Trichophyton mentagrophytes-associated Majocchi’s granuloma treated with cryotherapy Trichophyton mentagrophytes-associated Majocchi’s granuloma treated with cryotherapy

Abstract

We here report the case of a woman with dermatophytosis of the thighs due to Trichophyton mentagrophytes<br />where an unusual clinical picture posed considerable diagnostic and therapeutic problems. She presented numerous<br />skin lesions located on the dorsolateral face of the left thigh and the medial surface of the right calf. The initial lesions<br />consisted of small itchy pustules that evolved to exfoliation after scratching. Results of histopathologic examination of<br />a skin biopsy were consistent with dermatophytosis, although the negativity of PAS staining did not allow confirmation<br />of this diagnosis. Direct microscopic examination with 10% KOH was negative; however, skin cultures on BioMerieux<br />media revealed Tr. Mentagrophytes. Following the diagnosis of Trichophyton infection, the patient was treated with<br />a combination of isoconazole nitrate and difluocortolone valerate. After therapy, both direct microscopic mycologic<br />examination and culture on BioMerieux medium were negative; however, the lesions persisted, assuming a completely<br />different aspect. Cryotherapy with liquid nitrogen was started. This led to a spectacular improvement: the surface of<br />the skin became almost normal, merely showing slight discoloration. An unusual clinical presentation and non-responsiveness<br />to treatment should prompt revision of the primary diagnosis. A negative result of direct microscopy<br />should not exclude the diagnosis of dermatophytosis. Cryotherapy should be considered in cases that do not respond<br />to conventional antifungal medication.We here report the case of a woman with dermatophytosis of the thighs due to Trichophyton mentagrophytes<br />where an unusual clinical picture posed considerable diagnostic and therapeutic problems. She presented numerous<br />skin lesions located on the dorsolateral face of the left thigh and the medial surface of the right calf. The initial lesions<br />consisted of small itchy pustules that evolved to exfoliation after scratching. Results of histopathologic examination of<br />a skin biopsy were consistent with dermatophytosis, although the negativity of PAS staining did not allow confirmation<br />of this diagnosis. Direct microscopic examination with 10% KOH was negative; however, skin cultures on BioMerieux<br />media revealed Tr. Mentagrophytes. Following the diagnosis of Trichophyton infection, the patient was treated with<br />a combination of isoconazole nitrate and difluocortolone valerate. After therapy, both direct microscopic mycologic<br />examination and culture on BioMerieux medium were negative; however, the lesions persisted, assuming a completely<br />different aspect. Cryotherapy with liquid nitrogen was started. This led to a spectacular improvement: the surface of<br />the skin became almost normal, merely showing slight discoloration. An unusual clinical presentation and non-responsiveness<br />to treatment should prompt revision of the primary diagnosis. A negative result of direct microscopy<br />should not exclude the diagnosis of dermatophytosis. Cryotherapy should be considered in cases that do not respond<br />to conventional antifungal medication.