mycoses Diagnosis,Therapy and Prophylaxis of Fungal Diseases

Case report

Case of dermatophyte abscess caused by Trichophyton rubrum:

a case report and review of the literature

Makoto Inaoki,1 Chihiro Nishijima,1 Miho Miyake,1 Toshiyuki Asaka,2 Youichi Hasegawa,3
Kazushi Anzawa4 and Takashi Mochizuki4
1
Department of Dermatology, National Hospital Organisation Kanazawa Medical Center, Kanazawa, Japan, 2Department of Laboratory Medicine, National
Hospital Organisation Kanazawa Medical Center, Kanazawa, Japan, 3Hasegawa Skin Clinic, Kanazawa, Japan and 4Department of Dermatology,
Kanazawa Medical University, Uchinada, Japan

Summary A 54-year-old Japanese man without apparent immunosuppression presented with

nodules with purulent drainage on the right lower leg. He had ringworm of the right
leg and tinea unguium. A biopsy specimen of the nodule showed intradermal
abscesses with fungal elements, and Trichophyton rubrum was cultured from both the
pus and the biopsy specimen. Treatment with oral terbinafine resolved the nodules.
Dermatophyte abscess is a rare, deep and invasive dermatophytosis, which is often
associated with immunocompromised conditions. We provide a review of the litera-
ture including Japanese cases.

Key words: Abscess, dermis, dermatophytosis, Trichophyton rubrum, terbinafine.

had a history of valvular disease of heart, nephritis

Introduction
Deep, invasive infection of dermatophytes is defined
as the growth of dermatophytes in the dermis and
subcutis, and is believed to result from injury to the
lesions of superficial dermatophytosis or the ruptur-
ing of infected follicles into the dermis. Granulomas
are the most prevalent pathological finding,1 but
lesions consists primarily of abscesses in a few cases.
We present a case of dermal abscess caused by
Trichophyton rubrum in a patient without signs of
immunosuppression.
Case report
A 54-year-old Japanese man presented with a 3-
month history of nodules on the right lower leg. He
Correspondence: M. Inaoki, Department of Dermatology, National Hospi-
tal Organisation Kanazawa Medical Center, 1-1 Shimoishibiki-machi,
Kanazawa, Ishikawa 920-8650, Japan.
Tel.: +81 76 262 4161. Fax: +81 76 222 2758.
E-mail: inaoki-m@kinbyou.hosp.go.jp
Submitted for publication 23 December 2014
Revised 9 February 2015
Accepted for publication 25 February 2015
and mycoplasma pneumonia. He had hypertension
that was not being treated at the time of first visit. Six
months ago, he was diagnosed with ringworm of the
right lower leg and feet. Topical treatment with lulico-
nazole cream resolved the skin lesions. Thereafter,
there was no abnormality of the skin of the right
lower leg before appearance of the nodules. The
patient did not use topical corticosteroid on his legs.
Examination showed a reddish nodule 2 cm in diame-
ter with purulent drainage on the posterior surface of
the right leg (Fig. 1a). There were also a red nodule
1 cm in diameter that was biopsied on the lateral sur-
face of the right leg and a normal-coloured nodule
0.5 cm in diameter on the surface of the right calca-
neal tendon (Fig. 1b). There was a scaly erythematous
lesion on the right lower leg, which was negative for
fungus by direct potassium hydroxide (KOH) prepara-
tion of the scale (Fig. 1a). Application of topical diflu-
prednate ointment cleared the erythematous lesion.
The nail of the right first toe was discoloured and
showed clinical features of total dystrophic onychomy-
cosis. Mycelia were seen on the KOH preparation of
the nail scrapings and a diagnosis of tinea unguium
was made. A biopsy specimen of the nodule showed
intradermal abscesses filled with neutrophils (Fig. 2a

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doi:10.1111/myc.12317 Mycoses, 2015, 58, 318323

(a)
Figure 1 (a) Reddish nodule with puru-
lent drainage 2 cm in diameter and a
scaly erythematous lesion on the poster-
ior surface of the right leg. (b) A red
nodule 1 cm in diameter on the lateral
surface of the right leg.
and b). A small accumulation of histiocytes sur-
rounded by lymphocytes was seen in the deep dermis.
A small number of septate hyphae were seen in the
abscesses (Fig. 2c) but no hyphae were seen in the
cornified layer of the epidermis in the biopsy specimen.
Remnants of hair were not found in the abscesses or
in other part of the dermis. Bacterial cultures of the
pus and biopsy specimen showed negative results.
Four strains of Trichophyton rubrum (KMU 9102,
9106, 9107 and 9108) were cultured from the pus
and the biopsy specimen independently. Macroscopi-
cally, all strains produced similar white fluffy colonies
on Sabourauds dextrose agar slants, and showed port
wine red staining on the potato dextrose agar slants
(Fig. 2d and e). Microscopically, these strains showed
teardrop-shaped microconidia borne sessile on the
hyphae and a few thin-walled macroconidia. Restric-
tion enzyme analysis using Mva I and Hinf I of the
internal transcribed spacer regions (ITS) of ribosomal
gene (rDNA) of these strains were compatible with
those of T. rubrum. Although the fungal culture of the
discoloured nail was negative, restriction enzyme pro-
files of direct PCR products targeting the ITS of rDNA
were identical to those of the strains isolated from the
present case. Results of routine haematological and
serological studies, urinalysis, subsets of lymphocytes
and immunoglobulin levels were normal. The skin test
with trichophytin was negative. The patient received
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Mycoses, 2015, 58, 318323
Dermatophyte abscess
(b)
oral itraconazole 200 mg per day for 10 days, but
stopped treatment after complaining of abdominal dis-
tention. Treatment with oral terbinafine 125 mg per
day for 3 weeks resolved the nodules on the leg, but
the lesion on the toenail remained.
Discussion
Dermatophytosis is a communicable skin disease
affecting the stratum corneum and also may invade
the hair and nails. It is also possible for dermatophytes
to invade the dermis and hypodermis, especially in
cases where the patient is immunocompromised. A
number of cases of deep, invasive dermatophytosis
have been reported. However, a classification for the
disease has not yet been determined.
Fukushiro categorised dermatophytosis occurring in
regions deeper than the epidermis into four clinical
entities: dermatophyte granuloma, nodular granulom-
atous perifolliculitis of the legs, dermatophyte abscess
and dermatophyte mycetoma.2 Dermatophyte granu-
loma shows granulomas containing dermatophytes
around the hair follicles as well as in the deeper der-
mis and/or subcutis. Nodular granulomatous perifollic-
ulitis of the legs typically presents as a nodular
eruption composed of a chronic granulomatous infil-
trate surrounding infected hair follicles within the con-
fines of plaques of superficial dermatophytosis on the
319
M. Inaoki et al.
(a)
(b) (c)
(d) (e)
lower portions of the legs of dark-haired women.3 Der-
matophyte granulomas and nodular granulomatous
perifolliculitis of the legs may have tiny foci of neutro-
philis but they never accompany visible pustulation or
abscess formation.3 Dermatophyte abscess consists
mainly of abscesses containing dermatophytes in the
dermis and/or subcutis. Trichophytic mycetoma is a
pyogranulomatous firm nodule containing dermato-
phytic granules. On the other hand, Marconi et al.
have classified invasive dermatophyte infections into
three forms: Majocchis granuloma, deeper dermal der-
matophytosis and disseminated dermatophytosis.1
320
Figure 2 (a) The biopsy specimen of the
nodule showed nodular aggregations of
inflammatory cells in the dermis (original
magnification 920). (b) The inflamma-
tory cells mainly consisted of neutrophils
(original magnification 9200). (c) A sep-
tate hypha in the abscess (original mag-
nification 9400). (d) The surface of the
colonies grown on the potato dextrose
agar slants. (e) The reverse of the colo-
nies on the potato dextrose agar slants
showing port wine red staining.
Majocchis granuloma is the most indolent form, and
is subclassified into fungal suppurative folliculitis and
nodular granulomatous perifolliculitis. Deeper dermal
dermatophytosis is not necessarily associated with hair
follicles, tends to have a more rapid onset, is larger,
and extends deeper than Majocchis granuloma. Dee-
per dermal dermatophytosis can present in various
forms, including granulomas, abscesses or mycetomas.
Disseminated dermatophytosis involves skin and inter-
nal organs, including the lymph nodes, bone, muscle
and liver. Deep dermatophytosis is often used as a gen-
eric term for deeper dermal dermatophytosis and
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 Table 1 Cases of dermatophyte abscess reported after Fukushiros review.

Mycoses, 2015, 58, 318323

Abscess

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Superficial Trichophytin Cultured Associated
Reference Age/sex Location Size Number dermatophytosis skin test fungus diseases Treatment and outcome

Smith and Head8 24/F Thigh <2 cm Multiple +, thigh N/A T. mentagrophytes None Griseofulvin, resolved
Faergemann et al.9 72/M Leg, foot < 1 cm Multiple +, sole, nail N/A T. rubrum Myelodysplastic Itraconazole, died due to
syndrome underlying disease
Watanabe et al., 28/M Trunk, leg N/A Multiple N/A N/A T. verrucosum Nephrotic syndrome Itraconazole, resolved
Yonebayashi et al.10 52/F Hand 3 mm1 cm Several +, trunk, N/A T. rubrum Relapsing Itraconazole, stopped by
extremities, nail polychondritis liver dysfunction
Patel and Mills11 4/F Cheek 2 cm One +, cheek N/A M. canis None Terbinafine, resolved
Franco12 46/M Foot, back N/A Two +, all over the N/A T. rubrum Renal transplantation Fulconazole, under
body, nail observation
Colwell et al.13 19/F Scalp 4 cm One N/A N/A M. canis None Excision, resolved
Kobayashi et al.14 57/F Pubic region, <15 cm Multiple +, trunk T. rubrum Autoimmune hepatitis Excision and fluconazole,
thighs, trunk resolved
Iijima et al.15 62/M Leg <2 cm Several +, leg, foot, nail N/A T. rubrum Plasmacytosis Micafungin and excision,
resolved
Marconi et al.1 45/M Extremities, <1 cm Multiple +, extremities, N/A T. rubrum Haemochromatosis Amphotericin B, died due to
face, trunk face, trunk pneumonia
Fukuyama 58/M Groin <1.7 cm Several +, groin N/A T. rubrum Nephrotic syndrome Terbinafine, resolved
Azib et al.16 53/M Leg 12 cm Multiple +, foot, nail N/A T. rubrum Renal transplantation Terbinafine, improved
Matsuzaki et al.17 44/F Face, extremities, <7 cm Multiple +, foot N/A T. rubrum Myasthenia gravis Terbinafine, resolved
trunk
Present case 54/M Leg 0.52 cm Three +, leg, nail T. rubrum None Terbinafine, resolved

M, male; F, female; N/A, not available.

These cases were published earlier than Fukushiros review but were not included in the review.

Meeting abstract, Jpn J Med Technol 1998; 47: 585.

Meeting abstract, Med Mycol J 2011; 52(Suppl. 1): 89.

The size is estimated by using the figures of the article.
Dermatophyte abscess

321
M. Inaoki et al.
disseminated dermatophytosis.4,5 The present case pre-
sented as dermal abscesses caused by T. rubrum, and is
classified as deeper dermal dermatophytosis.
In patients with deeper dermatophytosis including
dermatophyte abscess, the portal of entry of fungi is
usually unknown. Possible causes include rupture of
a fungal folliculitis and direct invasion from a pre-
existing epidermal dermatophyte infection.6 Cases
with multiple lesions from deeper dermatophytosis
and dermatophytosis that has disseminated to the
internal organs may result from draining lymphatics
or haematogenous spread.5,7 The portal of entry for
dermatophytes in the present case may be an injured
hair follicle or epidermis rather than lymphatic or ha-
ematogenous dissemination because the abscesses
appeared only in the area of pre-existing dermatophy-
tosis and were few in number. However, the biopsy
specimen did not show the evidence of follicular inva-
sion or direct invasion from the epidermis, including
dermatophyte infection of hair follicles or the stratum
corneum, ruptured hair follicles or remnants of hair
in the abscesses. Although rupture of infected hair
follicles may be a common pathological process in the
majority of invasive dermatophyte infections, the clin-
ical features of the disease vary from mild localised
Majocchis granuloma to a severe widespread disease
of the internal organs. The pathological mechanism
of this diversiy remains to be determined, but it may
reflect the patients immunity, fungal virulence, the
duration of infection or a combination of these
factors.
Fukushiro reviewed 32 cases of dermatophyte
abscess including 25 Japanese cases.2 Afterwards, 14
cases of dermatophyte abscess, including seven Japa-
nese cases, have been reported (Table 1).1,817 This
article provides a descriptive review of 46 cases of der-
matophyte abscess. Overall, 28 cases (61%) were male
and median age was 44.5 years (range 4 84). Thirty-
eight patients (83%) had coexisting conditions that
may lower immunity, including six cases of renal
transplantation, one case of liver transplantation, six
cases of haematological malignancy, four cases of col-
lagen disease, three cases of nephrotic syndrome, three
cases of bullous pemphigoid and three cases of diabetes
mellitus. Most reports described pre-existing superficial
dermatophytosis including tinea unguium. Most
patients (n = 38, 83%) presented with multiple nod-
ules whereas only six patients had a single nodule.
The lesions were most frequently observed on the
lower extremities (n = 25, 54%), followed by the trunk
(n = 15, 33%), the upper extremities (n = 15, 33%)
and the head and face (n = 10, 22%). The most
322
commonly isolated organism was T. rubrm (n = 37,
80%), followed by T. violaceum (n = 3), T. mentagro-
phytes (n = 2), M. canis (n = 2), M. ferrugineum
(n = 1) and T. verrucosum (n = 1). Various therapies
were used to treat the dermatophyte abscesses. Griseo-
fulvin was used in 23 of the early cases and was
determined to be effective in 20 cases and ineffective
in three cases. Terbinafine was used in five of the
recent cases and resulted in a resolution or an
improvement in all cases. Itraconaszole was effective
in one case and was stopped due to liver dysfunction
in one case. Combination therapy with surgical exci-
sion and antifungals was successful in two cases. One
patient required surgery to recover. Two patients died
during treatment due to complications or underlying
diseases. The clinical features of dermatophyte abscess
cases including its frequent association with an immu-
nocompromised condition, a most common isolation of
T. rubrum, and an improvement of the disease by anti-
fungal agents in most patients, are similar to those of
cases of deeper dermal dermatophytosis.1
When we find deep dermal abscess, we usually
think of bacterial infections, so we perform a bacterial
culture and administer antibiotics. However, this pro-
tocol may miss fungal abscesses even though they are
rare. Therefore, we should also perform a culture for
fungus in cases of deep dermal abscess to reduce a
potential diagnostic delay. Furthermore, we should
perform clinical laboratory tests for immune function
in patients with dermatophyte abscess because most of
the cases are associated with immunocompromised
conditions.
Conflict of interest
None declared.
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