ARTICLE
Recently, human cases of dermatophytosis transmitted from animals have
been increasing in number due to changes in the environments of human
and animal life. Three species of dermatophytes, Microsporum canis,
Trichophyton mentagrophytes and Trichophyton verrucosum (T. verrucosum)
are the most important pathogens from animal to human [1]. T. verrucosum,
a causative agent of bovine dermatophytosis in Japan, is considered to
transfer easily from infected cattle to other healthy ones [2].
We report an interesting case of tinea barbae due to T. verrucosum
infection, which was confirmed histopathologically by Grocott staining
and cultured colony characteristics on the BHI (brain heart infusion)
agar slant medium. Additionally, cases of tinea barbae due to T. verrucosum
reported in the literature are also reviewed.
Case report
A 25 year-old male, a dairy farmer, had noticed an annular scaly erythema
on the left cheek since 3 weeks, and visited a dermatological clinic for
the eruption. Diagnosis of tinea faciei was made and treated by oral anti-histamine
medicine and by topical application of anti-fungal ointment. However,
the eruption worsened and enlarged so that he presented at the Department
of Dermatology of Kumiai Hospital on October 19, 1997. There was also
a family history of his sister, mother and father with tinea corporis
due to T. verrucosum infection [3]. He was in good general health.
Physical examination disclosed papules and pustules with swelling and
erythema on the chin and cheeks as shown in Figure
1a and b. Several tender lymph nodes were palpable in the bilateral
jaw region.
The results of routine laboratory investigations were within normal
limits except for white blood cell (9,800/mm3) and C reactive
protein (CRP) (2+). There were no abnormalities of immunological examination
including immunoglobulins G, A and M. The results of physiological examinations
including electrocardiogram and chest X-ray film were within normal limits.
Several small white-yellowish colonies were grown on brain heart infusion
(BHI) agar medium culture from the biopsied specimen of the lower jaw
(Fig. 2A). Slide culture
revealed fungal rod-shaped elements as revealed in Figure
2B.
Histopathological features showed epidermal hyperplasia with elongation
of rate ridges and granulomatous changes around hair follicles in the
dermis with numerous mononuclear cells and giant cells (Fig.
1c). Under a higher magnification of the cell infiltration, there
were no positive colonial or fungal elements around the hair follicles
except for hair-shaft as determined by Grocott stain (Fig.
1d an arrow) as well as PAS stain (Fig.
1c), which consisted of fine ovale or round spores or fungal component
(Fig. 1e). Clinical, histopathological
and mycological characteristics led to a diagnosis of tinea barbare due
to T. verrucosum. A 2-month course of itraconazole (100 mg/day)
produced excellent effects without any side effects. There was no recurrence
during three years and 6 months after the treatment.
Obervation by using transmission
electron microscopy
Samples of cultured organisms were fixed for several hours at 37°
C with 2% glutaraldehyde in 0.1 M phosphate buffer, pH 7.3, and after
washing with 0.05 M phosphate buffer, samples were transferred to increasing
concentrations of alcohol and aceton, embeding with peon 812. The electron
microscopic observation was performed with a JEOL 100S electron microscope
operating at 80 or 100 kV.
There were many hyphal or conidial elements sectioned transversely (Fig.
2a). Many fungal elements contained mitchondoria (Fig.
2b) and vacuoles (Fig.
2c) as well as dense bodies (Fig.
2d) and vesicles (Fig.
2e).
Discussion
It is important for public health to take preventive measures against
infection, because many investigators have already reported many human
cases of dermatophytosis transmitted from animals, especially cattle [4-6].
Zienicke and Korting [7] reported interesting intra familial transmission
of T. verrucosum to a newborn, whose father, having contact with
cattle as a farmer, had fallen ill from tinea barbae (a severe pustular
eruption on the face and neck) and T. verrucosum could be detected
by culture in both cases. Similar occurrence of tinea due to T. verrucosum
in a mother and child was reported by Czaika et al. [6].
Sabota et al. [8] reported five patients, three of whom had severe
pustular tinea barbae and two of whom had eruptions on the forearms due
to T. verrucosum which may be mistaken for a Staphylococcus
aureus infection by cliniclans, including infectious disease experts,
because zoophilic dermatophytes infections produce a deep dermal inflammatory
reaction, as described by Kiska and Cynamon [9] and other investigators
[10, 11]. In addition, similar cases were previously reported [12, 13].
Clinically, it is most important for differential diagnosis of these
diseases to examine a 20% KOH sample of infectious hairs before histopathological
examination, because chained giant spores (about 4 micron in diameter)
are seen around the hairs in T. verrucosum infection.
In this study, there were no significant characteristics in the ultrastructural
investigation for the strain of T. verrucosum although many vacuoles
or vesicles were seen inside the fungus as showed in Figure
2e.
It is of special interest to note that the father of the presented case
had been diagnosed having as tinea corporis due to T. verrucosum
[3]. Since the present case and his father had had tinea barbae and tinea
corporis, respectively, we should be careful in taking the history of
human patients with reference to their contacts with animals such as cattle
in our case, because T. verrucosum was one of the zoonotic fungi.
Against Trichophyton spp, itraconazole is of similar activity
to terbinafine, which is effective for fungal diseases by the inhibition
of squalene epoxidase, following decreas-ing of ergosterol synthesis [14].
It is well known that therapy with antifungal agents such as terbinafine,
fluconazole as well as griseofulvin are effective in these cases of tinea
[15, 16]. In our case, oral administration of itraconasole was effective.
This case suggets that close cooperation between medical doctors and
cattle farmers is very important and that attention should be paid to
the family history with animal pets and cattle.
Article accepted on 29/1/02
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