mycoses
Diagnosis,Therapy and Prophylaxis of Fungal Diseases
Case report
Case of dermatophyte abscess caused by Trichophyton rubrum: a case report and review of the literature Makoto Inaoki,1 Chihiro Nishijima,1 Miho Miyake,1 Toshiyuki Asaka,2 Youichi Hasegawa,3 Kazushi Anzawa4 and Takashi Mochizuki4 1 Department of Dermatology, National Hospital Organisation Kanazawa Medical Center, Kanazawa, Japan, 2Department of Laboratory Medicine, National Hospital Organisation Kanazawa Medical Center, Kanazawa, Japan, 3Hasegawa Skin Clinic, Kanazawa, Japan and 4Department of Dermatology, Kanazawa Medical University, Uchinada, Japan
Summary
A 54-year-old Japanese man without apparent immunosuppression presented with nodules with purulent drainage on the right lower leg. He had ringworm of the right leg and tinea unguium. A biopsy specimen of the nodule showed intradermal abscesses with fungal elements, and Trichophyton rubrum was cultured from both the pus and the biopsy specimen. Treatment with oral terbinafine resolved the nodules. Dermatophyte abscess is a rare, deep and invasive dermatophytosis, which is often associated with immunocompromised conditions. We provide a review of the literature including Japanese cases.
Key words: Abscess, dermis, dermatophytosis, Trichophyton rubrum, terbinafine.
Introduction Deep, invasive infection of dermatophytes is defined as the growth of dermatophytes in the dermis and subcutis, and is believed to result from injury to the lesions of superficial dermatophytosis or the rupturing of infected follicles into the dermis. Granulomas are the most prevalent pathological finding,1 but lesions consists primarily of abscesses in a few cases. We present a case of dermal abscess caused by Trichophyton rubrum in a patient without signs of immunosuppression.
Case report A 54-year-old Japanese man presented with a 3month history of nodules on the right lower leg. He Correspondence: M. Inaoki, Department of Dermatology, National Hospital Organisation Kanazawa Medical Center, 1-1 Shimoishibiki-machi, Kanazawa, Ishikawa 920-8650, Japan. Tel.: +81 76 262 4161. Fax: +81 76 222 2758. E-mail: [email protected] Submitted for publication 23 December 2014 Revised 9 February 2015 Accepted for publication 25 February 2015
doi:10.1111/myc.12317
had a history of valvular disease of heart, nephritis and mycoplasma pneumonia. He had hypertension that was not being treated at the time of first visit. Six months ago, he was diagnosed with ringworm of the right lower leg and feet. Topical treatment with luliconazole cream resolved the skin lesions. Thereafter, there was no abnormality of the skin of the right lower leg before appearance of the nodules. The patient did not use topical corticosteroid on his legs. Examination showed a reddish nodule 2 cm in diameter with purulent drainage on the posterior surface of the right leg (Fig. 1a). There were also a red nodule 1 cm in diameter that was biopsied on the lateral surface of the right leg and a normal-coloured nodule 0.5 cm in diameter on the surface of the right calcaneal tendon (Fig. 1b). There was a scaly erythematous lesion on the right lower leg, which was negative for fungus by direct potassium hydroxide (KOH) preparation of the scale (Fig. 1a). Application of topical difluprednate ointment cleared the erythematous lesion. The nail of the right first toe was discoloured and showed clinical features of total dystrophic onychomycosis. Mycelia were seen on the KOH preparation of the nail scrapings and a diagnosis of tinea unguium was made. A biopsy specimen of the nodule showed intradermal abscesses filled with neutrophils (Fig. 2a
© 2015 Blackwell Verlag GmbH Mycoses, 2015, 58, 318–323
Dermatophyte abscess
(b)
(a)
Figure 1 (a) Reddish nodule with puru-
lent drainage 2 cm in diameter and a scaly erythematous lesion on the posterior surface of the right leg. (b) A red nodule 1 cm in diameter on the lateral surface of the right leg.
and b). A small accumulation of histiocytes surrounded by lymphocytes was seen in the deep dermis. A small number of septate hyphae were seen in the abscesses (Fig. 2c) but no hyphae were seen in the cornified layer of the epidermis in the biopsy specimen. Remnants of hair were not found in the abscesses or in other part of the dermis. Bacterial cultures of the pus and biopsy specimen showed negative results. Four strains of Trichophyton rubrum (KMU 9102, 9106, 9107 and 9108) were cultured from the pus and the biopsy specimen independently. Macroscopically, all strains produced similar white fluffy colonies on Sabouraud’s dextrose agar slants, and showed port wine red staining on the potato dextrose agar slants (Fig. 2d and e). Microscopically, these strains showed teardrop-shaped microconidia borne sessile on the hyphae and a few thin-walled macroconidia. Restriction enzyme analysis using Mva I and Hinf I of the internal transcribed spacer regions (ITS) of ribosomal gene (rDNA) of these strains were compatible with those of T. rubrum. Although the fungal culture of the discoloured nail was negative, restriction enzyme profiles of direct PCR products targeting the ITS of rDNA were identical to those of the strains isolated from the present case. Results of routine haematological and serological studies, urinalysis, subsets of lymphocytes and immunoglobulin levels were normal. The skin test with trichophytin was negative. The patient received
© 2015 Blackwell Verlag GmbH Mycoses, 2015, 58, 318–323
oral itraconazole 200 mg per day for 10 days, stopped treatment after complaining of abdominal tention. Treatment with oral terbinafine 125 mg day for 3 weeks resolved the nodules on the leg, the lesion on the toenail remained.
but disper but
Discussion Dermatophytosis is a communicable skin disease affecting the stratum corneum and also may invade the hair and nails. It is also possible for dermatophytes to invade the dermis and hypodermis, especially in cases where the patient is immunocompromised. A number of cases of deep, invasive dermatophytosis have been reported. However, a classification for the disease has not yet been determined. Fukushiro categorised dermatophytosis occurring in regions deeper than the epidermis into four clinical entities: dermatophyte granuloma, nodular granulomatous perifolliculitis of the legs, dermatophyte abscess and dermatophyte mycetoma.2 Dermatophyte granuloma shows granulomas containing dermatophytes around the hair follicles as well as in the deeper dermis and/or subcutis. Nodular granulomatous perifolliculitis of the legs typically presents as a nodular eruption composed of a chronic granulomatous infiltrate surrounding infected hair follicles within the confines of plaques of superficial dermatophytosis on the
319
M. Inaoki et al.
(a)
(c)
(b)
(d)
(e)
Figure 2 (a) The biopsy specimen of the
nodule showed nodular aggregations of inflammatory cells in the dermis (original magnification 920). (b) The inflammatory cells mainly consisted of neutrophils (original magnification 9200). (c) A septate hypha in the abscess (original magnification 9400). (d) The surface of the colonies grown on the potato dextrose agar slants. (e) The reverse of the colonies on the potato dextrose agar slants showing port wine red staining.
lower portions of the legs of dark-haired women.3 Dermatophyte granulomas and nodular granulomatous perifolliculitis of the legs may have tiny foci of neutrophilis but they never accompany visible pustulation or abscess formation.3 Dermatophyte abscess consists mainly of abscesses containing dermatophytes in the dermis and/or subcutis. Trichophytic mycetoma is a pyogranulomatous firm nodule containing dermatophytic granules. On the other hand, Marconi et al. have classified invasive dermatophyte infections into three forms: Majocchi’s granuloma, deeper dermal dermatophytosis and disseminated dermatophytosis.1
320
Majocchi’s granuloma is the most indolent form, and is subclassified into fungal suppurative folliculitis and nodular granulomatous perifolliculitis. Deeper dermal dermatophytosis is not necessarily associated with hair follicles, tends to have a more rapid onset, is larger, and extends deeper than Majocchi’s granuloma. Deeper dermal dermatophytosis can present in various forms, including granulomas, abscesses or mycetomas. Disseminated dermatophytosis involves skin and internal organs, including the lymph nodes, bone, muscle and liver. Deep dermatophytosis is often used as a generic term for deeper dermal dermatophytosis and
© 2015 Blackwell Verlag GmbH Mycoses, 2015, 58, 318–323
© 2015 Blackwell Verlag GmbH Mycoses, 2015, 58, 318–323
24/F 72/M
28/M 52/F
4/F 46/M
19/F 57/F
62/M
45/M
58/M 53/M 44/F
54/M
Smith and Head8† Faergemann et al.9†
Watanabe et al.†,‡ Yonebayashi et al.10†
Patel and Mills11 Franco12
Colwell et al.13 Kobayashi et al.14
Iijima et al.15
Marconi et al.1
Fukuyama§ Azib et al.16 Matsuzaki et al.17
Present case
Extremities, face, trunk Groin Leg Face, extremities, trunk Leg
Scalp Pubic region, thighs, trunk Leg
Cheek Foot, back
Trunk, leg Hand
Thigh Leg, foot
Location
0.5–2 cm
The size is estimated by using the figures of the article.
Meeting abstract, Med Mycol J 2011; 52(Suppl. 1): 89.
§
Meeting abstract, Jpn J Med Technol 1998; 47: 585.
‡
¶
Multiple
Diagnosis,Therapy and Prophylaxis of Fungal Diseases
Case report
Case of dermatophyte abscess caused by Trichophyton rubrum: a case report and review of the literature Makoto Inaoki,1 Chihiro Nishijima,1 Miho Miyake,1 Toshiyuki Asaka,2 Youichi Hasegawa,3 Kazushi Anzawa4 and Takashi Mochizuki4 1 Department of Dermatology, National Hospital Organisation Kanazawa Medical Center, Kanazawa, Japan, 2Department of Laboratory Medicine, National Hospital Organisation Kanazawa Medical Center, Kanazawa, Japan, 3Hasegawa Skin Clinic, Kanazawa, Japan and 4Department of Dermatology, Kanazawa Medical University, Uchinada, Japan
Summary
A 54-year-old Japanese man without apparent immunosuppression presented with nodules with purulent drainage on the right lower leg. He had ringworm of the right leg and tinea unguium. A biopsy specimen of the nodule showed intradermal abscesses with fungal elements, and Trichophyton rubrum was cultured from both the pus and the biopsy specimen. Treatment with oral terbinafine resolved the nodules. Dermatophyte abscess is a rare, deep and invasive dermatophytosis, which is often associated with immunocompromised conditions. We provide a review of the literature including Japanese cases.
Key words: Abscess, dermis, dermatophytosis, Trichophyton rubrum, terbinafine.
Introduction Deep, invasive infection of dermatophytes is defined as the growth of dermatophytes in the dermis and subcutis, and is believed to result from injury to the lesions of superficial dermatophytosis or the rupturing of infected follicles into the dermis. Granulomas are the most prevalent pathological finding,1 but lesions consists primarily of abscesses in a few cases. We present a case of dermal abscess caused by Trichophyton rubrum in a patient without signs of immunosuppression.
Case report A 54-year-old Japanese man presented with a 3month history of nodules on the right lower leg. He Correspondence: M. Inaoki, Department of Dermatology, National Hospital Organisation Kanazawa Medical Center, 1-1 Shimoishibiki-machi, Kanazawa, Ishikawa 920-8650, Japan. Tel.: +81 76 262 4161. Fax: +81 76 222 2758. E-mail: [email protected] Submitted for publication 23 December 2014 Revised 9 February 2015 Accepted for publication 25 February 2015
doi:10.1111/myc.12317
had a history of valvular disease of heart, nephritis and mycoplasma pneumonia. He had hypertension that was not being treated at the time of first visit. Six months ago, he was diagnosed with ringworm of the right lower leg and feet. Topical treatment with luliconazole cream resolved the skin lesions. Thereafter, there was no abnormality of the skin of the right lower leg before appearance of the nodules. The patient did not use topical corticosteroid on his legs. Examination showed a reddish nodule 2 cm in diameter with purulent drainage on the posterior surface of the right leg (Fig. 1a). There were also a red nodule 1 cm in diameter that was biopsied on the lateral surface of the right leg and a normal-coloured nodule 0.5 cm in diameter on the surface of the right calcaneal tendon (Fig. 1b). There was a scaly erythematous lesion on the right lower leg, which was negative for fungus by direct potassium hydroxide (KOH) preparation of the scale (Fig. 1a). Application of topical difluprednate ointment cleared the erythematous lesion. The nail of the right first toe was discoloured and showed clinical features of total dystrophic onychomycosis. Mycelia were seen on the KOH preparation of the nail scrapings and a diagnosis of tinea unguium was made. A biopsy specimen of the nodule showed intradermal abscesses filled with neutrophils (Fig. 2a
© 2015 Blackwell Verlag GmbH Mycoses, 2015, 58, 318–323
Dermatophyte abscess
(b)
(a)
Figure 1 (a) Reddish nodule with puru-
lent drainage 2 cm in diameter and a scaly erythematous lesion on the posterior surface of the right leg. (b) A red nodule 1 cm in diameter on the lateral surface of the right leg.
and b). A small accumulation of histiocytes surrounded by lymphocytes was seen in the deep dermis. A small number of septate hyphae were seen in the abscesses (Fig. 2c) but no hyphae were seen in the cornified layer of the epidermis in the biopsy specimen. Remnants of hair were not found in the abscesses or in other part of the dermis. Bacterial cultures of the pus and biopsy specimen showed negative results. Four strains of Trichophyton rubrum (KMU 9102, 9106, 9107 and 9108) were cultured from the pus and the biopsy specimen independently. Macroscopically, all strains produced similar white fluffy colonies on Sabouraud’s dextrose agar slants, and showed port wine red staining on the potato dextrose agar slants (Fig. 2d and e). Microscopically, these strains showed teardrop-shaped microconidia borne sessile on the hyphae and a few thin-walled macroconidia. Restriction enzyme analysis using Mva I and Hinf I of the internal transcribed spacer regions (ITS) of ribosomal gene (rDNA) of these strains were compatible with those of T. rubrum. Although the fungal culture of the discoloured nail was negative, restriction enzyme profiles of direct PCR products targeting the ITS of rDNA were identical to those of the strains isolated from the present case. Results of routine haematological and serological studies, urinalysis, subsets of lymphocytes and immunoglobulin levels were normal. The skin test with trichophytin was negative. The patient received
© 2015 Blackwell Verlag GmbH Mycoses, 2015, 58, 318–323
oral itraconazole 200 mg per day for 10 days, stopped treatment after complaining of abdominal tention. Treatment with oral terbinafine 125 mg day for 3 weeks resolved the nodules on the leg, the lesion on the toenail remained.
but disper but
Discussion Dermatophytosis is a communicable skin disease affecting the stratum corneum and also may invade the hair and nails. It is also possible for dermatophytes to invade the dermis and hypodermis, especially in cases where the patient is immunocompromised. A number of cases of deep, invasive dermatophytosis have been reported. However, a classification for the disease has not yet been determined. Fukushiro categorised dermatophytosis occurring in regions deeper than the epidermis into four clinical entities: dermatophyte granuloma, nodular granulomatous perifolliculitis of the legs, dermatophyte abscess and dermatophyte mycetoma.2 Dermatophyte granuloma shows granulomas containing dermatophytes around the hair follicles as well as in the deeper dermis and/or subcutis. Nodular granulomatous perifolliculitis of the legs typically presents as a nodular eruption composed of a chronic granulomatous infiltrate surrounding infected hair follicles within the confines of plaques of superficial dermatophytosis on the
319
M. Inaoki et al.
(a)
(c)
(b)
(d)
(e)
Figure 2 (a) The biopsy specimen of the
nodule showed nodular aggregations of inflammatory cells in the dermis (original magnification 920). (b) The inflammatory cells mainly consisted of neutrophils (original magnification 9200). (c) A septate hypha in the abscess (original magnification 9400). (d) The surface of the colonies grown on the potato dextrose agar slants. (e) The reverse of the colonies on the potato dextrose agar slants showing port wine red staining.
lower portions of the legs of dark-haired women.3 Dermatophyte granulomas and nodular granulomatous perifolliculitis of the legs may have tiny foci of neutrophilis but they never accompany visible pustulation or abscess formation.3 Dermatophyte abscess consists mainly of abscesses containing dermatophytes in the dermis and/or subcutis. Trichophytic mycetoma is a pyogranulomatous firm nodule containing dermatophytic granules. On the other hand, Marconi et al. have classified invasive dermatophyte infections into three forms: Majocchi’s granuloma, deeper dermal dermatophytosis and disseminated dermatophytosis.1
320
Majocchi’s granuloma is the most indolent form, and is subclassified into fungal suppurative folliculitis and nodular granulomatous perifolliculitis. Deeper dermal dermatophytosis is not necessarily associated with hair follicles, tends to have a more rapid onset, is larger, and extends deeper than Majocchi’s granuloma. Deeper dermal dermatophytosis can present in various forms, including granulomas, abscesses or mycetomas. Disseminated dermatophytosis involves skin and internal organs, including the lymph nodes, bone, muscle and liver. Deep dermatophytosis is often used as a generic term for deeper dermal dermatophytosis and
© 2015 Blackwell Verlag GmbH Mycoses, 2015, 58, 318–323
© 2015 Blackwell Verlag GmbH Mycoses, 2015, 58, 318–323
24/F 72/M
28/M 52/F
4/F 46/M
19/F 57/F
62/M
45/M
58/M 53/M 44/F
54/M
Smith and Head8† Faergemann et al.9†
Watanabe et al.†,‡ Yonebayashi et al.10†
Patel and Mills11 Franco12
Colwell et al.13 Kobayashi et al.14
Iijima et al.15
Marconi et al.1
Fukuyama§ Azib et al.16 Matsuzaki et al.17
Present case
Extremities, face, trunk Groin Leg Face, extremities, trunk Leg
Scalp Pubic region, thighs, trunk Leg
Cheek Foot, back
Trunk, leg Hand
Thigh Leg, foot
Location
0.5–2 cm
The size is estimated by using the figures of the article.
Meeting abstract, Med Mycol J 2011; 52(Suppl. 1): 89.
§
Meeting abstract, Jpn J Med Technol 1998; 47: 585.
‡
¶
Multiple
