Deep Infection by Trichophyton rubrum in an Immunocompromised Patient

Abstract

Dermatophytes are common pathogens of skin but rarely cause invasive disease. We present a case of deep infection by Trichophyton rubrum in an immunocompromised patient. T. rubrum was identified by morphological characteristics and confirmed by PCR. Invasiveness was apparent by histopathology and immunohistochemistry. The patient was treated successfully with itraconazole. CASE REPORTA 56-year-old male was admitted for evaluation of elevated erythrocyte sedimentation rate (ESR), anemia, and multiple subcutaneous nodules on both legs. The patient was under close medical supervision due to an autoimmune disease with liver, cardiac, and lung involvement.His medical history included pericarditis (27 years before admission), and a profound jaundice after a respiratory infection treated with cefuroxime (3 years before admission). Serology was negative for hepatitis viruses and positive for antiparietal, antinuclear, and antineutrophil cytoplasmic antibodies. Liver biopsy revealed a profound destruction of liver architecture, fibrosis, active inflammation, and cholestasis. Treatment with steroids was followed by a good clinical response and normalization of liver enzymes. Attempts to wean the patient from steroids including administration of azathioprine and cyclosporine failed, and during the 2 years prior to admission he received both prednisone and cyclosporine. Several weeks before admission, he was evaluated for a chronic cough. He had undergone a transbronchial biopsy that disclosed chronic inflammation and thickening of the basement membrane, without any specific diagnosis, but responded to an increase of the dose of steroids. A few weeks later, while trying to taper the steroids, he developed multiple, hard cutaneous nodules, distributed mainly on the lower limbs. Some later softened and discharged caseous material spontaneously.Other underlying conditions included glucose-6-phosphate dehydrogenase deficiency, nephrolithiasis, benign prostate hypertrophy, bilateral inguinal hernia repair, and osteoporosis.On admission, medications included prednisone (10 mg once a day [QD]), cyclosporine (100 mg QD), ursodeoxycholic acid (300 mg twice a day), alendronate (10 mg QD), omeprazole (20 mg QD), and calcium (600 mg) and vitamin D (0.25 g) once daily. On physical examination, rhonchi were heard over both lungs. A few hard, mobile subcutaneous nodules were present on both lower limbs, mainly around the knees and thighs (Fig. 1a), and the sacral area. Some of these nodules were purplish and soft. Onychomycosis was present on the feet and both hands (Fig. 1b and c).Laboratory test results were as follows: ESR, 80; hemoglobin level, 10.8 g/dl; leukocyte count, 7,900/l (42% granulocytes); albumin level, 34 g/liter; total protein level, 83 g/liter; liver enzyme levels, normal.Two of the patient's nodules were excised. A granulomatous inflammatory reaction was present in the dermis and hypodermis. It was composed of monocytes, macrophages, multinucleated giant cells, and rare neutrophils (Fig. 2). Septate hyphae were revealed...

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