Several prolonged and significant outbreaks of dermatophytosis caused by Trichophyton indotineae, a new emerging terbinafine-resistant species, have been ongoing in India in recent years, and have since spread to various countries outside Asia. Miltefosine, an alkylphosphocholine, is the most recently approved drug for the treatment of both visceral and cutaneous leishmaniasis. Miltefosine in vitro activity against terbinafine-resistant and susceptible T. mentagrophytes/T. interdigitale species complex, including T. indotineae, is limited. The current study aimed to assess miltefosine’s in vitro activity against dermatophyte isolates, which are the most common causes of dermatophytosis. Miltefosine, terbinafine, butenafine, tolnaftate, and itraconazole susceptibility testing was performed using Clinical and Laboratory Standards Institute broth microdilution methods (CLSI M38-A3) against 40 terbinafine-resistant T. indotineae isolates and 40 terbinafine-susceptible T. mentagrophytes/T. interdigitale species complex isolates. Miltefosine had MIC ranges of 0.063–0.5 µg/mL and 0.125–0.25 µg/mL against both terbinafine-resistant and susceptible isolates. In terbinafine-resistant isolates, the MIC₅₀ and MIC₉₀ were 0.125 µg/mL and 0.25 µg/mL, respectively, and 0.25 µg/mL in susceptible isolates. Miltefosine had statistically significant differences in MIC results when compared to other antifungal agents (p-value 0.05) in terbinafine-resistant strains. Accordingly, the findings suggest that miltefosine has a potential activity for treating infections caused by terbinafine-resistant T. indotineae. However, further studies are needed to determine how well this in vitro activity translates into in vivo efficacy.

Aspergillus endocarditis (AE) accounts for a-quarter of all fungal endocarditis, mainly in immunocompromised hosts prior to heart-valve surgery with high mortality, even with treatment. Herein, we report a rare case of AE in a diabetic 60-year-old woman with a history of redo mitral valve prosthesis suspecious of acute endocarditis. She underwent second redo surgical mitral valve replacement in combination with mechanical aortic valve replacement. Blood cultures were negative. The explanted valve and vegetation were subjected to identification. Grown colonies were identified as Aspergillus flavus, based on conventional and molecular methods. Despite the administration of liposomal amphotericin B and improvement in her general condition shortly after initiation of therapy, the patient passed away. As AE is a late consequence of redo prosthetic valve replacement, extended follow-up, early diagnosis, repeating valve-replacement surgeries, and timely selective antifungal treatments are warranted.