Pseudomycetoma of the scalp caused by Microsporum canis,

AnBrasDermatol.2020;95(3):372---375

Anais

Brasileiros

de

Dermatologia

TROPICAL/INFECTOPARASITARY

DERMATOLOGY

Pseudomycetoma

of

the

scalp

caused

by

Microsporum

canis

夽,夽夽

Ligia

Rangel

Barboza

Ruiz

_,

_Clarisse

_Zaitz

_,

_Rute

_Facchini

_Lellis

_,

John

Verrinder

Veasey

a_{ClinicofDermatology,FaculdadedeCiênciasMédicas,SantaCasadeMisericórdiadeSãoPaulo,SãoPaulo,SP,Brazil} b_{PathologyLaboratory,HospitaldaSantaCasadeMisericórdiadeSãoPaulo,SãoPaulo,SP,Brazil}

Received28March2019;accepted22July2019 Availableonline19March2020

KEYWORDS Histology; Microsporum; Mycetoma; Tinea; Tineacapitis

Abstract Pseudomycetomaisanextremelyraredeepmycosis,causedbydermatophyticfungi

thatpenetratethetissuefrominfectedfolliclesoftineacapitis.Bothclinicallyand histopathol-ogyaresimilartoeumycetoma,beingdistinguishedthroughtheisolationofthefungus,whichin thecaseofpseudomycetomacanbeMicrosporumspp.orTrichophytonspp.genre.Wepresenta 24-year-oldmanwithanexuberanttumorintheoccipitalregionwithfistula,whose histopatho-logical examinationevidencedgrainscomposedofhyalinehyphaeandthe cultureforfungi isolatedtheagentMicrosporum canis. Combinedtreatment ofsurgicalexcisionfollowed by oralgriseofulvinfortwoyearswasperformed,withresolutionofthecondition.

©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.Thisisan openaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

Case

report

A24-year-oldimmunocompetentmale,withtumorallesion intheoccipitalareawhichstartedattwoyearsofagewith areasofalopeciathatprogressivelyevolvedtoatumor.His

夽 _{Howtocitethisarticle:RuizLRB,ZaitzC,LellisRF,VeaseyJV.} PseudomycetomaofthescalpcausedbyMicrosporumcanis.AnBras Dermatol.2020;95:372---5.

夽夽_{StudyconductedattheClínicadeDermatologiadaSantaCasa} deMisericórdiadeSãoPaulo,SãoPaulo,SP,Brazil.

∗_{Correspondingauthor.}

E-mail:johnveasey@uol.com.br(J.V.Veasey).

firstconsultationwasat age14,presenting attheclinical examinationahardenedtumorwithgranularfundus ulcer-ations. Heabandonedfollow-up, returningtenyearslater witha considerable increase of the lesion (Fig. 1). Mate-rialanalysisofulcerscalingidentifiedatdirectmicroscope examination grains composed of septate hyaline hyphae, andmicologialcultureisolatedMicrosporumcanis(Fig.2). Histopathologicalexamination revealed atthe dermis and hypodermis clusters of septated hyalinehyphae of varied sizesinvolvedbyhistiocyticSplendore-Hoepplireactionwith numerous multinucleatedgiant cellsofforeignbodytype, besides neutrophilicexudate,edema andvascular conges-tion.Nofistulatedpathwayswerevisualizedpromotingthe continuitybetweenthe‘‘grains’’andtheepidermalsurface

https://doi.org/10.1016/j.abd.2019.07.012

0365-0596/©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC BYlicense(http://creativecommons.org/licenses/by/4.0/).

PseudomycetomaofthescalpcausedbyMicrosporumcanis 373

Figure1 Clinicalaspectofpseudomycetomaatoccipitallesion.AandB,patientwith14-years-old.C,patientwith24-years-old.

Figure2 AandB,Directmycologicalexaminationclarifiedwith20%KOH.×100augmentation,showingagglomeratesofseptated

hyphae,and×400augmentation,identifyingthestructuresofhyalineseptatedhyphae.CandD,fungalculture,withwhite filamen-touscolonyandyellowpigmentedagarandmicroculturewithhyalineseptatedhyphaeinthebackgroundandthreemacroconidia inthecenter(Cottonblue,×400).

Figure3 Histopathologicalexamination.A,identifyinggrainssurroundedbyinflammatorysuppurativeprocessand

lymphohisti-ocyticreaction(Hematoxylin&Eosin,×100).B,graincomposedofseptatedhyalinehyphaesurroundedbyeosinophilicmaterial (Splendore-Hoeppliphenomenon)(Hematoxylin&eosin,×200).C,evidencingthemorphologyofhyphae(PAS,×200).

374 RuizLRetal.

Figure4 Patientwithclinicalaspectaftertreatment.

inthe sample (Fig. 3).He denied useof any immunosup-pressive medication, presented non-reactive serology for HIV,and hadnoother comorbidities. Associatingthe clin-icalaspectwiththecomplementarytests,thediagnosisof pseudomycetomabyMicrosporumcaniswasconfirmed.The patientwassubmittedtosurgicalexcisionofthetumorand associatedoralgriseofulvin,onegramperdayfortwoyears. Ina oneyear follow-up after theend of griseofulvin,the patientshowednosignsofrelapse(Fig.4).

Discussion

Chronic inflammatory and invasive forms of dermatophy-tosisaretheresultofan intensehypersensitivityreaction tothe fungal infection,morefrequent in immunocompro-mised individuals.1 _{The clinical presentations are kerion}

celsi, Majocchi granuloma and pseudomycetoma.2

Pseu-domycetomais an extremely rare mycosis, caused bythe penetrationofdermatophytesintothetissuefromrupture ofinfectedfollicularepithelium.Ajelloetal.3_reported

sev-eralspeciesof dermatophytes producing grainsintissues, including Microsporum canis, Trichophyton tonsurans and

T.mentagrophytes.According totheseauthors,mycelium aggregatesformedbythedermatophyteswouldbe pseudo-granulesandthetermpseudomycetomashouldbeapplied tothisdeepdermatophyticinfection.4,5_{Theisolatedagent}

inthis case wascompatiblewiththe mostfrequent tinea capitisagentinBrazil.6,7

Clinical aspects of pseudomycetoma are identical to thoseofeumicetoma,yetincontrasttomycetomas, pseu-domycetomas aremore common in the scalp and do not haveahistoryoftraumaforitsinoculation.8_Althoughthe

dermatophytichyphae usuallyare moredelicate thanthe eumicetomaagentsatmycologicalexaminations,thesame doesnothappenintheclustersvisualizedonthe histopatho-logical examination.7---9 _{However, there is a difference}

between the two diseases at histopathology: mycetomas typically have sinus tracts through which fibrinopurulent exudateandgrainsarereadilyexcreted;bycontrast, pseu-domycetomas lack sinus tracts.8 _{Therefore, isolation of}

theagentshouldbeobtainedwithfungalculture,ashere presented. Although more frequent in immunosuppressed

patients, thereare reports of cases in immunocompetent patients,andtheeosinophilicreactionofSplendore-Hoeppli around pseudogranules is present in all cases of pseu-domycetoma, highlighting the intense reaction of the organismagainstthefungus.4

ThetreatmentofpseudomycetomabyM.canisissurgical excision of thefungal mass,sincethe systemicantifungal doesnotreachtherapeuticconcentrations,8_{associatedwith}

oralgriseofulvin1,6,7_{untilclinicalandmycologicalcure.}

Financial

support

Nonedeclared.

Authors’

contributions

Ligia Rangel Barboza Ruiz: Approval of the final version of the manuscript;conception andplanning of the study; elaborationandwritingofthemanuscript;obtaining, anal-ysis,andinterpretationofthedata;effectiveparticipation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; criticalreview of themanuscript.

Clarisse Zaitz: Approval of the final version of the manuscript;conceptionandplanningofthestudy; obtain-ing, analysis, and interpretation of the data; effective participationinresearchorientation;intellectual participa-tioninthepropaedeuticand/ortherapeuticconductofthe studiedcases.

Clarisse Zaitz: Intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.

JohnVerrinder Veasey:Approvalof the finalversion of themanuscript;elaborationandwritingofthemanuscript; critical review of the literature; critical review of the manuscript.

Conflicts

of

interest

PseudomycetomaofthescalpcausedbyMicrosporumcanis 375

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