LAUSR

Dear Editor, An 87-year-old Caucasian male presented with a 7-month history of multiple painful erythematous, infiltrated, crusty, scabbing plaques and nodules on his scalp, ears, and face (Figure 1). The lesions had been treated for several weeks with systemic antibiotics and topical steroid-antibiotic combinations, with progressive worsening of the lesions. The patient had no systemic symptoms except for lymphadenopathy of the latero-cervical district. He was bald. In view of the clinical aspect, and suspecting malignancy or fungal infection, we prescribed full blood tests, skin biopsies, mycological and bacterial cultures from the lesions of the scalp and the face. Full blood tests were negative except for increased erythrocyte sedimentation rate and C reactive protein levels. Mycological culture on Mycosel agar at 27 C for 2 weeks yielded flat colonies, white to cream in color, with a powdery granular surface and yellowish reverses. At microscopic examination with potassium hydroxide and lactophenol cotton blue preparation we observed numerous single-celled microconidia, and hyaline, smooth-walled, and spherical-to-subspherical microconidia, occasionally clavate to pyriform, that are aspects of Trichophyton mentagrophytes dermatophytosis. The presence of spherical chlamydoconidia, spiral hyphae, and smooth, thin-walled, clavate, multicelled macroconidia allowed the identification of T. mentagrophytes var. interdigitale. The isolate was subjected to antifungal susceptibility testing using the E-test against fluconazole and itraconazole: the minimum inhibitory concentration was respectively 0.125 mg/L and 0.002 mg/L. Bacterial cultures were positive for Staphylococcus aureus. Histopathology revealed a necrotic inflammatory ulcerative process. Patch tests with Italian baseline series were negative. We concluded for Majocchi's granuloma (MG) and started treatment with oral itraconazole 100 mg twice daily for 2 months, oral ciprofloxacin 500 mg twice daily for 1 week, topical aureomycin twice daily after surgical removal of the crusts. The skin lesions improved immediately, and healed in 3 months, leaving few scars. Mycological cultures from the skin of the scalp and the face repeated after the end of treatment were negative. MG is an uncommon deep follicular dermatophytosis caused by keratinophilic fungi that colonize the nails, hair, and skin; it was first defined in 1883 as a “granulomatous skin infection”. There are two forms of MG: the small, perifollicular papular form, which is a localized dermal infection that usually occurs in healthy individuals, and the form featuring deep subcutaneous plaques or nodular lesions that occurs in immunosuppressed hosts. It is commonly caused by Tricophyton (T.) rubrum, and more seldom by Tricophyton violaceum, Tricophyton verrucosum, T. mentagrophytes, Epidermophyton floccosum, and Microsporum canis. Diagnosis may be difficult in the absence of known risk factors, and delays in diagnosis may lead to scarring, alopecia, and incapacitation secondary to severe pain.