Atypical Presentation of Majocchi's Granuloma in an Immunocompetent Host
Am. J. Trop. Med. Hyg.
Images in Clinical Tropical Medicine Atypical Presentation of Majocchi's Granuloma in an Immunocompetent Host
Nisha V. Parmar 2 3 4
G. Johny Asir 1 2 4
Shivaprakash M. Rudramurthy 0 2 4
0 Department of Medical Microbiology, Centre of Advanced Research in Medical Mycology, World Health Organization Collaborating Centre, National Culture Collection of Pathogenic Fungi, Postgraduate Institute of Medical Education and Research , Chandigarh , India
1 Department of Clinical Microbiology, Pondicherry Institute of Medical Sciences , Puducherry , India
2 tology, Venereology and Leprosy, Pondicherry Institute of Medical Sciences , Puducherry 605014 , India
3 Department of Dermatology, Venereology and Leprosy, Pondicherry Institute of Medical Sciences , Puducherry , India
4 Authors' addresses: Nisha V. Parmar, Department of Dermatology, Venereology and Leprosy, Pondicherry Institute of Medical Sciences , Puducherry , India
A 42-year-old Indian man, farmer by occupation,
presented to the dermatology outpatient department with
complaints of itchy lesions on the lower abdomen of 2 weeks’
duration. He was otherwise in good health. There was no
history of trauma or application of topical corticosteroids
over the affected area. He also denied shaving the area.
General and systemic examinations were within normal
limits. Cutaneous examination revealed multiple nontender
erythematous folliculocentric nodules with central pustulation
clustered on an area of 10 × 8 cm on the suprapubic area
(Figure 1). The clinical differential diagnoses considered were
bacterial folliculitis, Majocchi’s granuloma, actinomycosis,
and tinea incognito. A Gram stain from the pustules showed
numerous polymorphs but no bacteria. A 10% potassium
hydroxide mount from a pustule revealed long branching
septate hyphae. Other laboratory investigations including
chest X-ray, fasting blood sugars, and liver and renal function
tests were normal. Serologies for Human Immunodeficiency
Virus, Hepatitis B and C viruses were nonreactive. Skin biopsy
from one of the nodules revealed perifollicular lymphohistiocytic
infiltrate with destruction of hair follicles (Figure 2). Bacterial
cultures were negative. Fungal cultures from the pus and
skin biopsy specimen revealed dermatophyte growth, which
was identified as Trichophyton sp. (Figure 3) and sent to
the National Culture Collection of Pathogenic Fungi,
Postgraduate Institute of Medical Education and Research,
Chandigarh, India. Based on the morphology and sequencing
of the internal transcribed spacer (ITS) region of the rDNA,
the isolate was confirmed as Trichophyton interdigitale.
The ITS sequence had 100% similarity with the standard
T. interdigitale strain, ATCC MYA-3108. The isolate is
deposited at the center as NCCPF_800018. The patient
was treated with oral terbinafine 250 mg once daily for
8 weeks. At 8 weeks’ follow-up, there was complete resolution
of the lesions (Figure 4).
Majocchi’s granuloma or fungal folliculitis is an uncommon
presentation of dermatophytosis, described by Domenico
Majocchi in 1883.1 Dermatophytes are keratinophilic fungi
that infect the superficial layers of the epidermis. A breech in
the epidermis paves way for the fungi to invade and reach
the dermis where they elicit a florid inflammatory response
due to their foreign nature. The commonest causative
organism is Trichophyton rubrum.2 Two forms of Majocchi’s
granulomas are recognized. The follicular form occurs after
trauma or chronic use of topical corticosteroids and is
known to affect women who shave their legs. The
subcutaneous nodular form is seen in immunocompromised hosts.3,4
This form can occur on any hair-bearing area of the body.
Treatment of both the forms is with oral antifungal agents
such as terbinafine or itraconazole for a prolonged duration,
usually for 4–8 weeks.5
This case is being reported as it demonstrates the
atypical location of Majocchi’s granuloma in the suprapubic area
in an immunocompetent host.
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