|Year : 2015 | Volume
| Issue : 3 | Page : 444-447
Problems in the diagnosis of profound trichophytosis barbae
D Kozielewicz1, J Wernik2, A Mikucka3, A Ciesielska4, E Kruszynska3, E Gospodarek3, M Pawlowska5, W Halota1
1 Department of Infectious Diseases and Hepatology, Faculty of Medicine, T. Browicz Provincial Infectious Diseases Hospital, Bydgoszcz, Poland
2 T. Browicz Provincial Infectious Diseases Hospital, Bydgoszcz, Poland
3 Department of Microbiology, Faculty of Pharmacy, T. Browicz Provincial Infectious Diseases Hospital, Bydgoszcz, Poland
4 Department of Microbial Genetics, University of Łódź, Toruń, Poland
5 Department of Children Infectious Diseases and Hepatology, Faculty of Medicine, Nicolaus Copernicus University, Toruń, Poland
|Date of Submission||26-May-2014|
|Date of Acceptance||07-Jan-2015|
|Date of Web Publication||12-Jun-2015|
Department of Infectious Diseases and Hepatology, Faculty of Medicine, T. Browicz Provincial Infectious Diseases Hospital, Bydgoszcz
Source of Support: None, Conflict of Interest: None
Zoophilic species of human dermatophytoses, such as Trichophyton mentagrophytes are significantly rare. We present a case of a 42-year-old male who for 2 months had been unsuccessfully treated and then referred to hospital with suspected actinomycosis. Lesions on the skin on his neck, submandibular area, cheeks and groins were consistent with extremely painful, merging inflammatory tumours and infiltrations with the presence of numerous pustules in hair follicles that poured purulent contents forming into yellow crusts after compression. The treatment with terbinafine was successful. The final identification of the Trichopyton mentagrophytes var. granulosum strain was performed based on a microscopic assessment of the culture, and the result of species identification was confirmed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis.
Keywords: PCR diagnostics, profound trichophytosis barbae, Trichophyton mentagrophytes
|How to cite this article:|
Kozielewicz D, Wernik J, Mikucka A, Ciesielska A, Kruszynska E, Gospodarek E, Pawlowska M, Halota W. Problems in the diagnosis of profound trichophytosis barbae. Indian J Med Microbiol 2015;33:444-7
|How to cite this URL:|
Kozielewicz D, Wernik J, Mikucka A, Ciesielska A, Kruszynska E, Gospodarek E, Pawlowska M, Halota W. Problems in the diagnosis of profound trichophytosis barbae. Indian J Med Microbiol [serial online] 2015 [cited 2019 Nov 22];33:444-7. Available from: http://www.ijmm.org/text.asp?2015/33/3/444/158591
| ~ Introduction|| |
Fungal infections develop in approximately 40% of the worldwide population and most frequently affect the skin and mucous membranes. , One of them are dermatophytes which include three genera: Trichophyton, Epidermophyton and Microsporum.  Currently, the most common cause of human dermatophytoses includes anthropophilic species, mainly Trichophyton rubrum, whereas zoophilic species, such as Trichophyton mentagrophytes and Microsporum canis, are significantly less common. 
| ~ Case Report|| |
A 42-year-old male was admitted to the Department with suspected actinomycosis. Two months earlier, the patient had developed single erythematous-exfoliating foci on the skin of his neck and lower face. The patient had been treated with local antibacterial agents, including bacitracin and neomycin. Despite applied treatment, pathogenic lesions widened peripherally, and then formed into painful infiltrations and tumours. Moreover, distant pathogenic foci appeared on the trunk, chest as well as on the upper and lower extremities. For many years, the patient had been taking oral prednisone and subcutaneous methotrexate due to rheumatoid arthritis. He used to manage his farm and was in everyday contact with cattle, poultry, cats and dogs. Within a week prior to admission to the Department, there had been a progression of pathological lesions combined with asthenia and increased sweating. On the day of admission, skin on his neck, submandibular area, cheeks and groins, there were extensive lesions consistent with merging inflammatory tumours and infiltrations with the presence of numerous pustules in hair follicles that poured purulent contents forming into yellow crusts after compression [Figure 1]. Moreover, erythematous-exfoliating foci were observed on the skin of the abdomen, lower extremities, nape and intergluteal cleft. The lesions were painful. They were accompanied by lymphadenopathy in the neck and nape. Laboratory tests revealed slightly elevated inflammatory markers. The C-reactive protein (CRP) levels were 39 mg/dL (norm up to 5 mg/dL), and the white blood cell count (WBC) was 11.9 × 10 3 /μL (norm 4-10 × 10 3 /μL). Because of suspected actinomycosis, empirical treatment with intravenous amoxicillin at a dose of 6.0 g/day was started, and ketoprofen was added due to severe pain. During patient hospitalisation systemic (asthenia, pain) and local symptoms exacerbated and inflammatory markers assessed in laboratory tests increased (CRP 160 mg/dL, WBC 15.9 × 10 3 /μL). Intravenous clindamycin - 1800 mg/day was added in three divided doses. On day 7 of hospitalisation, the Department of Microbiology provided initial information about the presence of filamentous fungi in a culture. Antibiotics were discontinued and the patient received oral itraconazole at a dose of 200 mg daily. After 2 days of itraconazole treatment, pathological lesions significantly regressed; however, therapy was discontinued due to generalised drug-induced exenthema. Oral terbinafine at a dose of 250 mg/day was applied, and gradual improvement was observed. On day 15 of patient hospitalisation, the Department of Microbiology provided the final test results indicating Trichopyton mentagrophytes var. granulosum. The strain was identified based on a microscopic assessment of the culture (round macroconidia aligned in irregular clusters, spiral hyphae), colony morphology [Figure 2], positive urease test, abundant growth at 37°C.  The result of species identification was confirmed by a restriction fragment length polymorphism analysis of polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) (Hinf I restrictase) [Figure 3]. This dermatophyte was sensitive to antifungal treatment applied so far. Therapy was continued and satisfactory improvement was observed. The patient was discharged home with a recommendation to take terbinafine up to 6 weeks.
|Figure 1: Typical lesion on the skin of the chin and neck prior to the start of antifungal treatment|
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|Figure 2: Surface of the colony of Trichopyton mentagrophytes var. granulosum on the Saboraud medium (7-day culture)|
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| ~ Discussion|| |
Trichophyton mentagrophytes is a pathogen commonly observed in cattle, dogs, cats, rabbits and rodents. Infection with zoophilic dermatophytes belonging to this species is a result of a direct contact with a sick animal. Most frequently, it is people who work with animals, as it was in the case of this patient, who was in everyday contact with livestock. Micro-organisms are rarely transferred between humans. , Trichophytosis can be divided into a superficial form caused by anthropohilic fungi and a profound form caused by zoophilic fungi.  Profound trichophytosis barbae is caused by epizootic fungi belonging to the genus Trichophyton (T. verrucosum, T. mentagrophytes var. granulosum). These dermatophytes occupy the interior of the hair (endothrix), and as a result hair shafts become broken near the skin surface (tinea tonsurans).  Dermal lesions are highly inflammatory (with adjacent lymphadenopathy) and are associated with a severe course and general symptoms (fever, malaise). Clinical manifestation mainly shows inflammatory tumouprs and inflammatory infiltrations with a tendency for merging. Purulent discharge oozes out of follicular ostia. Hair inside the foci can be easily removed mechanically. As a result of damage to the hair follicle apparatus, there may develop scars and permanent baldness. 
The treatment of trichophytosis barbae includes the same therapeutic regimens as in the fungal infection of the scalp, i.e., griseofulvin at a dose of 20 mg/kg b.w./daily for 8 weeks, terbinafine at a dose of 250 mg/day for 4-6 weeks, itraconazole 200 mg twice daily for 7 days (namely a pulse) or 100 mg/day for 4-6 weeks, possibly fluconazole 50-100 mg/day for 8 weeks. In the reported case, a significant improvement was observed as soon as after just 2 days since the introduction of antifungal treatment. Local treatment (i.e., creams with terbinafine, shampoos with selenium sulphide, ketoconazole or ciclopirox olamine) has supportive and alleviating properties. Patients are advised to use single-use shaving machines because shaving is a factor predisposing to the spread of infection. ,
The diagnosis of this disease may be difficult despite quite a typical clinical picture. In the reported case prior to hospital admission, the patient received local treatment with antibiotics, and then was referred with suspected actinomycosis. Apart from actinomycosis, the differential diagnosis usually include folliculitis, furunculus or furunculosis, as well as acne nodulocystica, iododerma, bromoderma . Results of microbiological tests are decisive in the diagnosis and making therapeutic decisions. Conventional mycological methods are methods which have been tested and commonly used. However, due to the possibility of falsely negative results of direct microscopic and/or culture tests, the long waiting period for the identification of species, and identification problems in the case of rarely occurring fungi, methods based on direct detection and identification of fungi in clinical material via PCR-based methods have become increasingly popular. ,
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[Figure 1], [Figure 2], [Figure 3]