Cellcept

Abstract

Trichophyton tonsurans is an uncommon cause of tinea corporis, and an even more uncommon cause of Majocchi's granuloma. We report a patient who developed tinea corporis with Majocchi's granuloma from T. tonsurans infection. Immunocompromised hosts are predisposed to develop cutaneous fungal infections, as was the case with this patient. Majocchi's granuloma is a rare complication with immunosuppression, but is significant to consider when a fungal infection is suspected because it may require more aggressive therapy.

Background

Cutaneous fungal infections are commonly seen in the US and affect all age, gender, and ethnic groups. Fungal infections have become especially significant in the immunocompromised population as well. Fungal infections are the most common cause of cutaneous infections seen in renal transplant patients, usually due to a dermatophyte infection and presenting as tinea corporis and/or cruris. (1) Most reported cases of tinea corporis infections are due to Trichophyton rubrum, but in this report we describe a case of tinea corporis in a renal transplant patient due to Trichophyton tonsurans, and complicated by the development of Majocchi's granuloma.

Case Report

A 27-year-old Caucasian male was referred to dermatology because of patchy hair loss on his body for 2 months. His past medical history was significant for having undergone kidney transplant 4 months prior secondary to the development of post-streptococcal glomerulonephritis. His current medication list included valate, clonidine, minoxidil, Protonix labetalol, Cellcept, Medrol, Bactrim, Adalat, and Renagel. On physical examination, he had scattered red scaly plaques on his body, mainly on his trunk, with multiple broken hairs. He was given oral ketoconazole for 2 weeks, but with no relief.

A biopsy of a lesion on his right lower back revealed Majocchi's granuloma. The periodic acid-Schiff stain was performed to confirm the presence of fungal hyphae and it demonstrated an invasive fungal infection with fungal hyphae replacing hair. Tissue culture reported a light growth of Trichophyton tonsurans.

The patient's oral medication was changed to griseofulvin 500 mg PO twice a day along with the application of Nizoral cream twice daily to affected areas. The patient's lesions showed significant improvement, but due to a rise in his levels of blood urea nitrogen and creatinine, the griseofulvin was discontinued after 8 weeks of therapy. At this time most of his lesions had resolved, but he still had minimal scaly patches on his posterior neck. The Nizoral cream was continued to these areas and Nizoral shampoo was added twice monthly for the prevention of future lesions.

Discussion

While T. tonsurans is the most common cause of tinea capitis in the US, the most common cause of tinea corporis, along with tinea pedis and cruris, is T. rubrum. Although T. tonsurans uncommonly causes tinea corporis, numerous cases have been reported over the years and its contribution to fungal infections continues to increase. (2) For example, it has been reported to cause outbreaks of tinea corporis in student wrestlers more often than T. rubrum. The reason for this finding is unknown, except that some wrestlers may be asymptomatic carriers. (3)

In a study looking at 100 renal transplant recipients, a population used to represent immunocompromised patients, dermatophytosis was found in 42% of the patients. (4) Fungal infections were found to be the most common skin infections in renal transplant patients in another study. (1) The most common types were tinea corporis and cruris, with the most common organism being T. rubrum. (4)

Tinea infections are frequent, but Majocchi's granuloma is an uncommon cutaneous fungal infection. Majocchi's granuloma occurs when a dermatophyte infection produces a subcutaneous granulomatous reaction. This occurrence is more common in the pediatric population, but can occur in any age. (5) It comes in 2 forms, a small perifollicular papular form and a deep subcutaneous nodular form. (6) The first form is usually due to local trauma, which is commonly found on the scalp, face, arms, or legs, while the latter form is usually found in immunocompromised patients. On histopathology, Majocchi's granuloma shows hyphal invasion of the hair follicle, which produces a supparative folliculitis eventually causing a granulomatous dermal response. (5) T. rubrum is the most commonly isolated dermatophyte from Majocchi's granuloma. (7) Other rare, but reported organisms include T. mentagrophytes, T. epilans, T. violaceum, Microsporum audouinii, Microsporum gypseum, Microsporum ferrugineum, and Microsporum canis. (8) In our review, only 2 cases of Majocchi's granuloma due to T. tonsurans have been reported, only one of which was in an immunocompromised host. (10)

Dermatophytosis infection is commonly seen in renal transplant patients. Nevertheless, Majocchi's granuloma is rare, but can cause significant complication and should be considered as part of the differential diagnosis of erythematous annular plaques. The most common organism found in Majocchi's granuloma is T. rubrum, with Trichophyton tonsurans being an extremely rare causative organism. Our case is unique because of this unusual complication (Majocchi's granuloma) due to an unusual organism (T. tonsurans) in an immunosuppressed patient. In addition, this case emphasizes the challenge in treatment because of the multiple medications that transplant patients take, which can limit the use of oral antifungal agents, as was the case with our patient.

References

1. Chugh KS, Sharma SC, Singh V, Sakhuja V, Jha V, Gupta KL. Spectrum of dermatological lesions in renal allograft recipients in a tropical environment. Dermatology. 1994;188:108-112.

2. Foster KW, Ghannoum MA, Elewski BE. Epidemiologic surveillance of cutaneous fungal infection in the United States from 1999 to 2002. J Am Acad Dermatol. 2004;50(5):748-52.

3. Adams BB. Tinea corporis gladiatorum. J Am Acad Dermatol. 2002;47:286-290.

4. Selvi GS, Kamalam A, Ajithados K, Janaki C, Thambiah AS. Clinical and mycological features of dermatophytosis in renal transplant recipients. Mycoses. 1999;42(1-2):75.

5. Janniger CK. Majocchi's granuloma. Cutis. 1994;50:267-8.

6. Radentz WH, Yanese DJ. Papular lesions in an immunocompromised patient. Arch Dermatol. 1993;129(9):1189-90, 1192-3.

7. Gupta S, Kumar B, Radotra BD, Rai R. Majocchi's granuloma trichophyticum in an immunocompromised patient. Int J Dermatol. 2000;39:140-159.

8. Smith KJ, Teperman L, Rosenthal SA, et al. Primary cutaneous infection by Aspergillus ustus in a 62-year-old liver transplant recipient. J Am Acad Dermatol. 1994;31:344-7.

9. Chen HH, Chiu HC. Facial Majocchi's granuloma cause by Trichophyton tonsurans in an immunocompetent patient. Acta Derm Venereol. 2002;83(1):65-6.

10. Liao YH, Chu SH, Hsiao GH, Chou NK, Wang SS, Chiu HC. Majocchi's granuloma caused by Trichophyton tonsurans in a cardiac transplant recipient. Br J Dermatol. 1999;140(6):1194-6.

Address for Correspondence

Keyvan Nouri MD

University of Miami

Sylvester Comprehensive Cancer Center

Department of Dermatology

1475 NW 12th Ave, 2nd Floor #2175

Miami, FL 33136

Vidya Rajpara MD, Stacy Frankel MD, Cindy Rogers MD, Keyvan Nouri MD

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