86
Indian Journal of Medical Microbiology
2006;89:40-4. Hong ST, Lee SH, Kim SI. A human case of Thelazia callipaeda infection with reference to its internal structures. Kisaengchunghak Chapchi 1988;26:137-40. 9. Otranto D, Dutto M. Human Thelaziasis, Europe. Emerg Infect Dis 2008;14:647-9. 10. Otranto D, Cantacessi C, Testini G, Lia RP. Phortica variegata as an intermediate host of Thelazia callipaeda under natural conditions: Evidence for pathogen transmission by a male arthropod vector. Int J Parasitol 2006;36:1167-73. 11. Nath R, Narain K, Saikia L, Pujari BS, Thakuria B, Mahanta J. Ocular thelaziasis in Assam: A report of two cases. Indian J Pathol Microbiol 2008;51:146-8. 12. Khan AM. Human thelaziasis in India. Indian J Med Microbiol 2007;25:72. 8.
vol. 32, No. 1
How to cite this article: Handique AK, Tamuli A, Khan AM. Ocular thelaziasis in a 7-month-old infant. Indian J Med Microbiol 2014;32:84-6. Source of Support: Nil, Conflict of Interest: None declared.
Access this article online Quick Response Code:
Website: www.ijmm.org PMID: *** DOI: 10.4103/0255-0857.124333
Bilateral Tinea Nigra of palm: A rare case report from Eastern India *G Sarangi, D Dash, N Chayani, SK Patjoshi, S Jena
Abstract A 14 year old girl from a coastal district of Odisha presented with a six month history of asymptomatic brownish patches on the palm of the both hands. Epidermal scrape from these patches showed brown septate hyphae with occasional yeast like cells. Hortaea wernekii was isolated from the fungal culture. A diagnosis of Tinea nigra was made. The patches resolved completely after treatment with topical 1% clotrimazole cream.
Key words: Black fungus, H.wernekii, Tinea nigra
Introduction
Case Report
Tinea nigra is a rare superficial fungal infection of the skin involving stratum corneum. It is caused by Hortaea werneckii (also known as Phaeoannellomyces werneckii, Exophialawerneckii, Cladospoiumwerneckii).[1] In some instances Stenellaaraguata also causes T. nigra.[1] The disease was first described by Cerqueirain 1891 in Brazil and published by Cerqueira Pinto in 1916 as “ keratomycosis nigricans palmaris”.[2] It is most commonly seen in tropical and sub-tropical areas of south to north America, Africa, Australia and Asia.[3-5] Typically the lesion presents as a solitary asymptomatic non-scaly, sharply marginated dark macule or patch. Palms are most commonly affected, but lesions may occur on soles or other parts of the body. Herein, we present a case of this unusual entity affecting bilateral palms.
A 14-year-old girl resident of Balasore (Odisha) presented with bilateral slow-growing hyperpigmented macules on her palms for a period of 6-month duration. The lesions were asymptomatic and her general health was good. The patient gave a history of frequent hand washing.
*Corresponding author (email: ) Department of Microbiology (GS, DD, NC, SJ), Departments of Dermatology and Veneral Diseases (SKP), Shrirama Chandra Bhanj Medical College and Hospital, Cuttack Utkal University (DD, SKP, SJ), Cuttack, Odisha, India Received: 17-04-2013 Accepted: 25-09-2013
Examination of the skin revealed multiple blackish patches with an irregular and well-demarcated border, size ranging from 0.2 × 0.2 cm to 1.0 × 1.0 cm resembling silver nitrate stain on the left palm in the volar region and the hypothenar eminence and extending up to the ulnar border of the wrist [Figure 1]. Similar lesions were also noted on the corresponding area of the right palm. The patient noted a gradual blackening of the lesions. There were no scales, vesicles or other inflammatory changes. Examination of the epidermal scrapping by 15% potassium hydroxide (KOH) mount showed light brownish short septate hyphae with scattered budding yeast-like cells. The epidermal scrapes were inoculated on Sabouraud’s dextrose agar (SDA) with cycloheximide in duplicate and incubated at 37°C and 25°C, respectively. Culture on SDA at 25°C yielded moist shiny yeast-like colonies on 10th day of incubation which were initially
www.ijmm.org
January-March 2014
Case Reports
yellowish brown in colour and later changed to shiny black by 3rd week. With age, the colonies produced abundant aerial hyphae [Figure 2]. The reverse of the colonies were black in colour [Figure 3]. A lactophenol cotton blue (LCB) mount of the culture revealed densely septate brown hyphal elements measuring about 5-6 m in diameter with some swollen cells and chlamydoconidia [Figure 4]. No growth was observed at 37°C. The organism was identified as Hortaea werneckii. The growth on SDA with 15% sodium chloride proved that the fungus is halophillic and no growth at 37°C differentiated it from other species of the genus. The patient was treated with topical clotrimazole (1%) cream. The lesions gradually disappeared over 2 weeks and no recurrence was noted. Discussion Tinea nigra is a rare superficial dermatomycosis. The aetiological agent is a black fungus, H. werneckii, first isolated in 1921 by Horta.[6] The present case is also due to the same species. Another less common aetiological agent is Stenella araguata which is found as endemic in Venezuela.[1] The infection usually occurs in tropical and sub-tropical areas including central and South America,
87
Africa and Asia. In a study of 12 patients during the period from 1972 to 2002, T. nigra in Venezuela was found to be more prevalent among young people with fair skin and who visited sea beaches.[1] It was noticed less frequently in the black population. T. nigra has been reported rarely from India. So far only six cases have been reported, out of which five were from south India and one from north India.[5,7,8] The classic presentation is an asymptomatic, solitary discrete oval-shaped macule or patch that is light brown to black in colour. In the present case the lesion appears to be multiple due to uneven pigmentation. It is commonly seen in the palmar surface of the hand, it appears less commonly on the feet or other cutaneous surface like neck and axilla. The reason for predilection for palmar surface is not known. H. wernekii uses decomposed lipids in the stratum corneum resulting in the formation of a dark-coloured macule due to the accumulation of a melanin-like substance within the fungus.[9] The disease is more prevalent among young people under the age of 20. Females are affected three to five times more commonly than males probably due to frequent
Figure 2: Moist yeast like yellowish brown colony on SDA with cycloheximide
Figure 1: Multiple brownish black macules in both palms
Figure 3: Reverse of the colonies showing black pigmentation
Figure 4: Lacto phenol cotton blue mount showing densely septate brown hyphal elements with some swollen cells (×40) www.ijmm.org
88
Indian Journal of Medical Microbiology
household work and hand washing. Most patients have hyperhidrosis as an associated feature[1] (although our patient did not have hyperhidrosis). In our case, the infection presumed to be contracted from the sandy soil as the patient is a resident of a coastal district of Odisha and the natural ecological niche of the fungus is presumed to be the salty environment of the sea shore.[6] T. nigra can be mistaken for melanocytic lesions such as junctional melanocytic nevus, malignant melanoma, pigmentation from Addison’s disease, melanosis from secondary syphilis, pinta or chemical exposure.[10] We should also consider the use of henna, staining due to silver nitrate, potassium permanganate or other plant or fruit stains. T. nigra can be differentiated from these by KOH examination. Misdiagnosis can lead to unnecessary biopsies or surgical excisions.[1] The disease may sometimes be confused with hyperpigmented lesion of pityriasis versicolor; from which it can be differentiated by absence of scales and presence of dematicious fungal element in KOH mount. Management is usually straight forward. It responds to topical therapy with keratolytics (Whitefield’s ointment, 2% salicylic acid), tincture of iodine, azole antifungal or terbenafine.[10] Oral agents are unnecessary and often ineffective. Our patient had a complete cure with topical clotrimazole cream. It is not certain that for how long one should treat this condition; however, in most cases one month treatment is sufficient.
Magaldi S, Mata-Essayag S. Tinea Nigra: Report of twelve cases in Venezuela. Mycopathologia 2005;160:235-8. 2. Kwon-Chung KJ, Bennet JE. Tinea nigra. In: Kwon-Chung KJ, Bennet JE, editors. Medical Mycology. Philadelphia: Lea and Febiger; 1992. p. 191-7. 3. Merwin CF. Tinea nigra Palmaris. Review of literature and case report. Pediatrics 1965;36:537-41. 4. Isaccs F, Reiss-Levy E. Tinea nigra planataris: A case report. Australas J Darmatol 1980;21:13-5. 5. Kamalam A, Thambiah AS. Tinea nigra: First case report from Madras. Mykosen 1982;25:626-8. 6. Chander J. Text book of medical mycology, 3rd ed. New Delhi: Mehta Publishers; 2011. p. 106-13. 7. Gnanaguruvelan S, Janaki C, Sentamilselvi G, Boopalraj JM. Tinea nigra. Indian J Dermatol Venereol Leprol 1998;64:91-2. 8. Tilak R, Singh S, Prakash P, Singh DP, Gulati AK. A case report of tinea nigra from North India. Indian J Dermatol Venereol Leprol 2009;75:538-9. 9. Schwartz RA. Superficial fungal infection. Lancet 2004;364:1173-82. 10. Scheike SM, Garg A. Superficial fungal infection: Dermatophytosis, onychomycosis, tinea nigra, piedra. In: Goldsmith LA, Katz SI, Gilchrist BA, Paller AS, Leffel DJ, Wolff K. Fitzpatrick’s Dermatology in General Medicine. 8th ed., Vol 2. McGraw-Hill; 2012. p. 2277-97.
How to cite this article: Sarangi G, Dash D, Chayani N, Patjoshi SK, Jena S. Bilateral Tinea Nigra of palm: A rare case report from Eastern India. Indian J Med Microbiol 2014;32:86-8. Source of Support: Nil, Conflict of Interest: None declared.
To the best of our knowledge, the present case is perhaps the first case of T. nigra from eastern India. Much emphasis must be given for a proper laboratory confirmation of such cases not only to avoid unnecessary biopsy procedure but also to alleviate cosmetic stigma in young women. References 1.
vol. 32, No. 1
Perez C, Colella MT, Olaizola C, Hartung de Capriles C,
www.ijmm.org
Access this article online Quick Response Code:
Website: www.ijmm.org PMID: *** DOI: 10.4103/0255-0857.124336
Copyright of Indian Journal of Medical Microbiology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Indian Journal of Medical Microbiology
2006;89:40-4. Hong ST, Lee SH, Kim SI. A human case of Thelazia callipaeda infection with reference to its internal structures. Kisaengchunghak Chapchi 1988;26:137-40. 9. Otranto D, Dutto M. Human Thelaziasis, Europe. Emerg Infect Dis 2008;14:647-9. 10. Otranto D, Cantacessi C, Testini G, Lia RP. Phortica variegata as an intermediate host of Thelazia callipaeda under natural conditions: Evidence for pathogen transmission by a male arthropod vector. Int J Parasitol 2006;36:1167-73. 11. Nath R, Narain K, Saikia L, Pujari BS, Thakuria B, Mahanta J. Ocular thelaziasis in Assam: A report of two cases. Indian J Pathol Microbiol 2008;51:146-8. 12. Khan AM. Human thelaziasis in India. Indian J Med Microbiol 2007;25:72. 8.
vol. 32, No. 1
How to cite this article: Handique AK, Tamuli A, Khan AM. Ocular thelaziasis in a 7-month-old infant. Indian J Med Microbiol 2014;32:84-6. Source of Support: Nil, Conflict of Interest: None declared.
Access this article online Quick Response Code:
Website: www.ijmm.org PMID: *** DOI: 10.4103/0255-0857.124333
Bilateral Tinea Nigra of palm: A rare case report from Eastern India *G Sarangi, D Dash, N Chayani, SK Patjoshi, S Jena
Abstract A 14 year old girl from a coastal district of Odisha presented with a six month history of asymptomatic brownish patches on the palm of the both hands. Epidermal scrape from these patches showed brown septate hyphae with occasional yeast like cells. Hortaea wernekii was isolated from the fungal culture. A diagnosis of Tinea nigra was made. The patches resolved completely after treatment with topical 1% clotrimazole cream.
Key words: Black fungus, H.wernekii, Tinea nigra
Introduction
Case Report
Tinea nigra is a rare superficial fungal infection of the skin involving stratum corneum. It is caused by Hortaea werneckii (also known as Phaeoannellomyces werneckii, Exophialawerneckii, Cladospoiumwerneckii).[1] In some instances Stenellaaraguata also causes T. nigra.[1] The disease was first described by Cerqueirain 1891 in Brazil and published by Cerqueira Pinto in 1916 as “ keratomycosis nigricans palmaris”.[2] It is most commonly seen in tropical and sub-tropical areas of south to north America, Africa, Australia and Asia.[3-5] Typically the lesion presents as a solitary asymptomatic non-scaly, sharply marginated dark macule or patch. Palms are most commonly affected, but lesions may occur on soles or other parts of the body. Herein, we present a case of this unusual entity affecting bilateral palms.
A 14-year-old girl resident of Balasore (Odisha) presented with bilateral slow-growing hyperpigmented macules on her palms for a period of 6-month duration. The lesions were asymptomatic and her general health was good. The patient gave a history of frequent hand washing.
*Corresponding author (email: ) Department of Microbiology (GS, DD, NC, SJ), Departments of Dermatology and Veneral Diseases (SKP), Shrirama Chandra Bhanj Medical College and Hospital, Cuttack Utkal University (DD, SKP, SJ), Cuttack, Odisha, India Received: 17-04-2013 Accepted: 25-09-2013
Examination of the skin revealed multiple blackish patches with an irregular and well-demarcated border, size ranging from 0.2 × 0.2 cm to 1.0 × 1.0 cm resembling silver nitrate stain on the left palm in the volar region and the hypothenar eminence and extending up to the ulnar border of the wrist [Figure 1]. Similar lesions were also noted on the corresponding area of the right palm. The patient noted a gradual blackening of the lesions. There were no scales, vesicles or other inflammatory changes. Examination of the epidermal scrapping by 15% potassium hydroxide (KOH) mount showed light brownish short septate hyphae with scattered budding yeast-like cells. The epidermal scrapes were inoculated on Sabouraud’s dextrose agar (SDA) with cycloheximide in duplicate and incubated at 37°C and 25°C, respectively. Culture on SDA at 25°C yielded moist shiny yeast-like colonies on 10th day of incubation which were initially
www.ijmm.org
January-March 2014
Case Reports
yellowish brown in colour and later changed to shiny black by 3rd week. With age, the colonies produced abundant aerial hyphae [Figure 2]. The reverse of the colonies were black in colour [Figure 3]. A lactophenol cotton blue (LCB) mount of the culture revealed densely septate brown hyphal elements measuring about 5-6 m in diameter with some swollen cells and chlamydoconidia [Figure 4]. No growth was observed at 37°C. The organism was identified as Hortaea werneckii. The growth on SDA with 15% sodium chloride proved that the fungus is halophillic and no growth at 37°C differentiated it from other species of the genus. The patient was treated with topical clotrimazole (1%) cream. The lesions gradually disappeared over 2 weeks and no recurrence was noted. Discussion Tinea nigra is a rare superficial dermatomycosis. The aetiological agent is a black fungus, H. werneckii, first isolated in 1921 by Horta.[6] The present case is also due to the same species. Another less common aetiological agent is Stenella araguata which is found as endemic in Venezuela.[1] The infection usually occurs in tropical and sub-tropical areas including central and South America,
87
Africa and Asia. In a study of 12 patients during the period from 1972 to 2002, T. nigra in Venezuela was found to be more prevalent among young people with fair skin and who visited sea beaches.[1] It was noticed less frequently in the black population. T. nigra has been reported rarely from India. So far only six cases have been reported, out of which five were from south India and one from north India.[5,7,8] The classic presentation is an asymptomatic, solitary discrete oval-shaped macule or patch that is light brown to black in colour. In the present case the lesion appears to be multiple due to uneven pigmentation. It is commonly seen in the palmar surface of the hand, it appears less commonly on the feet or other cutaneous surface like neck and axilla. The reason for predilection for palmar surface is not known. H. wernekii uses decomposed lipids in the stratum corneum resulting in the formation of a dark-coloured macule due to the accumulation of a melanin-like substance within the fungus.[9] The disease is more prevalent among young people under the age of 20. Females are affected three to five times more commonly than males probably due to frequent
Figure 2: Moist yeast like yellowish brown colony on SDA with cycloheximide
Figure 1: Multiple brownish black macules in both palms
Figure 3: Reverse of the colonies showing black pigmentation
Figure 4: Lacto phenol cotton blue mount showing densely septate brown hyphal elements with some swollen cells (×40) www.ijmm.org
88
Indian Journal of Medical Microbiology
household work and hand washing. Most patients have hyperhidrosis as an associated feature[1] (although our patient did not have hyperhidrosis). In our case, the infection presumed to be contracted from the sandy soil as the patient is a resident of a coastal district of Odisha and the natural ecological niche of the fungus is presumed to be the salty environment of the sea shore.[6] T. nigra can be mistaken for melanocytic lesions such as junctional melanocytic nevus, malignant melanoma, pigmentation from Addison’s disease, melanosis from secondary syphilis, pinta or chemical exposure.[10] We should also consider the use of henna, staining due to silver nitrate, potassium permanganate or other plant or fruit stains. T. nigra can be differentiated from these by KOH examination. Misdiagnosis can lead to unnecessary biopsies or surgical excisions.[1] The disease may sometimes be confused with hyperpigmented lesion of pityriasis versicolor; from which it can be differentiated by absence of scales and presence of dematicious fungal element in KOH mount. Management is usually straight forward. It responds to topical therapy with keratolytics (Whitefield’s ointment, 2% salicylic acid), tincture of iodine, azole antifungal or terbenafine.[10] Oral agents are unnecessary and often ineffective. Our patient had a complete cure with topical clotrimazole cream. It is not certain that for how long one should treat this condition; however, in most cases one month treatment is sufficient.
Magaldi S, Mata-Essayag S. Tinea Nigra: Report of twelve cases in Venezuela. Mycopathologia 2005;160:235-8. 2. Kwon-Chung KJ, Bennet JE. Tinea nigra. In: Kwon-Chung KJ, Bennet JE, editors. Medical Mycology. Philadelphia: Lea and Febiger; 1992. p. 191-7. 3. Merwin CF. Tinea nigra Palmaris. Review of literature and case report. Pediatrics 1965;36:537-41. 4. Isaccs F, Reiss-Levy E. Tinea nigra planataris: A case report. Australas J Darmatol 1980;21:13-5. 5. Kamalam A, Thambiah AS. Tinea nigra: First case report from Madras. Mykosen 1982;25:626-8. 6. Chander J. Text book of medical mycology, 3rd ed. New Delhi: Mehta Publishers; 2011. p. 106-13. 7. Gnanaguruvelan S, Janaki C, Sentamilselvi G, Boopalraj JM. Tinea nigra. Indian J Dermatol Venereol Leprol 1998;64:91-2. 8. Tilak R, Singh S, Prakash P, Singh DP, Gulati AK. A case report of tinea nigra from North India. Indian J Dermatol Venereol Leprol 2009;75:538-9. 9. Schwartz RA. Superficial fungal infection. Lancet 2004;364:1173-82. 10. Scheike SM, Garg A. Superficial fungal infection: Dermatophytosis, onychomycosis, tinea nigra, piedra. In: Goldsmith LA, Katz SI, Gilchrist BA, Paller AS, Leffel DJ, Wolff K. Fitzpatrick’s Dermatology in General Medicine. 8th ed., Vol 2. McGraw-Hill; 2012. p. 2277-97.
How to cite this article: Sarangi G, Dash D, Chayani N, Patjoshi SK, Jena S. Bilateral Tinea Nigra of palm: A rare case report from Eastern India. Indian J Med Microbiol 2014;32:86-8. Source of Support: Nil, Conflict of Interest: None declared.
To the best of our knowledge, the present case is perhaps the first case of T. nigra from eastern India. Much emphasis must be given for a proper laboratory confirmation of such cases not only to avoid unnecessary biopsy procedure but also to alleviate cosmetic stigma in young women. References 1.
vol. 32, No. 1
Perez C, Colella MT, Olaizola C, Hartung de Capriles C,
www.ijmm.org
Access this article online Quick Response Code:
Website: www.ijmm.org PMID: *** DOI: 10.4103/0255-0857.124336
Copyright of Indian Journal of Medical Microbiology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
