mycoses
Diagnosis,Therapy and Prophylaxis of Fungal Diseases
Original article
Thirty-six cases of epidemic infections due to Trichophyton violaceum in Siena, Italy Clara Romano, Luca Feci and Michele Fimiani Dermatology Section, Department of Clinical Medicine and Immunogical Sciences, Siena University, Siena, Italy
Summary
Trichophyton violaceum is an anthropophilous dermatophyte endemic to parts of Africa and Asia, sporadic in Europe. It is an emerging pathogen in Italy due to immigration. We report 36 cases of infections due to T. violaceum, diagnosed in the last 5 years by mycological examination. The source of contagion was 13 children adopted from orphanages.
Key words: Dermatomycosis, epidemiology, tinea capitis, tinea corporis.
Introduction Trichophyton violaceum (T. violaceum) is an anthropophilous dermatophyte that causes tinea capitis and sometimes tinea corporis, tinea manuum, tinea pedis, tinea cruris, tinea faciei and onychomycosis. It is endemic to parts of Africa1 and Europe.2 In Europe, it is an emerging pathogen due to immigration from endemic areas. We report 36 cases of infections due to T. violaceum, microbiologically diagnosed, observed in Siena in the last 5 years. They had seven epidemic foci. Thirteen children adopted from orphanages (eight boys, five girls, age 2–8 years, 11 African and two Ukrainian) were the source of contagion and in all cases tinea was misdiagnosed. To our knowledge, orphanages have not previously been reported as epidemic foci.
Case reports Table 1 shows the age, gender, clinical diagnosis and any associated pathologies in the 13 children who were the source of contagion. The table also indicates Correspondence: C. Romano, Mycology Unit, Dermatology Section, Department of Clinical Medicine and Immunological Sciences, University of Siena, Viale Bracci 1, 53100 Siena, Italy. Tel.: +0577585484. Fax: +057744238. E-mail:
[email protected] Submitted for publication 22 November 2013 Revised 27 November 2013 Accepted for publication 27 November 2013
© 2013 Blackwell Verlag GmbH Mycoses, 2014, 57, 307–311
their age at adoption and at diagnosis, treatment prior to mycological diagnosis and the duration of antimycotic therapy. Data on the 23 persons infected by the children are also included. There were no asymptomatic carriers. Briefly, of the 13 children, one had a swelling nodular erythematous–oedematous lesion typical of kerion, whereas the others had tinea capitis, which was pyoderma like in five cases (Fig. 1a) and presented as patches of alopecia with black dots in the other seven. More specifically, six of the children had typical alopecic patches with black dots on the scalp and a girl also had nodules. One patient with tinea capitis also had tinea faciei and another tinea corporis. Sixteen patients infected by the 13 index cases had tinea corporis; three patients had tinea faciei; three patients had tinea capitis (Fig. 1b), which in one patient was associated with tinea faciei, and in another with tinea corporis. In all cases of tinea capitis, dermoscopy was performed with a 3Gen DermliteFotoâ instrument (3Gen, Inc., San Juan Capistrano, CA, USA), revealing corkscrew pattern with black dots (Fig. 1c).3 Diagnosis was based on mycological examination. Pathological material from erythematous–squamous and alopecic patches soaked with 30% potassium hydroxide (KOH) revealed hyphae and spores under the microscope. Conidia with endothrix infection typical of Trichophyton and hyphae were observed in hair samples. Culture on Sabouraud dextrose agar with chloramphenicol and cycloheximide produced glabrous waxy violet colonies after 25–35 days. These turned purple in time (Fig. 1d) and microscopy showed
doi:10.1111/myc.12164
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Female, 36 years
Male, 37 years
Male, 78 years
Female, 41 years
Female, 7 years
Male, 6 years Female, 38 years
Male, 40 years
Female, 80 years
Male, 5 years
Female, 8 years
Male, 6 years
Female, 38 years
2
3
4
5
6
7 8
9
10
11
12
13
14
Female, 40 years
Male, 3 years
1
15
Gender and age
No.
Tinea faciei
Tinea faciei
Tinea faciei and tinea capitis
Tinea faciei
Tinea corporis
Tinea corporis
Tinea corporis
Tinea capitis Tinea corporis
Tinea capitis
Tinea corporis
Tinea corporis
Tinea corporis
Tinea corporis
Kerion C.C.
Diagnosis
– – – – 5 years 4 years – – – – – –
–
– – – – – – – – – – – –
– –
2½ years
–
–
Age at adoption
Concomitant pathology
40
38
6
8
5
80
40
6 38
7
41
78
35
36
3
Age at diagnosis (years)
Mother case 13
Mother case 12
Friend
Friend
Friend
Grandmother
Father
Index case Mother
Index case
Aunt
Grandfather
Father
Mother
Index case
Relation to index case
Table 1 Demographic and clinical data and therapy of 36 patients with dermatophytoses due to Trichophyton violaceum.
Erythromycin, amoxicillin + clavulanic acid Combined topical corticosteroids and antimycotics Combined topical corticosteroids and antimycotics Combined topical corticosteroids and antimycotics Combined topical corticosteroids and antimycotics Fluconazole, amoxicillin + clavulanic acid Topical antibiotics Combined topical corticosteroids and imidazoles Combined topical corticosteroids and imidazoles Combined topical corticosteroids and imidazoles Combined topical corticosteroids and imidazoles Combined topical corticosteroids and imidazoles Combined topical corticosteroids and imidazoles Combined topical corticosteroids and imidazoles Combined topical corticosteroids and imidazoles
Previous treatment
20
15
17
20
16
15
15
46 15
45
15
15
15
15
45
Duration antimycotic therapy (days)
(continued)
Healed
Healed
Healed
Healed
Healed
Healed
Healed
Healed Healed
Healed
Healed
Healed
Healed
Healed
Healed
Outcome
C. Romano et al.
© 2013 Blackwell Verlag GmbH Mycoses, 2014, 57, 307–311
Gender and age
Male, 2 years
Male, 3 years
Female, 30 years Male, 36 years Male, 4 years
Female, 2 years
Female, 35 years
Male, 36 years Male, 5 years
Female, 4 years
Female, 37 years Male, 39 years Male, 6 years Female, 4 years Female, 35 years Male, 4 years Male, 5 years Male, 6 years Female, 5 years Female, 38 years Male, 40 years
No.
16
17
18 19 20
21
22
23 24
25
26 27 28 29 30 31 32 33 34 35 36
Table 1 (Continued)
© 2013 Blackwell Verlag GmbH Mycoses, 2014, 57, 307–311
Tinea capitis Tinea capitis Pyoderma-like tinea capitis and tinea faciei Pyoderma-like tinea capitis Tinea corporis and tinea capitis Tinea corporis Pyoderma-like tinea capitis Pyoderma-like tinea capitis Tinea corporis Tinea corporis Tinea capitis Tinea capitis Tinea corporis Tinea corporis Tinea corporis Tinea capitis Pyoderma-like tinea capitis Tinea corporis Tinea corporis
Tinea capitis
Tinea capitis and tinea corporis
Diagnosis
11 months – – 3.5 years
– – – Pediculosis capitis Pediculosis capitis – – – – – – – – – – – 36 5
35
2
30 36 4
37 39 6 6 35 4 5 6 5 38 40
– – 2 years 11 months
– – –
3
– – 5½ years 5½ years – – – 4 years 4½ years – –
2 years
–
2
4
6 months
–
Age at diagnosis (years)
4 months
Age at adoption
Concomitant pathology
Mother Father Index case Index case Mother Friend Friend Index case Index case Mother Father
Index case
Father Index case
Mother
Index case
Mother Father Index case
Index case
Index case
Relation to index case
Topical Topical Topical Topical Topical Topical Topical Topical Topical Topical Topical
imidazoles imidazoles antibiotics antibiotics antibiotics antibiotics antibiotics antibiotics antibiotics antibiotics antibiotics
Topical imidazoles
Topical imidazoles Topical imidazoles
Topical imidazoles
Topical antibiotics
Alternate cycles of topical corticosteroid ointment for 15 days and topical antimycotics for 15 days Alternate cycles of topical corticosteroid ointment for 15 days and topical antimycotics for 15 days Topical corticosteroids Topical corticosteroids Topical antibiotics
Previous treatment
20 20 45 45 20 15 15 45 45 20 20
45
15 45
40
45
45 45 45
48
45
Duration antimycotic therapy (days)
Healed Healed Healed Healed Healed Healed Healed Healed Healed Healed Healed
Healed
Healed Healed
Healed
Healed
Healed Healed Healed
Healed
Healed
Outcome
Epidemic infections due to T. violaceum in Siena
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C. Romano et al.
(a)
(b)
(c)
(d)
Figure 1 (a) Alopecic pyoderma-like
patches in a 6-year-old boy; (b) tinea capitis due to Trichophyton; (c) corkscrew dermoscopic pattern of black dots; (d) colonies of T. violaceum.
dermatophytic hyphae of irregular shape. In some cases, electron microscope examination was also performed (Fig. 2a,b).4 We did not find any cases of onychomycosis, although it has recently been associated with T. violaceum infection. Material was also collected from all contact persons by scalp brushing and scraping. In all cases, mycological examination was negative. All 29 children (i.e. the 13 index cases and the 16 patients infected by them) were treated with 10 mg kg 1 day 1 griseofulvin for 45 days and topical imidazoles for 20–30 days. The adults with spreading tinea corporis were treated with 100 mg itraconazole for 15–20 days and those with tinea capitis with the same dose of the antimycotic for 45 days
(a)
(b)
Figure 2 SEM show (a) highly distorted hyphae typical of Trichophyton violaceum and (b) intercalated chlamydospore.
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and with topical imidazoles for 15–20 days, depending on the number of patches. In all patients recovery was confirmed by clinical and mycological examination 3 months after healing.
Discussion Trichophyton violaceum mostly causes tinea capitis and tinea corporis. It is endemic to parts of Africa, especially north Africa,1 and is widespread in Asia.5 In Europe, it has been reported sporadically from parts of France and Sweden,2 and is an emerging pathogen in Spain,6 Greece7 and Italy,8 as a consequence of immigration from endemic areas. In Italy, it is autochthonous in Sardinia, Apulia and Lombardy. Isolated sporadically in many regions,9 it has also reappeared in Tuscany, where the source of contagion is mainly immigrants from endemic areas.8 Trichophyton violaceum prevalently causes tinea capitis and corporis, which are sometimes associated. The clinical picture of trichophytic tinea capitis is characterised by many small erythematous–squamous alopecic patches and hairs broken off a few millimetres from the follicular opening (black dots). However, in tinea capitis, mildly scaling patches resembling seborrhoeic dermatitis10 or pseudotinea amiantacea with pyoderma-like lesions and multiple pustules and crusts adhering to the scalp, similar to bacterial folliculitis, have also been reported.8,11 Tinea corporis typically begins as a spreading erythematous–squamous patch. Following central healing, the lesion may become annular in shape. The inflammation can give rise to scales, crusts, papules,
© 2013 Blackwell Verlag GmbH Mycoses, 2014, 57, 307–311
Epidemic infections due to T. violaceum in Siena
vesicles and even bullae. Vesicular and vesicobullous patches similar to eczema and pyoderma have been described.12 Tinea corporis may occasionally be purpuric.13 Dermatological examination of children from areas where anthropophilous dermatophytes are endemic could therefore help prevent epidemics of T. violaceum infection. It is also true that paediatricians and general practitioners may not always recognise dermatophytoses, as in our cases. Many patients were initially treated with systemic antibiotics, often preceded or associated with topical antibiotics or corticosteroids, because clinical picture and symptoms were misdiagnosed as pyoderma or eczema. In other cases, systemic or topical antifungal therapy was used, but not persistently enough to be successful. In all patients described here, diagnosis was confirmed mycologically and by dermoscopy, a technique recently used to test for tinea capitis in black children having non-inflammatory tinea capitis lacking the typical features.3 As reported in Table 1, much time elapsed between manifestations of the infection (as reported by adoptive parents) and mycological diagnosis. In this interval, the orphans were treated in incongruous ways. Tinea capitis and widespread tinea corporis should be treated with systemic antimycotics, except in rare neonatal cases of tinea capitis, when only topical antimycotics may be used.14 For children, griseofulvin is still the best antimycotic, whereas for adults imidazoles and allylamines are an alternative. Use of suitable shampoo and topical antimycotics is also advisable, especially in children.
© 2013 Blackwell Verlag GmbH Mycoses, 2014, 57, 307–311
References 1 2
3
4
5
6
7
8
9
10 11 12 13
14
Meziou TJ, Dammak A, Zaz T et al. Scalp ringworm tinea capitis in Tunisian infants. Med Mal Infect 2011; 41: 486–8. Ginter-Hanselmayer G, Weger W, Ilkit M, Smolle J. Epidemiology of tinea capitis in Europe: current state and changing patterns. Mycoses 2007; 2: 6–13. Hughes R, Chiaverini C, Bahadoran P et al. Corkscrew hair: a new dermoscopic sign for diagnosis of tinea capitis in black children. Arch Dermatol 2011; 147: 355–6. de Hoog GS, Guarro J, Gene J, Figueras MJ. Hyphomycetes, dermatophytes: Trichophyton. In: de Hoog GS, Guarro J, Gene J, Figueras MJ (eds), Atlas of Clinical Fungi, 2nd edn. Utrecht/Reus: Centraalbureau voor Schimmelcultures/Universitat Rovira i Virgili, 2000: 992–4. Zhu M, Li L, Wang J, Zhang C, Kang K, Zhang Q. Tinea capitis in Southeastern China: a 16-year survey. Mycopathologia 2010; 169: 235–9. Juncosa T, Aguilera P, Jaen A, Vicente A, Aguilar AC, Fumad o V. Trichophyton violaceum: an emerging pathogen. Enferm Infecc Microbiol Clin 2008; 26: 502–4. Frangoulis E, Papadogeorgakis H, Athanasopoulou B, Katsambas A. Superficial mycoses due to Trichophyton violaceum in Athens, Greece: a 15-year retrospective study. Mycoses 2005; 48: 425–9. Romano C, Massai L, Difonzo EM. Dermatophytosis due to Trichophyton violaceum in Tuscany from 1985 to 1997. Mycoses 2000; 43: 169–72. Calabr o G, Nino M, La Bella S, Gallo L. Trichophyton violaceum infection in an adult black patient in Europe. Int J Dermatol 2011; 50: 761–3. Romano C, Gianni C, Papini M. Tinea capitis in infants less than 1 year of age. Pediatr Dermatol 2001; 18: 465–8. Martin ES, Elewski BE. Tinea capitis in adult women masquerading as bacterial pyoderma. J Am Acad Dermatol 2003; 49: 177–9. Romano C, Massai L, Fimiani M. Case report. Two cases of tinea corporis bullosa. Mycoses 2002; 45: 1–6. Romano C, Massai L, Strangi R, Feci L, Miracco C, Fimiani M. Tinea corporis purpurica and onychomycosis caused by Trichophyton violaceum. Mycoses 2011; 54: 175–8. Mosseri R, Finkelstein Y, Garty BZ. Topical treatment of tinea capitis in a neonate. Cutis 2002; 69: 88–90.
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