|Year : 2014 | Volume
| Issue : 1 | Page : 86-88
Bilateral Tinea Nigra of palm: A rare case report from Eastern India
G Sarangi1, D Dash2, N Chayani1, SK Patjoshi3, S Jena2
1 Department of Microbiology, Shrirama Chandra Bhanj Medical College and Hospital, Cuttack, Odisha, India
2 Department of Microbiology, Shrirama Chandra Bhanj Medical College and Hospital; Department of Dermatology and Veneral Diseases, Cuttack Utkal University , Cuttack, Odisha, India
3 Department of Dermatology and Veneral Diseases, Shrirama Chandra Bhanj Medical College and Hospital, Cuttack, Odisha; Department of Dermatology and Veneral Diseases, Cuttack Utkal University , Cuttack, Odisha, India
|Date of Submission||17-Apr-2013|
|Date of Acceptance||25-Sep-2013|
|Date of Web Publication||4-Jan-2014|
Department of Microbiology, Shrirama Chandra Bhanj Medical College and Hospital, Cuttack, Odisha
Source of Support: None, Conflict of Interest: None
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.
Keywords: Black fungus , H.wernekii, Tinea nigra
|How to cite this article:|
Sarangi G, Dash D, Chayani N, Patjoshi S K, Jena S. Bilateral Tinea Nigra of palm: A rare case report from Eastern India. Indian J Med Microbiol 2014;32:86-8
|How to cite this URL:|
Sarangi G, Dash D, Chayani N, Patjoshi S K, Jena S. Bilateral Tinea Nigra of palm: A rare case report from Eastern India. Indian J Med Microbiol [serial online] 2014 [cited 2019 Aug 18];32:86-8. Available from: http://www.ijmm.org/text.asp?2014/32/1/86/124336
| ~ Introduction|| |
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).  In some instances Stenellaaraguata also causes T. nigra.  The disease was first described by Cerqueirain 1891 in Brazil and published by Cerqueira Pinto in 1916 as " keratomycosis nigricans palmaris".  It is most commonly seen in tropical and sub-tropical areas of south to north America, Africa, Australia and Asia. ,, 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.
| ~ Case Report|| |
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.
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 10 th day of incubation which were initially yellowish brown in colour and later changed to shiny black by 3 rd 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 μm 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.
|Figure 2: Moist yeast like yellowish brown colony on SDA with cycloheximide|
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|Figure 4: Lacto phenol cotton blue mount showing densely septate brown hyphal elements with some swollen cells (×40)|
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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.  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.  The infection usually occurs in tropical and sub-tropical areas including central and South America, 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.  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. ,,
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. 
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 household work and hand washing. Most patients have hyperhidrosis as an associated feature  (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. 
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.  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.  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.  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.
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.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]