HISTORY:
A 10+ year-old male wrestler initially presented with persistent rashes on his body for several weeks diagnosed at first visit clinically and supported by (+) KOH as tinea corporis. He had done well with Ketoconazole shampoo and cream for several months, but presented again with a persistent enlarging annular plaque at left distal posterior thigh. The patient was concerned about a tick bite, however, clinical concern for tinea was raised. Borrelia IgG and IgM panels were ordered (and were subsequently negative) and KOH was noted to be negative at this time. DTM culture was performed and the patient was started on Fluocinonide ointment to help treat dermatitis while DTM was in process. The patient returned in 6 weeks with a more pronounced, mostly smooth annular plaque with pruritus and erythema.
A punch biopsy was performed for diagnosis.
QUESTION:
Which differential diagnoses should you be considering pending biopsy results?
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ANSWER
Nummular eczema, tinea corporis with Majocchi’s granuloma, cutaneous larva migrans, and annular/gyrate erythema
PATHOLOGY
Histologic sections revealed suppurative folliculitis with a mixed inflammatory infiltrate consisting of neutrophils, lymphocytes, histiocytes and rare eosinophils with overlying epidermal acanthosis, hyperkeratosis and parakeratosis. In certain sections, with larger segments of the follicle for review, fungal organisms are demonstrated by H&E staining, while, in other areas, where very small portions of the follicle are present, a PAS stain demonstrates fungal organisms within the hair follicle (“endothrix”). The PAS stain does, in this case, highlight rare hyphae in the overlying stratum corneum.
CASE SUMMARY
Majocchi’s Granuloma is an uncommon fungal infection that invades the dermis and subcutis by dermatophytes, usually Trichophyton Rubrum. This typically occurs on hair bearing skin of the extremities, face or scalp. This condition can occur after trauma, with progression of tinea corporis in immunocompromised individuals or as a consequence of using potent topical corticosteroids in the setting of undiagnosed (or suspected, but KOH -) tinea corporis. In this case, despite the patient having been adequately treated for tinea corporis and using a potent topical steroid, there was noted to be residual pruritus overlying persistent annular erythematous plaques having minimal surface scaling. Paradoxically, these areas of “treated” tinea corporis kept showing a negative KOH upon repeated skin scrapings. Due to the findings at that time, it was strongly suspected that there was a deeper follicular component to this superficial dermatophyte infection-namely Majocchi’s granuloma! With this likely diagnosis in mind, the patient was asked to return to the clinic for a punch biopsy that would allow for evaluation of the follicular units with a special fungal stain (PAS) to identify the fungal organisms within the hair follicles. Thankfully, the punch biopsy did confirm Majocchi’s granuloma with the presence of fungal organisms within hair follicles as well as focally at the skin surface.
FOLLOW-UP
With the diagnosis of Majocchi’s granuloma confirmed by biopsy, this patient was given oral antifungals and has since resolved his deep (and superficial) fungal infection.
By: Dr. John Pujals, MD and Ms. Carol A. Menke, PA-C