Tinea Capitis Favosa Misdiagnosed As Tinea Amiantacea

Medical Mycology Case Reports 2 (2013) 29–31

Contents lists available at ScienceDirect

Medical Mycology Case Reports

journal homepage: www.elsevier.com/locate/mmcr

Tinea capitis favosa misdiagnosed as tinea amiantacea

Sonia Anane a,n, Olfa Chtourou b a Laboratory of Parasitology-Mycology, Faculty of Medicine, 15, Jabbari-Jebel Lakhdar Street, Tunis 1007, Tunisia b Clinical dispensary of Mellassine, 4048 street, Tunis 1007, Tunisia article info abstract

Article history: Introduction: Favus of the scalp or tinea capitis favosa is a chronic dermatophyte infection of the scalp. In Received 13 November 2012 almost cases, favus is caused by Trichophyton schoenleinii, anthropophilic dermatophyte. It is character- Received in revised form ized by the presence of scutula and severe alopecia. Besides the classic clinical type of tinea capitis favosa, 7 December 2012 there are many variant of clinical form which may persist undiagnosed for many years. In this work, we Accepted 20 December 2012 report an atypical form of favus to Trichophyton schoenleinii which was misdiagnosed as tinea amiantacea. Case-report: An 11-year old girl came to the outpatient department of dermatology (day 0) with history Keywords: of tinea amiantacea treated unsuccessfully with keratolytic shampoo (day – 730). She presented a diffuse Tinea favosa scaling of the scalp with thick scaly patches and without scutula or alopecia. A diagnosis of tinea favosa Favus by T. schoenleinii was made by mycological examination. She was treated with griseofulvin and Trichophyton schoenleinii ketoconazole in the form of foaming gel for twelve weeks. Despite treatment, clinical evolution was Tinea amiantacea Tunisia marked by appearance of permanent alopecia patches. The follow-up mycological examination was negative. Conclusion: Because of ultimate evolution of favus into alopecia, we emphasize the importance of mycological examination in case of diffuse scaling. & 2012 International Society for Human and Animal Mycology. Published by Elsevier B.V All rights reserved.

1. Introduction hairless patches containing hairs which are broken in some cm of their emergence, without scutula. No other dermatological or Tinea favosa is a chronic dermatophyte infection of the scalp ungueal abnormality was observed (Fig. 1). and, less commonly, of the glabrous skin and nails. In most cases, Scales and altered hairs were collected. The direct microscopic favus is due to Trichophyton schoenleinii which is an anthropo- examination of the hairs in 20% potassium hydroxide revealed an philic dermatophyte. Favus of the scalp is characterized by the endothrix pilar invasion with the presence of septate hyaline presence of scutula and severe alopecia. Besides this classic hyphae (Fig. 2). The culture on Sabouraud glucose agar at 27 1C clinical form, there are many atypical clinical forms which can yielded in twenty days white limited colonies producing ramiﬁca- persist for years before being diagnosed [1–4]. tions that submerged into agar (Fig. 3). Microscopic examination Tinea capitis favosa has been frequent in Tunisia presenting revealed the presence of multiple branched hyphae known as favic 23% of tinea cases in 1950 [5]. Thanks to the anti-favus campaigns chandeliers, terminal dilation of hyphae giving a nail head shape and the improvement in living conditions and hygiene, favus is known as favic nails and some chlamydoconidia (Fig. 4a and b). becoming exceptional; it is only presenting 0.24% to 1.6% of total Based on the clinical and mycological data, the diagnosis of tinea cases [6,7]. This infection is so rare that tinea favosa can be favosa by T. schoenleinii was made. The patient was treated with misdiagnosed. By this atypical observation, we should recall the 20 mg/kg/d of oral grisofulvin and ketoconazol in the form of foaming tinea favosa in order to an early and adequate management. gel (once a day) during twelve weeks. Despite the regular intake of the treatment, the clinical evolution was marked by the appearance of grey hair and permanent alopecia patches (Fig. 5). The follow-up 2. Case mycological examination was twice negative (two months (day þ60) and three months (day þ90) after the end of the treatment). The An 11-year old girl came to the outpatient department of epidemiologic survey did not reveal the origin of the contamination. dermatology (day 0) with history of tinea amiantacea treated unsuccessfully with keratolytic shampoo (day – 730). Physical examination revealed a diffuse scaling of the scalp with thick 3. Discussion

* Corresponding author. Tel.: þ216 98665006; fax: þ216 71706305. Although the favus occurred worldwide, it is at present limited E-mail address: [email protected] (S. Anane). to some endemic regions. It was mainly endemic in the Middle

2211-7539/$ - see front matter & 2012 International Society for Human and Animal Mycology. Published by Elsevier B.V All rights reserved. http://dx.doi.org/10.1016/j.mmcr.2012.12.005 30 S. Anane, O. Chtourou / Medical Mycology Case Reports 2 (2013) 29–31

Fig. 1. Tinea favosa with a diffuse scaling of the scalp.

Fig. 4. (a and b). Microscopic examination of Trichophyton schoenleinii showing characteristic favic chandelier and favic nail (lactophenol cotton blue 100 ). Fig. 2. Direct microscopic examination showing endothrix hair invasion with septate hyaline hyphae (20% Potassium hydroxide, 400 ).

Fig. 5. Clinical evolution after treatment: gray hair and ultimate alopecia patches.

Fig. 3. Macroscopic examination of Trichophyton schoenleinii on Sabouraud medium. eradicated or became very rare in the majority of these regions especially Tunisia. It is now limited to some endemic regions like East, Iran, Kashmir, certain North and South African regions, China, Iran and Nigeria [2,8–11]. Denmark and some foci in America, especially the USA, Canada, Favus could occur during childhood or adolescence and Brazil [2]. Thanks to the improvement in living conditions and persists to adulthood in case of absence of treatment [2,12]. hygiene and the introduction of grisofulvin in 1958, favus was Contrary to the other types of tinea, tinea favosa does not S. Anane, O. Chtourou / Medical Mycology Case Reports 2 (2013) 29–31 31 disappear until puberty but persists as long as there is hair. Its impermeable to griseofulvin [17]. In this case, other antifungal evolution is slow [1,2]. treatment could be used like the terbinafine and itraconazole. T. T. schoenleinii which is the isolated specie in our patient is schoenleinii is transmitted from one person to another by the use responsible for the majority of tinea favosa cases [1–4,9,13,14]. of common combs or hats [1,2,13]. It is then necessary to look for Other species could rarely determine this tinea. It is the anthro- an infesting family or school environment. In our case, the survey pophilic species, Trichophyton violaceum, zoophilic species, Tricho- has remained negative. phyton verrucosum, Trichophyton mentagrophytes and Microsporum canis and geophilic species, Microsporum gypseum [1,2]. The classic favus lesion is the scutula, a yellowish cup-shaped Conflict of interest crust of 0.5 to 1.5 cm of diameter on the scalp from where come out dull grey hair. The fusion of many scutula determines the There is none. crust favic which is straw-colored and crisp. It is the origin of the name favosa which means honeycomb. The scalp is characterized by an unpleasant ‘‘mousy’’ odor. The parasitized hair will fall Acknowledgments down causing a final alopecia. This typical form which associates scutula, dull grey hair and alopecia patches is met in 95% of the There is none. cases [1,2,15]. Besides this clinically typical form, there are atypical tinea favosa which makes about 5% of the cases. In References presence of scaly patches without alopecia, favus could be similar to seborrheic dermatitis, psoriasis or tinea amiantacea [2,3,14]. [1] Chabasse D, Guiguen CP, Contet-Audonneau N. Mycoses autochtones et This was the case of our patient in whom favus was misdiagnosed cosmopolites, diagnostic et traitement.Mycologie Me´dicale. Paris: Masson; as a tinea amiantacea. This confusion was also reported by other 1999 p. 127–49. [2] Ilkit M. Favus of the scalp: an overview and update. Mycopathologia 2010;170: authors [14]. Tinea amiantacea is characterized by scaling of the 143–54. scalp. The scaling is white yellowish, thick, ‘‘asbestos-like’’ and [3] Khaled A, Ben Mbarek L, Kharfi M, Zeglaoui F, Bouratbine A, Fazaa B, et al. binds down tufts of hair [1,16]. It may be difficult clinically to Tinea capitis favosa due to Trichophyton schoenleinii. Acta Dermatovenerolo- gica Alpina, Panonica, et Adriatica 2007;16:34–6. distinguish from atypical favus of the scalp without doing [4] Zaraa I, Hawilo A, Aounallah A, Trojjet S, El Euch D, Mokni M, et al. mycological examination. Inflammatory Tinea capitis: a 12-year study and a review of the literature. Regardless of the clinical form, lesions evolve in all cases into Mycoses July 3, 2012 (Epub ahead of print). [5] Coutelen J, Cochet G, Biguet J, Mullet S, Doby-Dubois M, Deblock S. ultimate scarring alopecia, which imposes an early diagnostic and Contribution a la connaissance e´pide´miologique et mycologique des teignes therapeutic management. Indeed, if treated at an early stage of infantiles en Tunisie. Annales de Parasitologie Humaine Comparee 1956;31: evolution, tinea favosa will cured without sequelae. However, if 449–69. the treatment is late established it will not prevent the ultimate [6] Belhaj S, Jguirim H, Anane S, Kaouech E, Kallel K, Chaker E. Evolution des teignes du cuir chevelu a Microsporum canis et a Trichophyton violaceum a scarring alopecia, which was the case of our patient [1,2,4]. It is Tunis. Journal of Medical Mycology 2007;17:54–7. then important to diagnose tinea favosa at an early stage. The [7] Saghrouni F, Bougmiza I, Gheith S, Yaakoub A, Gaıëd-Meksi S, Fathallah A, diagnostic lies on the mycological examination of the parasitized et al. Mycological and epidemiological aspects of tinea capitis in the Sousse region of Tunisia. Annales de Dermatologie et de Venereologie 2011;138: hair and scutula. The sample should be made easier by the 557–63. Wood’s light examination which reveals a green fluorescence [8] Deng S, Bulmer GS, Summerbell RC, De Hoog GS, Hui Y, Graser¨ Y. Changes in [1,2,4]. The direct examination reveals a strict endothrix pilar frequency of agents of tinea capitis in school children from Western China suggest slow migration rates in dermatophytes. Medical Mycology 2008;46: invasion with an entanglement of the mycelial filaments at the 421–7. scutula [1–4,9,13,14]. [9] Jahromi SB, Khaksar AA. Aetiological agents of tinea capitis in Tehran (Iran). In Sabouraud medium, T. schoenleinii has been growing slowly Mycoses 2006;49:65–7. [10] Nweze EI. Etiology of dermatophytoses amongst children in northeastern between 2 to 4 weeks giving two macroscopic aspects of colonies: Nigeria. Medical Mycology 2001;39:181–4. waxy colonies or limited white colonies with ramifications that [11] Seebacher C, Bouchara JP, Mignon B. Updates on the epidemiology of emerging in agar. This last aspect was noticed in our case dermatophyte infections. Mycopathologia 2008;166:335–52. [1–4,9,13,14]. [12] Gupta AK, Summerbell RC. Tinea capitis. Medical Mycology 2000;38: 255–87. The treatment of tinea favosa lies on the association of an oral [13] Matte SM, Lopes JO, Melo IS, Costa Beber AA. A focus of favus due to and topical treatment. The local treatment consists in cutting of Trichophyton schoenleinii in Rio Grande do Sul. Revista do Instituto de hair around the alopecia patches and applying once or twice a day Medicina Tropical de Sao~ Paulo 1997;39:1–3. [14] Velho GD, Selores M, Amorim I, Lopes V. Tinea capitis by Trichophyton of antifungal imidazol (shampoo, foam gel, lotion and spray). The schoenleinii. European Journal of Dermatology : EJD 2001;11:481–2. systemic treatment is mainly based on a 15 to 20 mg/kg/d [15] Viguie´ Vallanet C. Les teignes. Annales de Dermatologie et de Venereologie griseofulvin per os during 10 to 12 weeks [1–4,14]. The resistance 1999;126:349–56. [16] Moon CM, Schissel DJ. Pityriasis amiantacea. Cutis 1999;63:169–70. of the T. schoenleinii to the griseofluvin has been described. The [17] Zheng YC. Morphology of griseofulvin-resistant isolates of Mongolian variant multiple-layered, thick cell wall of the fungi may act as a barrier Trichophyton schoenleinii. Chinese Medical Journal 1990;103:489–92.