Unusual Inflammatory Tinea Infections: Majocchi's Granuloma and Deep/Systemic Dermatophytosis

Dermatophytosis caused by Nannizzia gypsea: report of 155 cases from Western Mexico

BACKGROUND

Dermatophytosis caused by Nannizzia gypsea are considered rare. The clinical picture is indistinguishable from that produced by other dermatophytes, but, being this a geophilic fungus, it can cause more inflammatory disease.

METHODS

Retrospective study. Patients with positive culture for N. gypsea observed at the Dermatological Institute of Jalisco "Dr. José Barba Rubio", from 2001 to 2023, were included. Frequency, sex, age, evolution, and clinical variant were investigated. We compared the findings between the pediatric versus adult population. Descriptive and inferential statistics were used.

RESULTS

Over 23 years, 155 patients were diagnosed (6.7 cases per year). Female sex predominated (53.5%). The median age was 9 years (minimum 1year and maximum 85 years), the more affected age group was 1-10 years (54.2%). The median time of evolution was 30 days (minimum one day and maximum three years), and 74.8% had an evolution ≤30 days. Tinea capitis predominated in pediatric patients (41.0%, p<0.01) whereas tinea corporis predominated in adults (72.7%, p<0.01). Inflammatory tinea was more prevalent in the pediatric population (21.0% vs. 3.6%, p<0.01).

CONCLUSION

The ability of Nannizzia gypsea to cause inflammatory tinea was observed primarily in pediatric patients. Since there is no clinical data to suspect this fungus, it will always be necessary to carry out a mycological study to identify the species and to implement the appropriate treatment.

Deep Dermal Dilemma: A Case Report on Majocchi's Granuloma After Topical Steroid Use

Majocchi's granuloma represents a unique dermatological entity characterized by the invasion of dermatophytes into the dermis and subcutaneous tissue, typically following trauma or topical corticosteroids, most commonly caused by Trichophyton rubrum. The unrestrained use of over-the-counter topical steroids has led to the rise of Majocchi's granuloma in the past few years. A 57-year-old male presented with complaints of itchy skin lesions over his right ankle for 20 days. There was a history of over-the-counter topical steroid application, following which the lesions exacerbated. Clinical examination showed multiple ill-defined erythematous nodules, 2-3 cm in size, with serosanguinous discharge associated with right ankle swelling. A single annular hyperpigmented scaly patch was also noted over the right leg below the knee. Potassium hydroxide (KOH) examination was positive for fungal hyphae. Histopathological examination (HPE) of the nodule showed features suggestive of Majocchi's granuloma. Fungal culture was performed, which showed growth of Trichophyton rubrum. The patient was started on oral terbinafine 250 mg once daily and topical luliconazole cream twice daily topical application, which resolved the lesions in three weeks, but the patient was advised to continue the treatment for a total duration of two months.

Cutaneous Fungal Infections Caused by Dermatophytes and Non-Dermatophytes: An Updated Comprehensive Review of Epidemiology, Clinical Presentations, and Diagnostic Testing

Cutaneous fungal infection of the skin and nails poses a significant global public health challenge. Dermatophyte infection, mainly caused by Trichophyton spp., is the primary pathogenic agent responsible for skin, hair, and nail infections worldwide. The epidemiology of these infections varies depending on the geographic location and specific population. However, epidemiological pattern changes have occurred over the past decade. The widespread availability of antimicrobials has led to an increased risk of promoting resistant strains through inappropriate treatment. The escalating prevalence of resistant Trichophyton spp. infections in the past decade has raised serious healthcare concerns on a global scale. Non-dermatophyte infections, on the other hand, present even greater challenges in terms of treatment due to the high failure rate of antifungal therapy. These organisms primarily target the nails, feet, and hands. The diagnosis of cutaneous fungal infections relies on clinical presentation, laboratory investigations, and other ancillary tools available in an outpatient care setting. This review aims to present an updated and comprehensive analysis of the epidemiology, clinical manifestations, and diagnostic testing methods for cutaneous fungal infections caused by dermatophytes and non-dermatophytes. An accurate diagnosis is crucial for effective management and minimizing the risk of antifungal resistance.

Majocchi's Granuloma - The Great Mimicker: A Case Report

Fungal infections can be challenging to diagnose, but doctors of every specialty may encounter this issue. They can be mistaken for other common dermatoses such as eczema or psoriasis and inadvertently be treated with topical corticosteroids or calcineurin inhibitors. This may lead to tinea incognita, a term used to describe a fungal infection with an altered clinical appearance, which may confuse the clinician even further. This case report presents a 54-year-old previously healthy man with a 4-month history of a painful and pruritic rash in the genitoinguinal region. The patient's general practitioner had unsuccessfully attempted to treat the rash with topical terbinafine, econazole-triamcinolone, and betamethasone-fusidic acid, in addition to peroral dicloxacillin capsules. On examination, there were multiple red-bluish nodules and pustules coalescing into infiltrating erythematous plaques on both thighs and in the pubic region. Fungal cultures were negative, but the clinical features together with the history of prolonged use of combined topical steroids and antifungals raised suspicion of a deep fungal infection. Histopathological skin examination revealed deep suppurative and granulomatous folliculitis with ruptured hair follicles which was consistent with a diagnosis of Majocchi's granuloma. Treatment with itraconazole capsules was initiated, and after a 16-week course of systemic antifungal therapy, the rash resolved. In conclusion, our case report presents a case of Majocchi's granuloma, which is a great mimicker, especially for non-dermatologists. It is therefore important that the diagnosis is considered as a differential diagnosis, even though a patient has previously been treated with a topical antifungal.

Sexually acquired pubogenital dermatophytosis induced by Trichophyton quinckeanum

Tinea corporis is a common superficial dermatophytosis mostly located at the trunk and extremities. In contrast, tinea of the anogenital region is rare and predominantly occurs in tropical countries. In recent years, a distinctive variant of pubogenital tinea (PT) characterized by deep tissue infiltration and systemic symptoms has been reported, and transmission via sexual contacts has been hypothezised. In the majority of cases, a new genotype of Trichophyton mentagrophytes classified as T. mentagrophytes VII was detected as the causative pathogen. We report a case of PT caused by T. quinckeanum that experienced a strong inflammatory reaction following initiation of successful antifungal treatment with itraconazole.