Make the Diagnosis

A 36-year-old presents with a mildly pruritic rash consisting of pink papules on his hand

A 36-year-old male with a history of treated hepatitis C presented with a mildly pruritic rash consisting of pink papules on his right hand for 2 months. Over a 2-month course, he had multiple treatments, including intralesional triamcinolone, oral fluconazole, fluocinonide lotion, doxycycline, and methylprednisolone (a Medrol Dosepak). The patient works in construction and has an aquarium with a turtle at home. A biopsy for hematoxylin and eosin (H&E) and tissue culture were performed.

Make the diagnosis:

Mycobacterium marinum

Majocchi granuloma

Granuloma annulare

Dyshidrotic eczema

Majocchi granuloma (MG), a clinical variant of tinea corporis, is also known as fungal folliculitis and tinea incognito. MG is a dermatophytic folliculitis that classically presents as folliculocentric plaque, in which there are papules, pustules, and nodules, usually found on the lower leg and almost exclusively in adults.1 Wrists are commonly affected as well.

Kevin Hakimi, University of California, San Diego School of Medicine

MG is typically caused by mechanical disruption of hair follicles that allows fungi to penetrate deep into dermal tissue.2 Quite often, the source of infection is typically the patient’s skin or nails. Associated risk factors include longstanding fungal infection, shaving or other cutaneous trauma, topical steroids, and immunosuppressive therapy.3,4 Although MG can be caused by other fungal species, it is most often caused by Trichophyton rubrum or Trichophyton tonsurans.1 There are two types of MG, the perifollicular papular form, which is localized and typically occurs in healthy individuals, and the deep subcutaneous plaque or nodular forms that usually occur in immunocompromised individuals.5

MG is an important clinical manifestation to be familiar with because of the increase in the numbers of solid-organ transplants and patients on immunosuppressive therapies. These patients are highly predisposed to opportunistic infections with aggressive clinical courses and will usually require prolonged treatment as relapses are common.3,5

Dr. Brooke Resh Sateesh, San Diego Family Dermatology

Dr. Brooke Sateesh


Tissue culture and skin biopsy are often needed to establish the diagnosis. If a topical antifungal has been used, KOH (potassium hydroxide) and culture may be negative. This patient’s tissue culture was positive for T. rubrum. The histopathology revealed hyperkeratosis and acanthosis with focal parakeratosis and a lymphohistiocytic infiltrate in the dermis. On PAS (Periodic acid–Schiff ) stain, PAS-positive hyphae were identified in the keratin layer, confirming a diagnosis of tinea infection.

First line treatment includes systemic antifungals such as griseofulvin, ketoconazole, itraconazole, and terbinafine. Duration of therapy is typically 4-8 weeks or until all lesions are cleared.3,5

This case and photo were submitted by Mr. Hakimi of University of California San Diego School of Medicine and Dr. Sateesh of San Diego Family Dermatology. Donna Bilu Martin, MD, edited the column.

Dr. Donna Bilu Martin


Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at mdedge.com/dermatology. To submit a case for possible publication, send an email to [email protected].

References

1.“Fitzpatrick’s Dermatology in General Medicine” (New York: McGraw-Hill Medical, 2012).

2. Bonifaz A et al. Gac Med Mex. Sep-Oct 2008;144(5):427-33.

3. Romero FA et al. Transpl Infect Dis. 2011 Aug;13(4):424-3. doi:10.1111/j.1399-3062.2010.00596.x

4. Chou WY, Hsu CJ. Medicine (Baltimore). 2016 Jan;95(2):e2245. doi: 10.1097/MD.0000000000002245.

5. Ilkit M et al. Med Mycol. 2102 Jul;50(5):449-57.

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