Case for diagnosis

Abstracts

Paciente do sexo masculino, branco, 43 anos, apresentava há dois anos lesão única, localizada no joelho direito, além de descamação nas regiões plantares. O exame micológico direto das lesões plantares mostrava filamentos de dermatófitos, mas foi negativo na lesão do joelho. Porém o exame histopatológico dessa área demonstrou presença de granuloma de corpo estranho com hifas de dermatófitos, confirmando o diagnóstico de granuloma de Majocchi.

Granuloma de corpo estranho; Tinha dos pés; Trichophyton

WHAT IS YOUR DIAGNOSIS?

Case for diagnosis

Weber Soares Coelho^I; Lucia Martins Diniz^II; João Basílio de Sousa Filho^III; Cássio M. de Castro^IV

^IGraduate studies, Service of Dermatology, Santa Casa de Vitoria - Vitoria (ES), Brazil

^IIAssistant Professor, Service of Dermatology, Santa Casa de Vitoria - Vitoria (ES), Brazil

^IIIFull Professor, Service of Dermatology, Santa Casa de Vitoria - Vitoria (ES), Brazil

^IVPathologist, Brazilian Society of Pathology - Vitória (ES), Brazil

Mailing Address

ABSTRACT

Caucasian male patient, 43 years old, presented two years ago with one single lesion in the right knee, in addition to desquamation in the plantar region. Direct mycological exam of the plantar damage showed filaments of dermatophytes, but it was negative for the knee injury. However, histopathology of the area showed presence of foreign body granuloma with hyphae of dermatophytes, confirming the diagnosis of Majocchi's granuloma.

Keywords: Granuloma, Foreign-body; Tinea pedis; Trichophyton

HISTORY OF THE DISEASE

Male, Caucasian, 43-year-old patient, electrician, married, born and resident in Cariacica, state of Espirito Santo. For two years, he had had desquamative, slightly pruriginous lesion on the plantar region and single asymptomatic lesion on the right knee, of slow and progressive growth. He had used topical clobetasol for six weeks on the knee, with partial improvement and later recurrence, which brought him to the service of dermatology. The dermatological examination showed plantar erythematous-desquamative lesions, bilateral, in addition to a single lesion slightly erythematous, with elevated borders and depressed core, located on the right knee (Figure 1). Direct mycological exam of plantar lesions revealed the presence of dermatophyte filaments and modified Sabouraud culture showed growth of light brown color pulverulent colony, typical of Trichophyton mentagrophytes. Direct investigation of the fungi on the right leg was negative, but clinical pathology revealed inflammatory perifollicular reaction and multiple foreign body giant cells forming a granuloma, with hyaline septated hyphae inside it, detected by hematoxyllin-eosin staining (Figure 2).

The material collected by biopsy was submitted to culture with modified Sabouraud which showed the growth of Trichophyton mentagrophytes (Figure 3). Patient was treated with itraconazole 200mg/day, plus topical isoconazole for six weeks and presented improvement of the case.

COMMENTS

Granuloma trichophyticum was described in 1883 by Domenico Majocchi, in Italy, which named it Majocchi’s granuloma.¹ It is a nodular perifolliculitis with formation of foreign body granuloma owing to infection of the dermis and subcutaneous tissue by dermatophytes ^{1, 2}. Among the described etiological agents, Trichophyton rubrum is the most frequent one,^{1, 2} followed by Trichophyton violaceum, Trichophyton mentagrophytes, Microsporum audouinii, Microsporum gypseum, Microsporum canis² and Epidermophyton floccosum.³ It is a rare infection located on areas exposed to trauma (face, forearm, hands and legs) ², and it may be associated with waxing or use of high-power topical corticosteroids in areas infected with dermatophytes in immunocompetent patients ^{2, 3}. It is clinically characterized by single or multiple lesions, forming plaques, nodules, papule-pustule, or more rarely, keloid form presentation ^1-4.

Owing to response to agent or release of follicular content with cell immune reaction, histopathology shows formation of giant cells and foreign body granuloma containing fungi ^1-4. Treatment may be oral antifungal agents, such as griseofulvin 500mg/day ^{2, 3} or terbinafine 250 mg/day ⁵, for 30 days, leading to clinical regression of the lesion.

The authors found 27 published cases in the world literature in the past 30 years, from 1976 to 2006, confirming the rarity of this pathology.

REFERENCES

• 1.  Gupta S, Kumar B, Radotra BD, Rai R. Majocchis granuloma trichophyticum in an immunocompromised patient. Int J Dermatol. 2000;39:140-59.
• 2.  Chen HH, Chiu HC. Facial Majocchis granuloma caused by Trichophyton tonsurans in an immunocompetent patient. Acta Derm Venereol. 2002;83:65-6.
• 3.  Janniger CK. Majocchis granuloma. Pediatr Dermatol.1992;50:267-8.
• 4.  Gupta AK, Prussick R, Sibbald RG, Knowles SR. Terbinafine in the treatment of Majocchis granuloma. Int J Dermatol.
• 5.  Rajpara V, Frankel S, Rogers C, Nouri K. Trichophyton ton surans associated tinea corporis infection with the devel opment of Majocchis granuloma in a renal transplanted patient. J Drugs Dermatol. 2005;4:767-9.

*

Trabalho realizado no Serviço de Dermatologia da Santa Casa de Misericórdia de Vitória - Vitória (ES), Brasil.

Publication Dates

• Publication in this collection
  23 June 2009
• Date of issue
  Feb 2009

History

• Accepted
  01 Sept 2006
• Received
  01 Sept 2006