Epidemic of Microsporum canis infection in the region of Ljubljana 
Epidemiological and clinical study 
EPIDEMIC 
OF MICROSPORUM CANIS INFECTION 
IN THE REGION OF LJUBLJANA 
M. Dolenc-Voljč and M. Lunder 
ABSTRACT 
Background. In the last decades the incidence of Microsporum canis infection has been increasing in many 
European countries. In many regions of Slovenia microsporia has also aroused much epidemiological concern. 
Materials and Methods. The patients infected with Microsporum canis, treated in the Department of 
Dermatology in Ljubljana during the period from 1995 to 1997 were evaluated. The diagnosis was confirmed 
by microscopic examination of skin and hair specimens and by culture on Sabouraud's medium with added 
chloramphenicol and actidion. 
Results. During the above mentioned period 4109 positive cultures were assessed in patients, examined in our 
mycological laboratory. Microsporum canis has been the most frequently isolated dermatophyte. Tinea corporis 
was in 76% and Tinea capitis in 97% of cases caused by Microsporum canis. Patients were mostly children 
under 15 years of age with only one third of patients being adults. In younger patients scalp and face were 
involved most frequently compared to older patients in whom infection was commonly localized on the 
extremities. According to anamnestic data cats were the main origin of infection in our patients but they must 
have been asymptomatically infected in many instances. 
Conclusion. Microsporum canis infection remains a serious epidemiological problem in the region of Ljubljana. 
Consistent and integrated efforts of medica! and veterinary services associated with health education are 
required in future to eliminate further spread of infection. 
KEY WORDS 
Microsporum canis infection, epidemiology, Ljubljana area 
INTRODUCTION 
During the last 30 years Microsporum canis infection 
became a serious epidemiological problem in many 
regions of the world (1,2), especially in the South 
acta de,matovenerologica A .P.A. Vol 7, 98, No 3-4 
European Mediterranean countries (3). Before Micro-
sporum canis infection was first registered in Slovenia, 
the incidence of this infection bas been increasing · 
107 
Epidemic of Microsponun canis infection in the region of Ljubljana 
in Spain, South of France and Italy ( 4-12). In 
Slovenia, first cases were diagnosed in the year 
1977 among the inhabitants near the Italian border 
and also in patients visiting aforementioned countries 
as tourists (13). That is why we suppose that this 
infection was imported to our country from those 
countries. 
In Slovenia, Microsporum canis infection must be 
reported to National Institute of Public Health. 
During the last 20 years microsporia was diagnosed 
throughout the country. There have been great 
differences in the number of reported cases in each 
region. The largest numbers were reported in the 
regions of Ljubljana and Kranj during the whole 
period (14). One of the important questions is 
whether these differences reflect the real epidemio-
logical situation or they are due perhaps to failures 
in diagnosing and reporting the disease. Some of 
the patients have been treated by general practitioners 
and not in all of them diagnosis has been confirmed 
by laboratory examination. Because of that, falsely 
positive cases could have been reported or, on the 
contrary, some of the patients with microsporia 
might have not been reported at ali. 
MATERIALS AND METHODS 
In this article only data on patients, treated at the 
Clinical Center, Department of Dermatology in 
Ljubljana, in the period from 1995 to 1997, will be 
presented. In all of these patients diagnosis of 
microsporia was confirmed by laboratory identification 
of the dermatophyte by direct microscopic examination 
of skin or hair specimens and by culture on 
800 ..--------; 
400 +~-~-,-~-,,.~§---
---Microsporum 
= Tri chophyton 
- E idermophyton 
200 +-------+-----------1 
O +-,.....,-...;:i-,~M-i'--l'--1'-1~--f'"--f"--.,......,.-,--,-...-t 
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 
Figure l. Derrnatophytes, isolated in the period from 
1977 to 1997 at the Department oj Derrnatology in 
Ljubljana. 
108 
Table l. Localization oj Microsporum canis injection, 
according to age groups. 
Scalp 22.3 8.9 4.0 O.O 
Face 14.6 10.9 8.4 8.7 
Trunk 24.4 37.8 30.0 19.2 
Arm 19.6 19.8 30.9 48.8 
Leg 9.4 10.7 15.4 29.4 
Sabouraud's medium with added chloramphenicol 
and actidion. We collected data on patients' age, 
sex, and localization of microsporia as well as the 
anamnestic source of infection. In all cases the 
disease was reported. 
RESULTS 
Our previous epidemiological evaluations have shown 
an increasing incidence of microsporia during the 
80-s. Microsporum canis has been the most frequently 
isolated dermatophyte since 1989. Each year 400 to 
700 patients with Microsporum canis infection have 
been treated at the Department of Dermatology in 
Ljubljana. 
Figure 1 shows the rates of yearly isolated dermato-
phytes in the Mycological laboratory of the Department 
of Dermatology in Ljubljana during the period from 
1977 to 1997. Unlike increasing incidence of Micro-
sporum canis infection, Epidermophyton species was 
isolated quite rarely and the frequency of Trichophyhton 
species did not vary importantly within this period 
in our patients. 
Figure 2 presents the proportion of different 
causative agents, isolated in our mycological laboratory 
in the period from 1995 to 1997. In these years 
4109 positive cultures were isolated in patients exa-
mined. Dermatophytes represent 73% of all positive 
isolates, among them Microsporum canis was isolated 
in 59%, Trichophyton rubrum in 29%, Trichophyton 
mentagrophytes in 9% and other dermatophytes -
Microsporum gypseum, Trichophyton verrucosum, 
Trichophyton violaceum, and some others only rarely 
(3%). Yeasts were isolated in 26% of patients with 
dermatomycosis and among them Candida albicans 
was predominant with 59%, other Candida . spec. 
were isolated in 31 % and Trichosporon spec. in 
10%. Microsporum canis contributed up to 43% of 
ali positive isolates. 
acta dermatovenerologica A.P.A. Vol 7, 98, No 3-4 
Epidemic of Microsporum canis infection in the region of Ljubljana 
mi'n1e'W'"';"'llhl . if~~ ~ Others 
T. mentagr. 
7% 
21% 
Figure 2. Distribution of Jungi, isolated in the period 
from 1995 to 1997 at the Department of Dermatology 
in Ljubljana. 
Great majority of patients with Microsporum canis 
infection were children under 15 years of age (Figure 
3). Microsporia has higher prevalence in schoolchildren 
in the age groups from 6 to 10 years and from 11 
to 14 years, as well as in preschool-age children. In 
older patients the infection was diagnosed in less 
than 10% in each age group. In ali age groups 
microsporia was more frequent in females (Figure 
4). Most of our patients were living in towns. 
In 31 % of patients the infection was disseminated 
on different parts of the body. In localized manifesta-
tions it was mostly observed on the upper extremity, 
especially on the forearm in 30%, on the face in 
14%, on the lower extremity in 12%, on the trunk 
in 10% and on the scalp in 8% of cases. In 
younger children scalp and face were involved more 
often than in older children and adults, in whom 
40 
1/l -C CII 30 :.:: 
ra 
Q. ---Oc 20 ,_ 
CII 
.C 
10 E 
:i z o••ll1i1illlli•~ 
~ ~ ~ ~ ~ ~ ~ ~ ~ 
(::)' Cč:,' ................ ~· '\,(::)' ,,,(::)· t,.(::)' ~(::)· -f 
Age groups (years) 
Figure 3. Distribution of patients with microsporia by age in 
the period from 1995-1997. 
110 
the infection was most commonly localized on the 
extremities and on the trunk (Table 1). 
In our patients Tinea capitis was in 97% of cases 
caused by Microsporum canis. Only in 3% of patients 
with scalp infection Trichophyton mentagrophytes and 
Trichophyton rubrum were isolated. Tinea corporis 
was in 76% due to Microsporum canis, in 15% 
Trichophyton rubrum was isolated, in 7% Trichophyton 
mentagrophytes, and in 2% Microsporum gypseum. 
Monthly distribution of patients within the last 
three years shows important seasonal variations. 
The number of patients was higher in the period 
between July and November. Most of the patients 
were infected during the summer and the epidemic 
was slowly decreasing in the autumn. 
Figure 5 refers to anamnestic data on potential 
origin of infection. In 79% of patients the infection 
seemed to be transmitted by cats, especially by own 
cats or by cats in the neighborhood. In more than 
a half of instances the animals were symptomless. 
In only 1 % contact with stray cats was mentioned. 
Dogs were mentioned as possible origin of infection 
in only 5% of patients. In 15% the origin of 
infection remained unknown. 
DISCUSSION 
The rise in frequency of Microsp01um canis infection 
during the last two decades is in our opinion not 
only the result of better surveillance of the disease 
and health-consciousness of the population but also 
the reflection of real increase of the disease prevalence. 
Microsporum canis remained the most frequently 
isolated dermatophyte in our patients in recent 
years. 
The results of the investigation confirm that micro-
sporia has a higher prevalence during the prepubertal 
period. Our patients were mainly children under 14 
years of age, which is in accordance with the 
reports by other authors (14-18). Like other authors 
we have also found a considerable prevalence of 
infection among females in ali age groups (15,18). 
This sexual difference is probably the result of 
different behavior of both groups. We presume that 
girls are playing more often with pets than boys, 
and that women are coming more often in contact 
with animals than men (15). 
Patient's age has some important influence on 
localization of Microsporum canis infection. Scalp 
and face were more frequently involved in younger 
children. This might be due to fungistatic properties 
of sebum which is not produced in significant amount 
acta dennatovenerologica A .P.A. Vol 7, 98, No 3-4 
Epidemic of Microsporum canis infection in the region of Ljubljana 
Percent 
100% 
50% 
0% 
1987 1989 1991 1993 1995 1997 
Year 
Figure 4. Distribution of patients with microsporia by 
sex at the Department of Dermatology in Ljubljana in 
the years from 1987 to 1997. 
in younger cbildren. 
Microsporum canis bas been reported to be tbe 
dominant agent of Tinea capitis in many regions of 
tbe world (1,2). During tbe last tbree years Micro-
sporum canis was tbe dominant agent of Tinea 
capitis as well of Tinea corporis in our patients. 
Similar causative agents and tbeir frequency of 
distribution in Tinea capitis and Tinea corporis as 
in our patients were noticed also in some regions 
of Italy and Spain (6,8,9,11,19). 
Tbe bigbest number of microsporia was registered 
during tbe autumn-winter period. Similar monthly 
variations were observed in neigbboring countries 
witb bigb disease prevalence (8,9). We assume that 
cbildren are playing more often witb young infected 
cats during summer bolidays and that epidemic is 
continuing to spread at tbe tirne wben scbools 
reopen (8). 
Our results sbowed tbat infected cats were the 
main source of infection but only minority of them 
seemed to be symptomatically affected. The possibility 
of tbe spreading of infection from asymptomatic 
1% 
11% 
at relatives 
dog 11% 
5% 
1% 
Figure 5. Anamnestic data on source of infection in 
patients with Microsporum canis infection. 
acta detmatovenerologica A.P.A. Vol 7, 98, No 3-4 
animal carriers is well known and sbould be taken 
into account wben searcbing for tbe origin of infection 
(20,21). Contact witb stray cat was mentioned only 
in 1 % of patients. In spite of tbat we believe tbat 
stray cats remain an important reservoir for spreading 
of tbis infection (15,22). From epidemiological point 
of view interpersonal transmission from man to man 
seemed to be quite insignificant but it could be 
underestimated. 
Microsporum canis infection is known to be one 
of tbe most resistant to treatment among dermato-
mycoses. There are no uniform tberapeutic recomrnen-
dations for treatment of this infection. Tbe tberapy 
of our patients was ratber individual. Topical tberapy 
was preferred only in patients witb localized micro-
sporia, witb one or two lesions and in younger 
children. Most bave been treated witb botb, systemic 
and topical antifungals (18). Griseofulvin bas been 
tbe mainstay of treatment for many years. In recent 
years tbis drug was replaced by terbinafine because 
of more favorable dosage regimen, fewer side effects 
and its fungicida! activity. Tbe average tirne of 
systemic treatment in Tinea corporis was 4 weeks, 
but it lasted longer in Tinea capitis (18,23). After 
tbe completion of systemic tberapy topical tberapy 
was continued until complete clinical cure was achieved 
and until two negative laboratory examinations 
( negative microscopy and negative culture) were 
establisbed. 
CONCLUSIONS 
Microsporum canis infection remains a serious 
epidemiological problem in many regions of Slovenia, 
especially in tbe region of Ljubljana. Correct diagnosis 
and consistent reporting of disease are needed in 
all regions of Slovenia for furtber epidemiological 
evaluations. Microsporia is associated witb many 
epidemiological, tberapeutic, and economic as well 
as social cballenges. Tbe prevalence is very bigh 
among school-age cbildren. Tbe duration of treatment 
is long and the costs of treatment are higb. Because 
of higb degree of infectivity some of tbe cbildren 
with disseminated microsporia have to absent from 
scbool at tbe beginning of therapy and to abstain 
from sports activities. Elimination of tbe infection 
source among animals is very difficult and the 
control of the stray cats inadequate. Preventive 
measures, including botb medica! and veterinary 
services as well as health education, are needed to 
restrain further spread of infection. 
111 
Epidernic of Microspomrn canis infection in the region of Ljubljana 
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AUTHORS' ADDRESSES 
112 
Mateja Dolenc-Voljč, MD, dermatologist, Department of Dermatology, 
Clinical Center, Zaloška 2, 1525 Ljubljana, Slovenia 
Majda Lunder, MD, PhD, professor of dermatology, same address 
acta dennatovenerologica A.P.A. Vol 7, 98, No 3-4