Review Article

Submitted: 12.3.2014
Accepted: 4.5.2014
Conflict of interest
None.

DOI: 10.1111/ddg.12390

Trichophyton species of Arthroderma

benhamiae a new infectious agent in
dermatology
Pietro Nenoff 1, Silke Uhrla1,
Constanze Krger 1, Marcel
Erhard2, Uta-Christina
Hipler 3, Florian Seyfarth4,
Jrgen Herrmann1, Tino
Wetzig5, Wieland Schroedl6,
Yvonne Grser 7
(1) Laboratory for Medical Microbiology, Mlbis, Germany
(2) RIPAC-LABOR LLC, Potsdam-Golm,
Germany
(3) Department for Dermatology, University Hospital Jena, Germany
(4) Dermatologists in Private Practice:
Priv.-Doz. Dr. Kirsten Jung, Uta Zell &
Dr. Florian Seyfarth, Erfurt, Germany
(5) Department of Dermatology,
Dermatosurgery, and Allergology, Asklepios Hospital Weienfels,
Germany
(6) Institute for Bacteriology and Mycology, Veterinary Faculty, University
of Leipzig, Germany
(7) Consultant Laboratory for Dermatophytes, Institute for Microbiology
and Hygiene, Medical Faculty Berlin
Charit, Berlin, Germany

Summary
In Germany, infections due to the zoophilic dermatophyte Trichophyton ( T.) species of Arthroderma benhamiae are being more frequently diagnosed. The source of
infection of this emerging pathogen overlaps with that of the zoophilic species T.
interdigitale. The most common source are guinea pigs. T. species of Arthroderma
benhamiae causes inflammatory dermatophytosis in children and adolescents. In addition to tinea capitis, it may cause both tinea corporis, tinea manus and frequently
tinea faciei. In Germany, T. species of Arthroderma benhamiae is a frequent zoophilic
dermatophyte, which in regions is probably more frequent than Microsporum canis.
The mycological identification of the isolates with their yellow stained colonies is based on their macroscopic and microscopic features. However, some exhibit colony
features consistent with those of T. interdigitale. These strains only can be identified
unambiguously by means of molecular techniques. Using detection methods such as
PCR-ELISA or real-time PCR, the dermatophyte can be identified directly from clinical
material. Sequencing of the internal transcribed spacer region (ITS) of the ribosomal
DNA has been approved as culture confirmation test for T. species of Arthroderma
benhamiae. In addition, matrix-assisted laser desorption/ionization time-of-flight
mass spectrometry (MALDI TOF MS) is useful. Widespread dermatophytosis due to
T. species of Arthroderma benhamiae, in particular of tinea capitis, requires oral antifungal agents. Terbinafine is most effective, alternatives are fluconazole and itraconazole.

Introduction
Thus far, dermatophytoses resulting from contact with
small rodents, especially guinea pigs, have almost exclusively been caused by zoophilic Trichophyton (T.) interdigitale strains (formerly T. mentagrophytes) [1]. Over the
past five years, however, isolates exhibiting distinctly yellow colonies have increasingly been detected (Figure1ac).
Although macroscopically resembling Microsporum (M.)
canis, the microscopic features of these yellow-stained der-

matophyte strains, if expressed, are consistent with those

of T. interdigitale. Only molecular biology methods, such
as sequencing of the internal transcribed spacer (ITS) region of ribosomal DNA, allow for the exact classification of
these strains as T. species of Arthroderma (A.) benhamiae
[2, 3]. Though known for a long time, this zoophilic dermatophyte species has domestically not been described in
recent decades. Nowadays, however, one has to assume that
T. species of A. benhamiae is the most common zoophilic

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Review Article Trichophyton species of Arthroderma benhamiae

pathogen of dermatophytoses, p a r t ic u l a rly a mong ch i ld ren a nd adole s c ent s , i n G er m a ny.

T. species of A. benhamiae may cause various kinds of
dermatophytoses, predominantly tinea corporis and tinea faciei, but frequently also tinea capitis and Kerion Celsi. Rare
cases of onychomycosis have also been reported. When using
conventional cultural detection methods, the diagnostic
challenge lies in the differentiation from dermatophytes with
similar morphology. Direct detection of pathogen DNA from
skin scrapings and hair roots through polymerase chain reaction (PCR) has therefore proven diagnostically useful. Therapeutic agents include topical antimycotics effective against
dermatophytes. Extensive infections as well as tinea capitis
require the administration of systemic antimycotics. Here,
terbinafine is the treatment of choice, with fluconazole and
itraconazole representing valid alternatives.

Prevalence of Trichophyton species of

Arthroderma benhamiae
Japan
The earliest and also most reports on infections by T. species
of A. benhamiae come from Japan [47]. T. species of A.
benhamiae as pathogenic agent in human dermatophytoses
was first isolated and described in Japan in the year 2002.
The isolates came from two patients with tinea corporis as
well as from a rabbit representing the source of infection [5].
At the time, differentiation was based on sequencing of the
gene coding for chitin synthase 1 (CHS1) as well as on crossing experiments. In 1998, A. benhamiae had already once
been isolated from a rabbit in Japan.
Shiraki et al. [6] reported on tinea corporis by T. species
of A. benhamiae with an atypical clinical presentation in a
Japanese patient working at a pet shop. The authors presumed that T. species of A. benhamiae had most likely already spread throughout Japan, however, to date, M. canis still
remains the most common zoophilic dermatophytic pathogen in that country [8]. It is closely followed in second place
by A. benhamiae (T. species of A. benhamiae) transmitted
by rabbits, rodents, and white-bellied hedgehogs, all of them
being popular pets in Japan, too.
Japan is expecting a future increase in infections by this
zoophilic dermatophyte [8]. In a recent study on molecular
identification and epidemiology of T. species of A. benhamiae in Japan, 46 of 61 strains showed high sequence homology
within the internal transcribed spacer (ITS) regions of ribosomal RNA (rRNA) genes. A total of eleven genotypes (NTS
types) were differentiated within these 46 strains by means
of strain typing through sequencing of the non-transcribed
spacer (NTS) gene region of rRNA [9], among them 22 Japanese isolates. Of those, ten belonged to the NTS8 type, six

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Figure 1 Trichophyton species of Arthroderma benhamiae:

Fungal cultures. Primary culture from skin scrapings in an
8-year-old girl with tinea faciei. Sabouraud 4 % dextrose slant
agar shows characteristic beige to yellow, flat, radiating colonies (a). Subculture of Trichophyton species of Arthroderma
benhamiae on Sabouraud 4 % dextrose agar in a Petri dish:
flat, yellow, peripherally radiating, centrally raised colonies
(b). Individual colonies of Trichophyton species of Arthroderma benhamiae displaying a yellow, radiating thallus (c).

to NTS1, and three to NTS2. Five epidemiologically related

strains, i.e. they were gathered from various body sites of the
same patient or his pet, revealed identical genotypes.

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Review Article Trichophyton species of Arthroderma benhamiae

Prevalence in Germany
So far, T. species of A. benhamiae has only rarely been detected as cause of dermatomycoses in Germany, yet not due to
the fact that this fungus does not occur, but rather because
T. species of A. benhamiae has been incorrectly identified.
This comes as no surprise, for, on the basis of its thallus color
and the large number of microconidia, this pathogen cannot
be unequivocally differentiated from other zoophilic species,
such as T. interdigitale and other morphologically similar
dermatophytes (e.g. M. canis). This is in contrast to the actual prevalence of T. species of A. benhamiae as dermatophytic
pathogen in Germany.
Predilection sites of T. species of A. benhamiae infections are the trunk and arms (tinea corporis) as well as the
face (tinea faciei) and scalp (tinea capitis and Kerion Celsi)
(Figure2a, b).
There has been one report of a German patient under immunosuppressive therapy following a kidney transplant who developed extensive tinea corporis by A. benhamiae[10]. The zoophilic pathogen was found on the patient, her husband as well
as on several pets (three guinea pigs, three rabbits, and a dog).
Here, identification was again based on sequencing of the ITS
region of rRNA. The immunosuppressed patient was successfully treated with oral terbinafine as well as topical ciclopirox.
One of our own patients was a 5-year-old girl with tinea
faciei et corporis by T. species of A. benhamiae. Source of
infection were two infected guinea pigs. The patients 10-year-old sister as well as her mother also showed tinea corporis.
As topical therapy with ciclopirox cream was unsuccessful,
oral administration of terbinafine (62.5 mg QD for 2 weeks)
was initiated and led to a swift resolution of lesions [11].
A 9-year-old boy presented with a painful, oozing, purulent swelling with abscess formation on the scalp that had
developed a few weeks earlier. He initially received antibiotic
treatment with cefuroxime axetil. The family had three pets:
one cat and two guinea pigs, one of which showed fur lesions. Conventional and molecular biology workup from swab
material and epilated hairs (from the boy) revealed T. species
of A. benhamiae. Administration of oral terbinafine over the
course of eight weeks resulted in complete resolution of tinea
capitis profunda (Kerion Celsi) lesions [12].
After an 11-year-old girl had suffered from tinea corporis
for several weeks, she additionally developed tinea capitis
with round alopecia and a hyperkeratotic scab (Figure3a, b).
Initially, she was topically treated with an antimycotic and
antiinflammatory agent (fluprednidene 21-acetate and miconazole nitrate). She had contact with a cat (at her grandmother's place), guinea pigs at home, and mice (in biology class
at school). Fungal cultures as well as PCR from scalp scrapings showed T. species of A. benhamiae. In addition to topical terbinafine and ciclopirox, oral terbinafine 125 mg QD

Figure 2 Tinea corporis by Trichophyton species of Arthroderma benhamiae in a 43-year-old man. Source of infection
for him and his 21-year-old daughter was a guinea pig (a).
Tinea manus caused by the same pathogen (and strain) in the
patients 21-year-old daughter (b).

was administered in the context of a so-called individual

therapeutic attempt over the course of 14 days. The fathers
written informed consent had to be obtained, as terbinafine
is not approved for the treatment of children. The intensive
therapy resulted in complete resolution of tinea capitis lesions
within two weeks [13].
Two of our own patients suffered from onychomycosis
caused by T. species of A. benhamiae: a teenager showed involvement of the fingernails, a woman of the toenails (own
observation).
Due to the clinical suspicion of pyoderma, a 24-year-old
patient with pustular nodular lesions on the chin and cheeks
was initially treated with oral amoxicillin and subsequently as inpatient with piperacillin/tazobactam IV. The correct
diagnosis of tinea barbae profunda by T. species of A. benhamiae was only made after identification of the isolate from
epilated hairs by means of PCR [14]. The pathogen was also
found on a guinea pig kept as pet. Treatment with oral fluconazole 100 mg QD and topical ciclopirox cream led to the
resolution of tinea barbae lesions.

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T. species of A. benhamiae. In 231 (2.9 %) of 7,680 patients, T. species of A. benhamiae was identified by means of
culture (yellow strains) and/or PCR [15]. Surprisingly, M.
canis was only the second most common zoophilic dermatophyte with a detection rate roughly 50 % lower. Among
patients infected by T. species of A. benhamiae, children
and adolescents up to 19 years of age were most frequently
affected (61.3%). In the Mlbis lab (serving Leipzig and
surrounding counties as well as parts of Middle Germany),
T. species of A. benhamiae is currently the most common
zoophilic dermatophytic pathogen. This, however, does not
necessarily reflect its overall prevalence within Germany.
Further studies are required, in order to ascertain whether
this pathogen shift will persist.

Trichophyton species of Arthroderma benhamiae

in Switzerland and Belgium

Figure 3 Tinea capitis by Trichophyton species of Arthroderma benhamiae in an 11-year-old girl. Right parietally, there
is a circular, centrifugally growing, erythemato-squamous,
centrally hyperkeratotic, scabbed area, 4 5 cm in diameter,
showing centrifugal growth and alopecia as well as causing
pruritus. Once more, guinea pigs were the source of infection
(from: P. Nenoff, C. Krger. Dermatophyten-Infektionen der
Haut, Haare, Ngel ein Update. Teil 1: Klinische Aspekte. Akt
Dermatol 2012; 38: 34759) (a). Following treatment with oral
terbinafine 125 mg QD for 14 days. The tinea capitis lesions
have completely healed. The remaining intact hair follicles
suggest a resolution without scar formation in terms of pseudopelade of Brocq (b).

The laboratory in Mlbis has analyzed a total of 8,464

samples from 7,680 patients collected over a 3-year period (March 2010 until March 2013), in order to ascertain
the prevalence of this particular dermatophyte species in
Germany. Samples came from skin scrapings, hairs or hair
roots as well as skin swabs. All samples were analyzed by
culture and a large percentage (> 90 %) was also subjected
to in-house PCR for dermatophyte detection, among them

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Nine rapidly growing dermatophytes isolated from eight children and one adult in Switzerland have been retrospectively
classified as T. species of A. benhamiae by sequencing of the
ITS region. Eight of the nine patients had contact with rodents, mostly guinea pigs [16].
A dermatophyte recently isolated from a Belgian child
with vesicular and markedly inflammatory tinea corporis
[17] morphologically resembled T. erinacei (formerly T. mentagrophytes var. erinacei). Because of the unusual infection
source guinea pig (T. erinacei is almost always transmitted by hedge hogs), the authors suggested the name T. mentagrophytes var. porcellae for this new subspecies. The
authors of the present review article, however, believe that
their colleagues were rather dealing with a yellow isolate
of T. species of A. benhamiae, for differentiation was merely
predicated on morphologic criteria, as no molecular biology
methods were implemented.

Sources of infection
Guinea pigs are the main source of infection for T. species of
A. benhamiae (Figure4). Other small rodents, however, may
also be potential carriers of this zoophilic dermatophyte, e.g.
hamsters and rats. Over a 14-month period, a Swiss veterinary clinic, apart from M. canis, also found T. species of
A. benhamiae and zoophilic T. interdigitale strains in pets.
While T. species of A. benhamiae was frequently isolated
from guinea pigs, zoophilic T. interdigitale strains mostly
came from European shorthair cats (predominantly strays)
and occasionally from dogs [18]. We have also been able to
identify T. species of A. benhamiae in a cat and a group from
Illinois, USA, recently isolated this strain from several dogs
affected by dermatophytosis [19]. A human infection by A.
benhamiae following contact with a Canadian porcupine in

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Review Article Trichophyton species of Arthroderma benhamiae

Figure 4 Dermatophytosis by Trichophyton species of Arthroderma benhamiae in a guinea pig. The pathogen was
identified by culture as well as molecular biology methods.
Caudally, there is a bald, sharply demarcated lesion with silvery shiny hyperkeratoses. The animal was the infection source for tinea corporis in two siblings.

a Japanese zoo has also been described [20].

Pathogenesis of dermatomycoses by Trichophyton species of Arthroderma benhamiae

Grumbt et al. [21] studied virulence genes of the human
pathogen A. benhamiae (better T. species of A. benhamiae). While examining infections by A. benhamiae in
guinea pigs, the same work group had previously already
identified the gene coding for malate synthase AcuE, a key
enzyme in the glyoxylate cycle. Malate synthase facilitates growth of A. benhamiae on lipids, which constitute an
essential structural component of skin. It remained unclear, however, in what way the enzyme mutants devised
by this work group actually played a pathogenetic role as
virulence factor in this guinea pig model of A. benhamiae
infections.
Burmester et al. [22] analyzed the genome of A. benhamiae and T. verrucosum, in order to gain insight into the
pathogens virulence and pathogenicity. With respect to A.
benhamiae, they found genomic evidence for secretory pro-

teases and other hydrolytic enzymes responsible for keratin

degradation.
Cambier et al. [23] recently examined cutaneous immune responses to infections by T. species of A. benhamiae and zoophilic T. interdigitale strains in a mouse model. They were able to show that cutaneous symptoms and
microscopic changes caused by both dermatophytes in a
guinea pig model as well as in humans, particularly the colonization of epidermal and follicular structures, were very
similar. The cutaneous inflammatory infiltrate consisted of
macrophages, dendritic cells, and especially polymorphonuclear neutrophils. According to the authors of that study,
the latter are known to represent the histologic key to
the diagnosis of dermatophytosis. The cytokine profile of
the infection in situ was characterized by overexpression of
TGF , interleukin (IL) 1, and IL6 mRNA, indicating the
significance of the Th17 pathway in the immune response
[23].
Unlike anthropophilic dermatophytes, e.g. T. tonsurans, T. species of Arthroderma benhamiae frequently
causes highly inflammatory infections (Figure5), which
is consistent with the, by now known, keratinocytic cytokine pattern. Infections by T. species of A. benhamiae
result in the secretion of numerous, particularly proinflammatory cytokines, chemokines and immunomodulating cytokines. Specifically, there is an upregulation in
the expression of genes coding for IL1, IL2, IL4, IL6,
IL10, IL13, IL15, IL16, IL17, and interferon gamma [24].
On the other hand, T. tonsurans causes an increase in
gene activity of only few cytokines (IL1 and IL16), leading to a distinctly more discreet inflammatory response.
Both dermatophytes increase IL8 mRNA expression in
keratinocytes.

Diagnostic workup
Microscopic workup and Wood light
In case of tinea capitis, spores invade the hair shaft in an endothrix pattern typical for Trichophyton species. T. species
of A. benhamiae may not be detected by Wood light.

Cultural features of Trichophyton species of

Arthroderma benhamiae
On Sabouraud agar, T. species of A. benhamiae forms flat
radiating colonies with beige to yellow mycelium and a dense
velvety surface (Figure6). The reverse side of the colonies
shows a strong, sometimes even bright, yellow (Figure7),
but may at times also appear ocher to brown or auburn. A
smaller percentage of isolates exhibits a different colony mor-

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Figure 5 Tinea corporis by Trichophyton species of Arthroderma benhamiae in a 43-year-old woman. The mammary
lesion shows an inflammatory erythema, erosion, scaling, and
accentuation at the periphery.

phology, resembling that of T. interdigitale (formerly T. mentagrophytes), with white granular, sometimes powdery, but
also radiating and flat colonies, at times slightly yellowish at
the margins (Figure8). These roughly 20 % of T. species of
A. benhamiae strains (percentage estimate based on figures
from our own mycology lab) may morphologically not be distinguished from T. interdigitale.
Using lactophenol cotton blue stains, microscopic features include predominantly round and occasionally oval to
clavate microconidia laterally and terminally inserting at the
hyphae (Figure9a, d). The botrytis-like (grape-like) arrangement of microconidia corresponds to the micromorphology
of T. interdigitale (Figure9 b, c). Apart from that, microconidia may also laterally insert at the hyphae in an ear of corn
fashion. Spiral hyphae may also occur, indicating they are
not species-specific for T. interdigitale. The cigarette-shaped
or sometimes clavate macroconidia are transversely septated
(three to eight septa) [25].
Yellow T. species of A. benhamiae colonies may be
confused with M. canis, T. erinacei, and even T. soudanense. With regard to the latter anthropophilic dermatophyte,
however, the history the patient is either of African descent
or the infection was contracted on a trip to Africa should
lead the mycologic workup in the right direction. It should
also be mentioned here that T. soudanense is generally no
longer regarded a separate species, as it genotypically corresponds to the African population of T. rubrum. The morphologic differentiation between T. species of A. benhamiae and
T. erinacei is feasible, though, if the phenotypic characteristics are fully developed. The urea hydrolysis test is negative

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Figure 6 Trichophyton species of Arthroderma benhamiae:

Swab isolate from the arm of a 9-year-old girl with tinea corporis. The colonies with their yellow reverse side on Sabouraud 4 % dextrose agar are similar to those of Microsporum
canis, Trichophyton interdigitale, and Trichophyton erinacei.

Figure 7 Trichophyton species of Arthroderma benhamiae:

Subculture from skin scrapings in tinea capitis. On Sabouraud
4 % dextrose agar, the colonies reverse side shows a bright
yellow.

in T. erinacei, whereas T. species of A. benhamiae shows a

positive reaction. M. canis may easily be differentiated on the
basis of its characteristic macroconidia.
Furthermore, there is a genetic relationship between T.
species of A. benhamiae and T. verrucosum, the pathogen causing ringworm in cattle, which, according to an initial study
[26], seems to also be corroborated by crossbreeding patterns.
This genetic relationship is diagnostically significant, because

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has recently been described [27]. The CandiSelect medium

is a chromogenic agar for the differentiation of yeasts, particularly Candida species. This procedure is easy to perform, as the colonies change in color denotes the respective
Candida species. All 21 M. canis strains developed a pink
to violet colony color on chromogenic agar. On the other
hand, Arthroderma benhamiae colonies were predominantly (25 of 30 strains) turquoise. Five of the 30 A. benhamiae
strains, however, displayed a violet color like M. canis. It
ought to be stressed that the chromogenic agar method has
been designed as quick test, since conidia formation takes
a long time.
Figure 8 Trichophyton species of Arthroderma benhamiae
(white colonies). Isolate from a 14-year-old girl with tinea
faciei. Sabouraud 4 % dextrose slant agar shows white, granular, powdery, and radiating colonies whose morphology
is similar to that of Trichophyton interdigitale (formerly T.
mentagrophytes). Identification as Trichophyton species of
Arthroderma benhamiae is based on molecular biology methods, e. g. PCR ELISA.

Molecular methods for the direct detection of Trichophyton species of Arthroderma benhamiae

some molecular detection assays for T. species of A. benhamiae

may show a certain degree of cross reactivity. In routine clinical
practice, it is therefore advisable to validate the species-specificity of the respective detection test. In case of clinical suspicion, particularly if the culture does not unequivocally show
a rapidly growing dermatophyte, species-specific PCR for T.
verrucosum or sequencing of the ITS region should additionally be performed. The latter pathogen is, however, much less
common than T. species of A. benhamiae and, as already mentioned, is transmitted by a different animal species.

PCR ELISA for the detection of Trichophyton species of Arthroderma benhamiae

Urea hydrolysis for the differentiation of Trichophyton species of Arthroderma benhamiae

Urea hydrolysis on Christensen's urea agar (Heipha Diagnostika Dr. Mller, Heidelberg) is positive (indicator:
phenolphthalein, reactive = red agar staining). As M. canis
and T. interdigitale are also urease positive, differentiation
from these two species is therefore not feasible using this
method. On the other hand, T. erinacei, which displays no
or only delayed urea hydrolysis, may be ruled out by this
technique.

Differentiation of Trichophyton species of

Arthroderma benhamiae by chromogenic agar
Identification of T. species of A. benhamiae by means of
CandiSelect 4 medium (Bio-Rad Laboratories, Munich)

Presently, unambiguous identification of T. species of A. benhamiae may only be achieved by means of molecular biology techniques. Specific ITS-based PCR constitutes a reliable
method for direct pathogen detection from clinical sample
material [2831].

Using a uniplex PCR ELISA (enzyme-linked immunosorbent

assay), whose primer pair amplifies specific sections of the topoisomerase 2 gene, allows for the detection of T. rubrum, T.
interdigitale, Epidermophyton floccosum, M. canis, T. tonsurans, T. verrucosum, and T. violaceum. The target gene for
the detection of T. species of A. benhamiae, however, is the
ITS 1 gene region (internal transcribed spacer). In general,
amplified gene segments are labeled with digoxigenin by one
of the primers and, using specific ELISA probes, subsequently optically or photometrically detected [28, 32, 33].

Molecular biology differentiation of yellow and

white colonies of Trichophyton species of Arthroderma benhamiae
With respect to the A. benhamiae (T. species of A. benhamiae) strains isolated in Switzerland, sequencing of the ITS
region as well as parts of the 28S rRNA gene revealed the
presence of two infraspecific groups corresponding to the
two markedly different colony phenotypes. Thus, group I
with white colonies may be differentiated from group II with
yellow colonies [34]. This classification ultimately also serves an important practical purpose, for it is impossible to
identify white colonies as T. species of A. benhamiae solely
based on morphologic colony features. The sophisticated

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Figure 9 Microarchitecture of Trichophyton species of Arthroderma benhamiae, lactophenol cotton blue stain: microscopy shows a vast number of small round microconidia (a). Clusters of round, partially relatively large microconidia (incipient
chlamydospore formation) (b). Botrytis-like (grape-like) microconidia (c). Microconidia, thickened septate mycelium, and
chlamydospores (d).

molecular biology method of sequencing has, however, not

yet become generally available for routine lab diagnostics.

MALDI-TOF mass spectrometry for the identification of Trichophyton species of Arthroderma

benhamiae
In order to confirm results obtained from cultures, MALDI-TOF (matrix-assisted laser desorption/ionization time-offlight) mass spectrometry (MS) may be used. The combination
of MALDI-TOF MS and e.g. AnagnosTec SARAMIS (formerly: spectral archiving and microbial identification system;
nowadays: VITEK MS Plus, bioMrieux, Nrtingen, Germany), a software and database, constitutes a quick and specific
procedure for the identification of bacteria and fungi. Here,
samples are prepared and analyzed without prior purification,
eventually yielding an unequivocal so-called fingerprint mass
spectrum of the microorganism in question. This fingerprint
is individual and may therefore, depending on the respecti-

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ve group of microorganisms, be used in the identification of

species, subspecies, and ultimately even strains. Protein mass
spectra allow for the detection of genus-, species-, type-, and
strain-specific signals (Figure10ad). The sample material
fungal colonies of dermatophyte cultures thus ultimately
biomolecules is embedded into a matrix and subsequently
desorbed and ionized by means of a laser. Acceleration of ions
thus generated in the gaseous phase by an electromagnetic field
is then followed by time-dependent detection after a flight distance of 1.2 meters. Flight times may then be matched with
molecular masses according to prior calibration. This method
offers an easy and outstandingly accurate way to differentiate all clinically relevant dermatophytes and even rare species,
provided they have been entered into the database. A comprehensive study on the establishment of MALDI-TOF MS in
285 dermatophytic isolates belonging to 21 different species
also included 17 T. species of A. benhamiae strains isolated
from actual patients [35]. While conventional methods had
failed to unambiguously identify these strains, MALDI-TOF

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tes may be used, e.g. imidazoles (clotrimazole, bifonazole), ciclopirox, or terbinafine. Extensive dermatophytoses by T. species of
A. benhamiae, especially tinea capitis, are generally treated with
oral antimycotics. Here, terbinafine is the drug of first choice,
with fluconazole and itraconazole representing valid alternatives.
The excellent efficacy of terbinafine in T. species of A.
benhamiae infections is mirrored by its low minimal inhibitory concentration (MIC) value of 0.0156 g/ml shown in
an in vitro study [37]. All other antimycotics revealed higher
MIC values with respect to T. species of A. benhamiae, to
wit, griseofulvin 1 g/ml, itraconazole 0.25 g/ml, ketoconazole 16 g/ml, fluconazole 32 g/ml, voriconazole 1 g/ml,
clotrimazole 0.0625 g/ml, ciclopirox 16 g/ml, and amorolfine 0.25 g/ml. It is unclear, however, to what extent these
MIC values actually reflect the in vivo situation in patients.
In our own experience, topical terbinafine and ciclopirox
both work well. Systemically, terbinafine has been very effective and well tolerated, yet the administration of fluconazole
has also yielded successful results.

Conclusion

Figure 10 MALDI-TOF mass spectra: Trichophyton species

of Arthroderma benhamiae, yellow strain (a). Trichophyton species of Arthroderma benhamiae (b). Trichophyton
interdigitale (formerly Trichophyton mentagrophytes),
zoophilic strain, isolated from a child with onychomycosis
following contact with a pet (c). Trichophyton
rubrum (d).

MS analysis enabled the distinct classification as T. species of

A. benhamiae. Sequencing of the ITS gene region eventually
confirmed the identification. Similar results have recently been
reported using an AXIMA confidence mass spectrometer (Shimadzu Biotech, Kyoto, Japan) [36].
In this context, it ought to be emphasized that although
MALDI-TOF MS is extremely useful in unequivocally
identifying mature T. species of A. benhamiae colonies,
the differentiation between yellow and white T. species of
A. benhamiae colonies, is not possible. Unlike PCR, direct
dermatophyte detection from skin scrapings or hair roots by
means of MALDI-TOF MS is currently not feasible, either.

In Germany, infections by T. species of A. benhamiae initially

went largely unnoticed. For the past five years, however, dermatophytoses caused by this new (emerging) pathogen have
been described all over the country. Dermatologists, but also
pediatricians, and ultimately even veterinarians, local health
authorities, and also pet shop employees should take note of the
rise in infections by this zoophilic dermatophyte in children and
adolescents and take appropriate action. Avoiding contact with
infected pets (guinea pigs) is the best form of prevention. Infected pets should therefore not be admitted to any household. T.
species of A. benhamiae causes markedly inflammatory and
even purulent, abscess-forming dermatophytoses, frequently
on the face and scalp. Although simple cultures easily provide
evidence for a fungus, the exact classification of a fungus as T.
species of A. benhamiae still poses difficulties. Newer, swiftly
practicable molecular methods such as PCR or MALDI TOF
MS allow for a specific mycologic workup.
Extensive tinea cases as well as tinea capitis should always
be treated with systemic antimycotic agents. Terbinafine has
proven to be effective and safe, with fluconazole and itraconazole representing valid alternatives. Oral antimycotic treatment
in children, however, requires the parents written informed
consent and should only be administered as so-called individual therapeutic attempt according to German drug laws.

Treatment of infections by Trichophyton species

of Arthroderma benhamiae

Acknowledgements

With regard to topical treatment of T. species of A. benhamiae

infections, any antimycotic agent effective against dermatophy-

The excellent macroscopic pictures of fungal cultures were

taken by the photographer Uwe Schoig (Leipzig).

2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1207

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Review Article Trichophyton species of Arthroderma benhamiae

Correspondence to
Prof. Dr. med. Pietro Nenoff
Haut- und Laborarzt/Allergologie, Andrologie
Labor fr medizinische Mikrobiologie
Partnerschaft Prof. Dr. med. Pietro Nenoff & Dr. med.
Constanze Krger
Strae des Friedens 8
04579 Mlbis
Germany

13

14

15

E-mail: nenoff@mykologie-experten.de

References
1

Nenoff P, Handrick W, Krger C et al. Dermatomykosen durch

Haus- und Nutztiere vernachlssigte Infektionen? Hautarzt
2012; 63: 84858.
2 Grser Y, El Fari M, Vilgalys R et al. Phylogeny and taxonomy
of the family Arthrodermataceae (dermatophytes) using sequence analysis of the ribosomal ITS region. Medical Mycol
1999; 37: 10514.
3 Grser Y, Scott J, Summerbell R. The new Spezies concept in
dermatophytes a polyphasic approach. Mycopathologia
2008; 166: 23956.
4 Mochizukia T, Kawasakia M, Ishizakia H et al. Molecular epidemiology of Arthroderma benhamiae, an emerging pathogen
of dermatophytoses in Japan, by polymorphisms of the nontranscribed spacer region of the ribosomal DNA. J Dermatol
Science 2001; 27: 1420.
5 Nakamura Y, Kano R, Nakamura E et al. Case Report. First report on human ringworm caused by Arthroderma benhamiae
in Japan transmitted from a rabbit. Mycoses 2002; 45: 12931.
6 Shiraki Y, Masataro Hiruma M, Matsuba Y et al. A case of tinea
corporis caused by Arthroderma benhamiae (teleomorph of
Trichophyton mentagrophytes) in a pet shop employee. JAAD
2006; 55: 1534.
7 Mochizuki T, Kobayashi H, Takeda K et al. The first human
cases of Americano-European race of Arthroderma benhamiae
infection in Japan. Jpn J Infect Dis 2012; 65:
5589.
8 Kano R. Cutaneous mycoses in Japan originating from animals. Med Mycol J 2012; 53: 1923.
9 Takeda K, Nishibu A, Anzawa K, Mochizuki T. Molecular epidemiology of a major subgroup of Arthroderma benhamiae isolated in Japan by restriction fragment length polymorphism
analysis of the non-transcribed spacer region of ribosomal
RNA gene. Jpn J Infect Dis 2012; 65: 2339.
10 Budihardja D, Freund V, Mayser P. Widespread erosive tinea
corporis by Arthroderma benhamiae in a renal transplant recipient: case report. Mycoses 2010; 53: 5302.
11 Nenoff P, Schetschorke C, Schleicher G et al. Tinea faciei et
corporis eines 5-jhrigen Kindes durch Arthroderma benhamiae erfolgreiche Behandlung mit Terbinafin per os. J Dtsch
Dermatol Ges 2011; 9 (Suppl 1): 223 (Abstract).
12 Nenoff P, Schulze I, Uhrla S, Krger C. Kerion Celsi durch
den zoophilen Dermatophyten Trichophyton Spezies von Ar-

580

16
17
18

19

20

21

22

23

24

25

26

27

28

throderma benhamiae bei einem Kind ein neuer Erreger von

Dermatomykosen in Deutschland. Hautarzt 2013; 64: 8469.
Nenoff P, Schetschorke C, Schleicher G et al. Tinea faciei and
Tineas capitis in two children due to the zoophilic dermatophyte Trichophyton spp. of Arthroderma benhamiae diagnostics using PCR and successful treatment by oral terbinafine. Mycoses 2011; 54: 3945 (Abstract).
Braun SA, Jahn K, Westermann A et al. Tinea barbae profunda
durch Arthroderma benhamiae. Eine diagnostische Herausforderung. Hautarzt 2013; 64: 7202.
Uhrla S, Ebert A, C. Krger C, Nenoff P. Trichophyton Spezies
von Arthroderma benhamiae ein neuer hufiger zoophiler
Dermatophyt in Deutschland Daten zur Prvalenz im mitteldeutschen Raum. Derm Prakt Dermatol 2013; 19: 3702.
Fumeaux J, Mock M, Ninet B et al. First Report of Arthroderma
benhamiae in Switzerland. Dermatology 2004; 208: 24450.
Khettar L, Contet-Audonneau N. Guinea pigs and dermatophytosis. Ann Dermatol Venereol 2012; 139: 6315.
Drouot S, Mignon B, Fratti M et al. Pets as the main source of
two zoonotic Spezies of the Trichophyton mentagrophytes
complex in Switzerland, Arthroderma vanbreuseghemii and
Arthroderma benhamiae. Vet Dermatol 2009; 20: 138.
Sieklucki U, Oh SH, Hoyer LL. Frequent isolation of Arthroderma benhamiae from dogs with dermatophytosis. Vet Dermatol 2014; 25(1): 39-e14.
Takahashi H. Takahashi-Kyuhachi H. Takahashi Y et al. An intrafamilial transmission of Arthroderma benhamiae in Canadian
porcupines (Erethizon dorsatum) in a Japanese zoo. Med Mycol 2008; 46: 46573.
Grumbt M, Defaweux V, Mignon B et al. Targeted gene deletion and in vivo analysis of putative virulence gene function
in the pathogenic dermatophyte Arthroderma benhamiae.
Eukaryot Cell 2011; 10: 84253.
Burmester A, Shelest E, Glckner G et al. Comparative and
functional genomics provide insights into the pathogenicity
of dermatophytic fungi. Genome Biol 2011; 12: R7.
Cambier L, Weatherspoon A, Defaweux V et al. Assessment of
the cutaneous immune response during Arthroderma benhamiae and Arthroderma vanbreuseghemii infection using an
experimental mouse model. Br J Dermatol 2014; 170(3): 62533.
Shiraki Y, Ishibashi Y, Hiruma M et al. Cytokine secretion profiles of human keratinocytes during Trichophyton tonsurans
and Arthroderma benhamiae infections. J Med Microbiol
2006; 55 (Pt 9): 117585.
De Hoog GS, Guarro J, Gen J, Figueras MJ. Atlas of clinical
fungi. 3rd Edition, Electronic Version 3.1, 2011, Centraalbureau
voor Schimmelcultures, Utrecht, The Netherlands & Universitat Rovira i Virgili, Reus, Spain.
Kawasaki M. Verification of a taxonomy of dermatophytes
based on mating results and phylogenetic analyses. Med Mycol J 2011; 52: 2915.
Mayser P, Budihardja D. A simple and rapid method to differentiate Arthroderma benhamiae from Microsporum canis. J
Dtsch Dermatol Ges 2013; 11: 3227.
Winter I, Uhrla S, Krger C et al. Molekularbiologischer
Direktnachweis von Dermatophyten im klinischen Material bei Verdacht auf Onychomykose und Tinea pedis eine

2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1207

ddg14568_eng.indd 580

18/06/14 10:13 PM

Review Article Trichophyton species of Arthroderma benhamiae

prospektive Studie zum Vergleich konventioneller dermatomykologischer Diagnostik und der Polymerasekettenreaktion.
Hautarzt 2013; 64: 2839.
29 Bergmans AM, Schouls LM, van derEnt M et al. Validation of
PCR-reverse line blot, a method for rapid detection and identification of nine dermatophyte species in nail, skin and hair
samples. Clin Microbiol Infect 2008; 14: 77888.
30 Bergmans AM, van derEnt M, Klaassen A et al. Evaluation of a
single-tube real-time PCR for detection and identification of 11
dermatophyte species in clinical material. Clin Microbiol Infect
2010; 16: 70410.
31 Li HC, Bouchara JP, Hsu MM et al. Identification of dermatophytes by an oligonucleotide array. J Clin Microbiol 2007; 45:
31606.
32 Pankewitz F, Grser Y. Development of a diagnostic method using PCR-ELISA for the most common dermatophytes.
Mycoses 2009; 52: 4001 (Abstract).

33 Uhrla S, Krger C, Herrmann J et al. Molekularbiologischer

Direktnachweis von Dermatophyten mittels Polymerasekettenreaktion in der dermatomykologischen Routinediagnostik eine prospektive Untersuchung ber 32 Monate. J
Dtsch Dermatol Ges 2011; 9 (Suppl. 1): 226 (Abstract).
34 Symoens F, Jousson O, Packeu A et al. The dermatophyte Spezies Arthroderma benhamiae: intraSpezies variability and mating behaviour. J Med Microbiol 2013; 62 (Pt 3): 37785.
35 Nenoff P, Erhard M, Simon JC et al. MALDI-TOF mass spectrometry a rapid method for identification of dermatophyte
species. Med Mycol 2013; 51: 1724.
36 De Respinis S, Tonolla M, Pranghofer S et al. Identification of
dermatophytes by matrix-assisted laser desorption/ionization
time-of-flight mass spectrometry. Med Mycol 2013; 51: 51421.
37 Adimi P, Hashemi SJ, Mahmoudi M et al. In-vitro activity of 10
antifungal agents against 320 dermatophyte strains using microdilution method in Tehran. Iran J Pharm Res 2013; 12: 53745.

2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1207

ddg14568_eng.indd 581

581

18/06/14 10:13 PM