SA62 TITLE: RINGWORM IN CATS: THE ECSTASY & THE... Overview of the Issue Valerie A. Fadok, DVM, PhD, Dipl. ACVD

Western Veterinary Conference 2013
SA62
TITLE: RINGWORM IN CATS: THE ECSTASY & THE AGONY
Valerie A. Fadok, DVM, PhD, Dipl. ACVD
Gulf Coast Veterinary Specialists
Houston, TX, USA
Overview of the Issue
Dermatophytosis (ringworm) can be a wonderful disease to treat, as it is one of the few skin
diseases we can actually cure! However, when feline dermatophytosis, caused by M. canis,
occurs in a multiple pet household, a cattery, or a shelter, it can be extremely difficult to
resolve and the treatment is very costly in terms of expense and time. It is important to make
a diagnosis as quickly as possible and to institute specific therapy to treat the individual cats,
to avoid contamination of the environment, and to prevent further transmission to other animals
and humans.
Objectives of the Presentation
1. To review the clinical signs (variable!) of dermatophytosis and the species of fungus
causing the disease in cats.
2. To discuss the pros and cons of each of the diagnostic tests we use.
3. To review the choices we have for systemic therapy and how to determine when we are
finished treatment.
4. To review our options for topical therapy and why it is important.
5. To discuss the options for environmental cleanup.
Key Etiologic and Pathophysiologic Points:
1. The three most common causes of dermatophytosis in cats are Microsporum canis,
Microsporum gypseum, and Trichophyton mentagrophytes. Of these, M. canis is the
most likely to spread from cat to cat, cat to dog, and cat to humans.
2. M. canis is well adapted to the cat and inapparent carriers are not rare. A lack of
observable lesions does not rule out dermatophytosis infection.
3. Inability to clear dermatophytosis may be associated with a pathogen-specific defect in
cell-mediated immunity. Humoral immunity is not protective.
4. Microsporum gypseum is a fungus contracted from the soil; it is not considered
contagious from animal to animal or animal to man, except under unusual
circumstances.
5. Infections with Trichophyton spp can mimic immunologic diseases such as pemphigus
foliaceus. This fungus seems the most likely to cause acantholysis.
Key Clinical Diagnostic Points:
1. Clinical signs are extremely variable, ranging from no visible lesions to alopecia with or
without erythema and crusting, to military dermatitis, to subcutaneous nodules. Pruritus
is variable.
2. Diagnostic tools include the Wood’s lamp, KOH digest of hairs and scale, fungal culture,
biopsy. Diagnosis by PCR remains controversial but may be useful in future.
3. Fungal culture most often relies on the use of Dermatophyte Test Medium. However, it
is critical to verify the diagnosis by microscopic examination of spores.
Key Therapeutic Points:
1. Systemic antifungal therapy is almost always needed when M. canis is involved; current
best choices include itraconazole, terbinafine, and fluconazole. Griseofulvin is not
recommended for use in cats, because the doses required can induce toxicosis.
2. Lime sulfur remains the most effective choice for topical therapy in the USA. In other
parts of the world, enilconazole would be the topical treatment of choice. Recent work
suggests that DOUXO chlorhexidine with climbazole might be very useful, although this
remains to be proven for cat M. canis infections.
3. Environmental cleanup is critical to prevent accumulation of fungal spores in the home,
cattery, or shelter. M canis spores can remain viable for many years.
Key Prognostic Points:
1. For most cats, the disease is curable.
2. Some cats may remain infected for life.
3. Endemic infections in catteries and shelters can be very difficult and costly to eradicate.
Isolation facilities for quarantine and systematic culture of all new intakes should be part
of the routine at these facilities.
5 KEY “TAKE HOME” POINTS:
1. M. canis is a significant cause of ringworm in cats.
2. Effective therapy requires the combination of systemic, topical, and
environmental treatments.
3. Fungal culture can have both false positive and false negative results.
4. Unless one is committed to learn the microscopy of the common dermatophyte
macroconidia to verify the identity of the cultured fungus, it is better to send the
cultures out to an experienced mycology laboratory.
5. Endemic infections in catteries and shelters can be very difficult and costly to
eradicate. Ideally these facilities should be constructed so that quarantine
facilities are available for the isolation of any new cats. Fungal cultures can and
should be done on all new intake animals to be sure that these cats are not put
into the general population, and are not sold or adopted out, particularly to
families with susceptible people and animals in their homes.
Dermatophytosis is one of the most common cutaneous fungal infections we see in cats. Most
dermatophytes in cats are caused by one of three fungi: Microsporum canis, Microsporum
gypseum, and Trichophyton mentagrophytes. M. canis is a fungus well adapted to cat skin
and is the most likely to cause inapparent or very mild infections. This fungus is the one most
likely to be transmitted to other cats, to dogs, and to humans. The likelihood of transmission
may be related to the virulence of particular strains of the fungus. M. canis infection results
from association with other cats, from fomites, or from environmental contamination. These
spores remain viable in the environment for many years, making endemic infections in
catteries and shelters common and difficult to eradicate. Clinical signs are often most severe
in kittens, becoming less severe as the animals age, whether the cats are treated or not. In
catteries, it is not unusual for normal appearing queens to have repetitive litters with severely
affected kittens. Lesions can range from very mild alopecia to erythematous patches and
plaques with crusting. Miliary dermatitis is one manifestation, as is the development of
pseudomycetomas. Infections with M. canis require the most aggressive treatment to prevent
chronic inapparent infections, to prevent spread from animal to animal and from animal to
humans.
Microsporum gypseum can affect cats, and infections seem to be more common in geographic
areas of high temperature and high humidity, such as that found in the southeastern United
States. Infections are often quite inflammatory with erythema and crusts. These
dermatophyte infections often spontaneously resolve fairly quickly without treatment, and
spread to other animals or humans is rare. Topical therapy may be all that is needed for
these infections, and treatment of the environment is not required.
Trichophyton mentagrophytes is most often associated with rodents and these animals are the
likely source for infection in cats; Trichophyton infections can also be contracted from soil.
Trichophyton infections can present with alopecia and crusting, and it is not unusual for these
infections to mimic diseases such as pemphigus foliaceus. Dermatophyte fungi have
proteases that cleave the intercellular adhesion molecules between keratinocytes, leading to
acantholysis. Treatment of Trichophyton infections often requires the combination of systemic
and topical therapy, and contagion to other animals and to humans is possible.
Diagnostic tools
Dermatophytosis can be on the list of differential diagnoses for any feline skin disease
characterized by alopecia and crusting. An excellent screening tool is the Wood’s lamp. A
positive test is an apple green fluorescence of the hairs themselves; fluorescence of scale or
crust is not significant. The brightness of the fluorescence will increase the longer the lamp is
on, so it has been recommended to turn the light on a few minutes prior to use. The lights
should be turned off. The results of the test should be confirmed by culture, so that no
misinterpretation of fluorescence occurs. While a negative test does not rule out
dermatophytosis, a positive test allows you to select hairs for culture with a high yield of
success, AND it allows you to institute therapy immediately. It is important to note that the
only dermatophyte found on cats to fluoresce is M. canis but not all cats with M. canis will
show positive fluorescence. Infections with M. gypseum and Trichophyton spp will not cause
fluorescence of the hairs. Every clinic that treats cats should have a Wood’s lamp.
Microscopy of infected hairs following KOH/DMSO digestion is a very useful tool although
somewhat time consuming. It does require some expertise, but a positive result allows for the
immediate start of treatment, rather than waiting 1-2 weeks for a fungal culture to grow. Fungal
culture is still performed in order to determine the species of fungus involved.
Fungal culture remains the test of choice for confirmation of the species involved. Knowing the
species of fungus involved is very important as it will determine how aggressively the infection
needs to be treated. To date, the standard Dermatophyte Test Medium (DTM) remains the
most reliable way to culture dermatophytes. This medium contains antibiotics to inhibit
contaminant bacteria, and antimetabolites to inhibit saprophytic growth. Suppression of these
microbes is not 100% effective. The color indicator is phenol red. Because dermatophyte
fungi utilize the proteins in the medium first, they produce alkaline metabolites which turn the
medium red as the fungus grows. Most BUT NOT ALL saprophytes will utilize the
carbohydrates in the medium first, producing acid metabolites which keep the color yellow.
Two features, therefore, can be used to identify dermatophytes, a change of color to red as the
fungus growths, and the gross morphology with white, or pale colonies. If the medium turns
red, but the colony is grey or green or brown, it is not a dermatophyte. Microscopy remains
important to verify the diagnosis, because there are a few saprophytes that are pale in color
and can turn the medium red as they grow. It is important to observe the cultures daily so that
the early color change is not missed. Most dermatophytes will grow at room temperature,
meaning 25oC. During winter, temperature drops within the clinic will slow the growth and
sporulation. In fact, dermatophytes grow best if the temperature is elevated to 27oC, so
investing in a small incubator is a good plan. Humidity should be about 30-40%, and this can
be achieved by having a pan of water in the incubator. Unless someone in the clinic is willing
to monitor these cultures, grow them properly, and do the microscopy to verify the species, it is
better just to submit samples to a good microbiology laboratory.
Microscopy is easy and rapid, and there are a number of websites which show the gross and
microscopic appearance of the common dermatophyte fungi. A particularly good one is
Doctor Fungus (http://www.doctorfungus.org/). Images can be downloaded as PowerPoint
slides and then you can generate your own “in clinic” fungal atlas. M. canis tends to produce
canoe-shaped macroconidia with thick walls; usually 6 or more chambers are present; these
findings can be correlated with the colony morphology which is white on the top and yellow on
the bottom. M. gypseum tends to produce rowboat-shaped macroconidia with thin walls and 6
or fewer chambers; these findings are correlated with the colony morphology which is tan in
color and looks like chamois. Trichophyton spp. tend to produce lots of microconidia and long
macroconidia may not be seen. I think it is sufficient to identify Trichophyton spp. to the
genera only! A key feature for all dermatophytes is the lack of pigment. If there is any pigment
in the material seen on microscopy it is NOT a dermatophyte.
At least 2 “rapid” or “improved” assays are commercially available. The Rapid Vet-D test
(DMS Laboratories, Inc) is meant to provide a diagnosis of dermatophytosis within 4 days,
without requiring microscopic identification. The medium contains a proprietary mix of
nutrients and antimicrobials that is suggested to promote more rapid growth of pathogens with
more aggressive suppression of contaminant fungi that might turn the medium red. The
problem is that there are only two publications evaluating this medium. It was shown that the
speed of growth was related to the size of the inoculum; small inoculates required more time.
Four days was not sufficient for all dermatophytes, and if the test was stopped at 4 days,
Trichophyton spp in particular could be missed. {Guillot 2001} {Moriello 2010} Furthermore,
identifying the fungus involved is an important factor in the choice of treatment and how
aggressive treatment needs to be. Another system touted as superior to standard DTM is the
In Tray DM for Dermatophytes (BioMed Diagnostics). This system is meant to allow both
observation of the colony grossly and microscopically without opening the tray. Growth is
listed to occur within 1-14 days. The one paper evaluating this system showed that it was
effective in growing known inoculates of M. canis only 65.4% of the time, suggesting that a
substantial percentage of cases could be missed. {Moriello 2010} The amount of medium is
very small and it has been observed to dry out prior to the growth of the fungus.
Like any test, fungal culture is not perfect. Both false negatives and false positives can occur.
The success of the test is related to the quality and quantity of the material inoculated. Higher
numbers of fungal spores will produce macroscopic growth more quickly. If fluorescence is
observed, and a number of fluorescent hairs are inoculated, early growth can be seen in 2-3
days. If there is no fluorescence, but there are broken hairs and scale or crust, you can use a
blade to scrape this material up to inoculate the medium. If there are no lesions visible, the
toothbrush technique is recommended. A clean toothbrush is used to pick up hair and scale,
and the tips of the bristles gently tamped into the medium. A variation on this technique is to
use a Swiffer cloth! {Carlotti 2010} Small pieces can be held in a forceps and swiped over the
cat; they are then trimmed and placed directly on the medium. False positive reactions can
occur when dermatophyte fungi are transiently carried on the skin of dogs or cats. I have seen
this most commonly with M. gypseum species and Trichophyton terrestre. False negatives
can occur if the inoculum is inadequate or the growth conditions for the culture are not ideal.
Another cause of false negatives is overgrowth by bacterial or saprophytic fungal
contaminants. Keep in mind that a negative culture does not rule out dermatophytosis.
Often if I am strongly suspicious that dermatophyte infection is present, I will biopsy the animal.
Results can be obtained fairly quickly and special stains requested. The situations in which I
use biopsy would be suspected kerion reactions, the pseudomycetomas of M. canis that we
see sometimes in long-haired cats, or some of the unusual asymmetric crusting disorders we
can see with Trichophyton infections.
What about PCR as a diagnostic tool? Currently PCR for dermatophyte identification is
offered by Research Associates Laboratories in Dallas TX USA and Healthgene in Toronto,
Ontario CANADA. Unfortunately the websites contains no information about quality control,
the primers used, what type of PCR is used or what to submit for a sample. For RAL, the order
form simply lists “ringworm” and suggests submitting a swab. What we can gather is neither
of these labs provides discrimination among the various species of ringworm for veterinary
species. There are no publications to support the use of these assays at this time. What does
a positive PCR test tell us? PCR tells us that the DNA of the dermatophyte is present in the
sample submitted. The presence of DNA does not necessarily prove infection. PCR is very
sensitive. There are many variables that need to be controlled to get a quality result.
Contamination is possible at every step. In addition, the specificity of the assay will be
determined by the primer design as well as the number of cycles, the controls, used and type
of PCR assay used. Recently, a publication showed the utility of this tool for veterinary
dermatophyte identification when a nested PCR protocol was used; this discrimination is not
possible with the single step PCR assay commercially available. Other peer-reviewed articles
support the notion that PCR for identification of human dermatophytes may be useful in future,
but we have no evidence that the commercial products offered to veterinarians have value.
Treatment Options
Treatment of dermatophytosis in cats will be determined by the species of dermatophyte
identified, whether the cat is an only cat or a member of a multiple cat or pet household,
whether you are dealing with a cattery or shelter situation, and whether human infection is a
risk or actuality.
My protocol for single cats with M. canis or Trichophyton spp. infections is to combine the use
of an oral antifungal agent with a topical antifungal shampoo twice weekly. While not the most
effective topical option (lime sulfur being more effective), using a chlorhexidine/miconazole
shampoo twice weekly has been shown to be helpful. In a recent poster presented by Patrick
Bourdeau and his colleagues at the World Congress Veterinary Dermatology, several products
were tested for their ability to reduce arthrospores in the hair of a cow infected with
Trichophyton verrucosum. {Bourdeau 2012} The most effective topical product was DOUXO
chlorhexidine with climbazole shampoo, followed in order by enilconazole, lime sulfur, and
chlorhexidine with miconazole. Chlorhexidine shampoo alone was ineffective. Assuming this
data can be extrapolated to M. canis, using DOUXO chlorhexidine with climbazole could be a
real advantage, as lime sulfur is messy, drying to the skin, and potentially irritating to some
cats.
Several options exist for systemic therapy of dermatophytosis. Griseofulvin is no longer
recommended for routine use in cats due to its potential for bone marrow suppression when
used at the doses required to resolve dermatophytosis. The gold standard has been the use
of itraconazole at 10 mg/kg/day. When used for 21 days daily, this drug was shown to be safe
and effective, and after that time, it can be used on a pulse basis, giving it daily for one week,
breaking for one week, then alternating weeks on with weeks off until the infections is resolved.
What has become clear is that Sporanox brand must be used (in the USA); when itraconazole
is compounded into liquids at compounding pharmacies, failure can occur. It is believed that
these compounded itraconazole liquid products are not well absorbed. Less expensive
alternatives include the use of terbinafine 30-40 mg/kg/day or fluconazole at 5-10 mg/kg/day.
Ketoconazole tends to be more toxic to cats, and we have seen some failures associated with
ketoconazole treatment of animals with ringworm, so it is not recommended.
Protocols for multiple cat households and any home in which humans have infection may
require the systemic antifungal drug, the use of weekly or twice weekly lime sulfur dips, and
environmental cleanup. Everything that can be bleached should be, and weekly vacuuming
and “swiffering” can help reduce the accumulation of spores in the home. A recent study
presented by Kunder and Moriello at the World Congress Veterinary Dermatology looked at
the efficacy of various household products to kill dermatophyte spores. The 4 that worked
best were Chlorox Cleanup (Chlorox Company), Formula 409 (Chlorox Company), Lysol
(Reckitt Benckiser), and Accel (Virox Technologies). {Kunder 2012}
Catteries and shelters present a special situation with regard to treatment. Virulent M. canis
can sweep through these facilities very rapidly, creating a major problem for control, and
raising ethical issues for the placement of kittens into new homes. These facilities should be
designed so that the general population of cats is kept infection free. Quarantine facilities are
needed for any new cats brought into the facility. These new cats should be screened for
dermatophytosis by Wood’s lamp exam and by culture before they are released into the
general population of cats. When there is a break with dermatophytosis, the facility needs to
shut down, accepting no new cats and placing no cats until the infection is brought under
control. Ringworm epidemics are expensive to treat because a combination of systemic
antifungal drugs, frequent topical therapy, and frequent environmental decontamination is
required. It is recommended that at least 2 negative cultures be obtained before the individual
animal is considered clear of infection. Good infection control measures including the isolation
of infected cats and the use of personal protective equipment is needed. Many no-kill cat
shelters operate on a limited budget, but there is no way to make treating epidemic ringworm
economical. Unless these infections are treated aggressively, the infections will become
endemic. There is then risk that kittens adopted out of such facilities will carry this zoonotic
disease into the homes of unsuspecting adopting families.
For an extensive review of handling infections in catteries or shelters, please see the
“ringworm bible” written by Dr. Karen Moriello, {Moriello 2003} {Moriello 2003a} {Moriello
2003b} {Moriello 2003c} {Moriello 2003d}and an excellent e-book written by Dr. Keith Hnilica
(http://management.ebooks6.com/Treating-Multi-animal-Facilities-Infected-withDermatophytosis-pdf-e35133.pdf#)
M. gypseum infections are much less likely to cause problems and in many cases will
spontaneously resolve. Certainly the use of a systemic antifungal drug is not contraindicated
but it may be sufficient to utilize topical therapy alone for these infections.
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