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Year : 2013  |  Volume : 31  |  Issue : 3  |  Page : 295--298

Microsporum gypseum dermatophytosis in a patient of acquired immunodeficiency syndrome: A rare case report

S Bhagra, SA Ganju, A Sood, RC Guleria, AK Kanga 
 Department of Microbiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India

Correspondence Address:
S Bhagra
Department of Microbiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh
India

Abstract

Microsporum gypseum, a geophillic dermatophyte is rarely isolated from patients with acquired immunodeficiency syndrome. We report tinea corporis due to Microsporum gypseum, an uncommon aetiological agent, in a patient with acquired immunodeficiency syndrome from our region. The clinical presentation resembled psoriasis characterised by atypical, scaly and hyperkeratotic lesions.

How to cite this article:
Bhagra S, Ganju S A, Sood A, Guleria R C, Kanga A K. Microsporum gypseum dermatophytosis in a patient of acquired immunodeficiency syndrome: A rare case report.Indian J Med Microbiol 2013;31:295-298

How to cite this URL:
Bhagra S, Ganju S A, Sood A, Guleria R C, Kanga A K. Microsporum gypseum dermatophytosis in a patient of acquired immunodeficiency syndrome: A rare case report. Indian J Med Microbiol [serial online] 2013 [cited 2019 Oct 14 ];31:295-298
Available from: http://www.ijmm.org/text.asp?2013/31/3/295/115656

Full Text

 Introduction



Dermatophytosis manifests as an opportunistic infection being four times more prevalent in acquired immunodeficiency syndrome (AIDS) patients. [1] The most common clinical manifestation of dermatophytosis is tinea pedis and tinea unguium, which can present any time during the course of illness in Human immunodeficiency virus (HIV) positive patients. The incidence of dermatophyte infection of the glabrous skin is reported to be approximately 40% in these patients. [2] The frequently isolated species are Trichophyton rubrum, Trichophyton mentagrophytes and Epidermophyton floccosum. [3] Microsporum gypseum is a geophillic dermatophyte, which is rarely isolated from skin lesions of immunocompromised patients. We report superficial mycosis due to Microsporum gypseum concomitant with oral Candidiasis in an AIDS patient.

 Case Report



A 48-year-old female farmer diagnosed with oral Candidiasis was referred to our tertiary care hospital for further management. The patient had complaints of difficulty in swallowing, weight loss and low grade fever. The symptoms had gradually worsened for the last 4 months.

On general physical examination, the patient was conscious, cooperative and well-oriented. The vitals were stable: Pulse-78/min, blood pressure-126/84 mm Hg and respiratory rate-16/min. Examination of the chest, cardiovascular system and central nervous system was apparently normal. On examination of the oral cavity, creamy white curd like plaques on the right side of buccal mucosa approximately 2 × 2 cm in size covering anterior one-third of tongue were seen. Relevant laboratory investigations were: Hb-10.4 gm%, peripheral blood smear-mild anisocytosis with microcytic hypochromic anaemia and erythrocyte sedimentation rate-8 mm in 1 st hour. Renal and liver function tests were within normal limits. Serum sample was detected positive for HIV-1 antibody according to the National AIDS Control Organisation (NACO) testing guidelines. The CD 4 count was 52 cells/mm 3 and CD 3 was 839 cells/mm 3 .

On detailed examination by the microbiologist, a dry looking scaly lesion approximately 5 × 5 cm with ill-defined borders, poorly erythematous and diffusely involving the right iliac fossa was noted [Figure 1]. Skin scrapings were collected from multiple sites along the margins of the lesion after cleaning with 70% alcohol. Direct mycological examination with 10% potassium hydroxide (KOH) revealed hyaline septate hyphae, 2-3 μm in diameter. Scrapings were inoculated on two sets of media: (i) Sabouraud's dextrose agar (SDA) with chloramphenicol (0.005%) (ii) SDA with cyclohexamide (0.05%), and incubated at 25°C and 37°C. After 5 days of incubation, growth of a flat spreading powdery surface, cinnamon to buff brown on obverse and light tan on the reverse was seen [Figure 2]. Lactophenol cotton blue preparation from colonies demonstrated elliptical macroconidia with four to six septae with rat tail appearance [Figure 3]. No microconidia were visualised. All findings were consistent with Microsporum gypseum infection. The patient was started on terbinafine 250 mg once a day for 14 days. However, the patient left against medical advice and could not be followed up.{Figure 1}{Figure 2}{Figure 3}

 Discussion



Worldwide dermatophytosis is frequently associated with people living with HIV/AIDS being 20-40% more than the general population. [4] In India, the incidence of superficial fungal infection in this group of patients is variable ranging from 8% to 22%. [5],[6] Microsporum gypseum, a geophillic dermatophyte frequently isolated from soil, is the most common member of the genus Microsporum It can infect humans, although rarely, depending upon the patient exposure frequency to infectious sources besides their immune status. [7] As reported earlier, Microsporum gypseum may cause tinea capitis and tinea corporis in immunocompetent hosts. [8] The lesions are inflammatory and sometimes bullous with rapid development and resolution. Usually, tinea corporis presents as erythematous patches with central clearing or large papulosquamous plaques. Involvement of unusual sites as the eyelids and celsus kerion have been recorded in immunocompetent hosts. [9],[10] In immunocompromised hosts, a rare favus like eruption has been documented. [11] In the present case, we could isolate only a single species Microsporum gypseum, though different dermatophytes along with yeast presenting a polymicrobial fungal infection can be associated with HIV patients. [7] In immunocompromised hosts, the lesions show remarkable hyperkeratosis, extensive scaling, lack elevated borders and central clearing consistent with anergic tinea, similar to our case. [12] Here, the systemic spread of fungus may occur more rapidly due to inability of the cellular immune system to mount an adequate immune response. The disease manifestations may be atypical, disseminated and difficult to control. In AIDS, the lesions may mimic other diseases like erythema multiforme, seborrhic dermatitis and psoriasis. Thus, microbiological characterisation is critical to establish diagnosis and treatment.

Some studies report tinea corporis in 53.7% cases while other mention tinea pedis to be present in 40% of patient with AIDS. [6],[13] Trichophyton rubrum has been identified as the frequent isolate overall and also in AIDS patients. [14] Microsporum gypseum is an uncommon agent of dermatophytosis, which has been documented from Rio de Janerio in only three out of 879 (0.34%) and in 71 cases from Brazil during the last 30 years. [3],[15] Few microepidemics have been reported from Ivory Coast, England, Brazil and Columbia. [7] Uncommon manifestations like facial tinea incognito along with cerebral mycoses, tinea circinata manus and subungual hyperkeratosis due to this geophillic species have been reported in AIDS patients. [16],[17],[18]

Even after extensive literature search, very few reports mention isolation of the geophillic species in AIDS patients worldwide [Table 1]. [3],[7],[16],[17],[18],[19],[20] In India, only one report from South India [20] mentions isolation of Microsporum gypseum in immunocompromised host but none from the northern region. This species is well adapted to the soil, sporadically infects humans and reported only in few cases of AIDS mainly in resource constraint settings. Microsporum gypseum is easily isolated from soil and is less virulent than human isolates. Infection in humans originates from infected animals and rarely due to direct contact. This patient, a farmer, could have acquired infection due to frequent contact with cattle and soil, so the acquisition of infection can be attributed to either source.{Table 1}

 Conclusion



This case report implies upon the changing pattern of infections caused by dermatophytes in immunocompromised individuals. This is probably the first case of tinea corporis due to an uncommon dermatophyte, Microsporum gypseum, in an AIDS patient from our region. The patient presented with atypical hyperkeratotic scaly lesions simulating psoriasis. A strong clinical suspicion, microscopic examination of KOH wet mount and confirmation with fungal culture are essential for diagnosis and appropriate treatment.

References

1Goodman DS, Telplitz ED, Wilshner A, Klein RS, Burk PG, Hershenbaum E. Prevalence of cutaneous disease in patients with acquired immunodeficiency syndrome (AIDS) or AIDS related complex. J Am Acad Dermatol 1987;17:210-20.
2Elmets CA. Management of common superficial fungal infections in patients with AIDS. J Am Acad Dermatol 1994;31:S60-3.
3Fernandes CN, Lamy F, Akiti T, Barreiros MG. Microsporum gypseum infection in Aids patient: A case report. An Bras Dermatol 1998;73:39-41.
4D'Antuono A, Bardazzi F, Andalou F. Unusual manifestations of dermatophytoses. Int J Dermatol 2001;40:164-6.
5Kumaraswamy N, Solomon S, Mahadivanan P, Ravikumar B, Thyagrajan SP, Yesudian P. Dermatologic manifestations among human immunodeficiency virus patients in South India. Indian J Dermatol 2000;39:192-5.
6Kaviarasan PK, Jaisankar TJ, Thappa DM, Sujatha S. Clinical variations in dermatophytosis in HIV infected patients. Indian J Dermatol Venereol Leprol 2002;68:213-6.
7Guidice MC, Szeszs MW, Scarpini RL, Ninomyia A, Trifilio MO, Pinto WP, et al. Clinical and epidemiological study in AIDS patient with Microsporum gypseum infection. Rev Iberoam Micol 1997;14:184-7.
8Pandey A, Pandey M. Isolation and characterization of dermatophytes with tinea infections at Gwalior (MP), India. Int J Pharm Sci Invent 2013;2:5-8.
9Machado AP, Hirata SH, Ogawa MM, Tomimori-Yamashita J, Fischman O. Dermatophytosis on the eyelids caused by Microsporum gypseum. Mycoses 2005;48:73-5.
10Monteiro CM, Martins CJ, Monterio CS, Paeva MB, Fagundes RO. Celsus kerion caused by Microsporum gypseum. An Bras Dermatol 2003;78:319-21.
11Bakos L, Bonamigo RR, Pisani AG, Mariante JC, Mallmann R. Scutular favus-like tinea cruris and pedis in a patient with AIDS. J Am Acad Dermatol 1996;34:1086-7.
12Aly R, Berger T. Common superficial fungal infections in patients with AIDS. Clin Infect Dis 1996;22:S128-32.
13Torssander J, Karlsson A, Morfeldt-Månson L, Putkonen PO, Wasserman J. Dermatophytosis and HIV infection. A study in homosexual men. Acta Derm Venereal 1998;68:53-6.
14Ncoza D, Mosam A. Cutaneous manifestations of HIV/AIDS: Part 1. South Afr J HIV Med 2004;5:12-7.
15Lopes JO, Alves SH, Benevenga JP. Dermatofitose por Microsporum gypseum no interior do Rio Grande do Sul: Estudo clinico. An Bras Dermatol 1992;67:71-2.
16Polilli E, Fazii P, Ursini T, Fantini F, Di Masi F, Tontodonati M, et al. Tinea incognito caused by Microsporum gypseum in a patient with advanced HIV infection: A case report. Case Rep Dermatol 2011;3:55-9.
17Nenoff P, Graser Y, Kibuka-Serunkuma L, Muylowa GK. Tinea circinata manus due to Microsporum gypseum in a HIV-positive boy in Uganda, east Africa. Mycoses 2007;50:153-5.
18Porro AM, Yoshioka MC, Kaminski SK, Palmeira Mo C, Fischman O, Alchorne MM. Disseminated dermatophytosis caused by Microsporum gypseum in two patients with acquired immunodeficiency syndrome. Mycopatholgia 1997;137:9-12.
19Galhardo MC, Wanke B, Reis RS, Oliveira LA, Valle AC. Disseminated dermatophytosis caused by Microsporum gypseum in an AIDS patient: Response to terbinafine and amorolfine. Mycoses 2004;47:238-41.
20Balajee A, Menon T. Extensive dermatophytosis caused by M. gypseum in AIDS patient in Madras. Med J Indones 1998;7:103-4.