations. They frequently fail when the slide is positive and are only rarely successful when the fungus is not visible microscopically (except in monilia infections). Of 1,213 cases at Fort Benning from which cultures were obtained, slides were positive in 95.6 at the time the culture was taken. In only 40 (4.5 did we obtain a culture when the slide was negative (table 14). The percentage of negative cultures in cases with positive slides were tabulated only as to one group of 419 cases. In table 1, these results are compared with those reported by Keeney et al. and by Muskatblit and with figures from the Vanderbilt Clinic, New York, which have previously been published (17). The last include cultures from hands as well as feet and M. albicans was frequently encountered. Many failures are caused by overgrowth by rapidly growing contaminants. Others may be due to fungicides previously applied by the patient. The possibility that the mycelium seen in some slide preparations was that of some nonpathogenic mold is remote, because the microscopic appearance of the hyphae was usually typical, and saprophytes rarely proliferate actively on normal skin. It seems probable that our present culture methods are inadequate to reveal the true frequency of fungus infections of the feet.

intertrigo. The etiology of cases of clinical intertrigo of the toes in which no fungi can be demonstrated is obscure. In many

AT AN INFANTRY POSTpeated weekly examinations for one or two months failed to reveal mycelium. Weidman (2) has discussed this problem and concluded that these cases of intertrigo may be caused (a) by hyphomycetic fungi (Trichophyta or epider mophyta); (b) by blastomycetic fungi (moniliae); (c) by bacteria; and (d) by physical and mechanical causes.

Moniliae were infrequently recognized in the series here reported (table 5). In many cases showing pronounced maceration as well as desquamation in all the interdigital spaces the skin changes appeared to be caused entirely by hyperidrosis and to be independent of any type of infection. In 428 cases of diffuse or localized hyperidrosis fungi were demonstrated in only 36 a frequency somewhat lower than in the general military population. In other cases with erythema and relatively dry desquamation, most manifest in the fourth interdigital space, bacterial infection was suspected. Observations by one of us (G. C. R.) (18) however, failed to show that coagulase positive staphylococci or hemolytic staphylococci of group A were any more prevalent in such cases

116 (27 ' 17 (11 30 (45 (69 137 (86 29 (43 (4 4 (3 8 (12 Vanderbilt Clinic (17) a. Trichophyta and Epi dermophyta b. Monilia.
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