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Extensive Tinea Corporis Caused by Trichophyton verrucosum in an HIV Positive Patient
VB Dohe*, SK Deshpande**, Usha Balasubramanian***, RS Bharadwaj****
Abstract
Cutaneous infections are common in HIV (Human Immunodeficiency Virus) positive patients and are usually severe, recurrent and caused by microorganisms that are unusual in immunocompetent patients. We report a case of an HIV positive 35 years old male, milkman by occupation who had multiple, large erythematous, vesicular and pustular plaques on his abdomen, arm and legs. We isolated Trichophyton verrucosum from the lesions. The skin biopsy showed suppurative deep dermatophytosis and folliculitis. The patient satisfactorily responded to systematic antifungal therapy.
Introduction
Cutaneous infections are quite common
in immunocompromised patients. Their incidence in HIV positive patients is well documented in literature.1,2 Very few cases of Tinea corporis due to Trichophyton verrucosum in HIV positive patient have been reported in literature.8 Kumarasamy et al gave 8% incidence of dermatophyte of all skin lesions in HIV infection.3 Also, little data on fungal skin disease in farmers and animal feeders is available. Maslen4 reported 32 isolates of Trichophyton verrucosum from 1962 to 1994 from dairy and cattle farmers. Therefore, the documentation of our case seems to be of paramount importance. We describe here a case of 35 years old HIV positive milkman having extensive tinea corporis due to Trichophyton verrucosum.
Case Report
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| A 35 year old male patient, milkman by occupation, came with complaint of pustular, painful, crusted lesion over right middle finger, right forearm and left arm since one month. Initially the patient observed single, scaly and patchy plaque with erythematous, irregular margin, which later studded with vesicles and pustules. He gave history of trauma by buffalo horn at same place, which was followed by ulceration with purulent discharge. Similar lesions developed all over the body suggestive of tinea corporis (Ringworm) infection.
Patient gave past history of Herpes zoster 2 years back and abdominal Kochs 6 months back for which he had taken treatment. Laboratory investigations revealed Hb- 9.89 mg%, ESR- 46 mm at 1 hour, and tuberculin test and VDRL negative. Antibodies to the HIV were detected by rapid HIV Comb test and confirmed by Enziaids HIV 1+2 (ELISA TEST KIT) test.
Purulent discharge was collected for aerobic culture and incisional skin biopsy was taken for fungal culture and histopathological examination. Bacterial culture grew Methicillin Resistant Staphylococcus aureus (MRSA) and Klebsiella pneumoniae. KOH examination showed presence of fungal hyphae and chlamydospores. Culture on Sabouraud dextrose agar (SDA) was very slow growing. Colonies were slightly folded, grayish brown in colour with no pigmentation on reverse side of the colony. Growth was better at 370C as compared to room temperature. Lactophenol cotton blue (LPCB) mount of the fungus grown on SDA showed distorted hyphae with chlamydospores in chains and was thus confirmed as Trichophyton verrucosum (Fig. 1). Histopathological examination revealed suppurative deep dermatophytosis and folliculitis.
The patient responded to injection Teicoplanin and systematic antifungal therapy i.e.; Itraconazole and topical Miconazole within a period of 4 weeks. No new lesions developed. Repeat cultures showed negative results.
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Fig. 1 : Showed distorted hyphae with chlamydospores in chains confirming Trichophyton verrucosum |
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Discussion
Ringworm (tinea) is the contagious fungal infection and spreads through direct contact or indirect contact with an infected individual or animal. More inflammatory lesions with weeping vesicles, pustules and ulceration are usually caused by animal ringworm Trichophyton verrucosum is more frequently associated with cattle ringworm.4,5 Isolation of Trichophyton verrucosum from human ringworm disease has been reported from India.6,7
In the present case, we have isolated Trichophyton verrucosum from extensive tinea corporis in HIV positive patient. He had acquired infection by contact with infected buffalo as he gave the history of similar crusted lesions in buffalo. Immuno-suppression due to HIV infection might have lead to chronic, extensive infection caused by the zoophilic species.
Trauma by buffalo horn caused superimposed bacterial infection isolating MRSA and Klebsiella pneumoniae. Balajee et al8 reported non-pustular and non-inflammatory lesions due to T. verrucosum in HIV positive patient.
Infection caused by zoophilic species usually resolve after a period of pronounced inflammation. In this case also, patient responded to Itraconazole and topical miconazole.
References
1. Cockerell CJ. HIV and the skin. Arch Intern Med 1991;151:1295-1303.
2. Bhandary PG, Kamath KN, Pai GS, Rao G. Cutaneous manifestations of HIV infection. Ind J Dermatol Venereol Leprol 1997; 63 : 35-37.
3. Kumarasamy N, Solomon S, Madhivanan P, Ravikumar B, Thyagarajan SP, Yesudian P. Dermatologic manifestation among HIV patients in South India. Ind J Dermatol 2000; 39 : 192-95.
4. Maslen MM. Human cases of cattle ringworm due to Trichophyton verrucosum in Victoria, Australia. Australas J Dermatol 2000; 41 (2) : 90-94.
5. Ruth AH, Glyn EV. Fungi and skin. Microbiol Today 2000; 27 : 133-34.
6 Dasgupta SN, Shome SK. Studies in medical mycology 1.on occurrence of mycotic disease in Lucknow. Mycopath Applic 1959; 10 : 177-86.
7 Huda MM, Chakraborty N, Sharma Bordoloi JN. Ind J Dermatol Venereol Leprol 1995; 61 (6) : 329-32.
8 Balajee SA, Menon T, Rangnathan S. Thirunvukkarsu. Extensive tinea corporis caused by Trichophyton verrucosum in patient of HIV infection. Ind J Dermatol Venereol Leprol 1996; 62 (2) : 126.
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