Clinical Picture
Kerion celsi caused by Trichophyton tonsurans in a child
Lancet Infect Dis 2018; 18: 812
Department of Paediatrics
(G Lapergola MD,
Prof A Mohn MD,
C Giannini MD), Department of
Paediatric Rheumatology
(L Breda MD), and Department
of Paediatric Surgery
(Prof P Lelli Chiesa MD),
University of Chieti, Chieti,
Italy
Correspondence to:
Prof Angelika Mohn, Department
of Paediatrics, University of
Chieti, 66100 Chieti, Italy
amohn@unich.it
812 www.thelancet.com/infection Vol 18 July 2018
Giuseppe Lapergola, Luciana Breda, Pierluigi Lelli Chiesa, Angelika Mohn, Cosimo Giannini
A 6-year-old boy was assessed for a pruriginous
swelling of the scalp that had been present for 2 weeks and
had persisted after a week of antibiotic treatment
(oral amoxicillin and clavulanic acid 50 mg/kg per day). A
round, tense-elastic mass (5 × 6 cm) was visible in the
right parietal area of the patient’s scalp, with crusted
lesions, purulent secretions, and alopecia. He showed
lateral–cervical and supraclavicular lymphadenopathy
(1 × 1 cm; figure). Hypochromic areas with alopecia on the
right leg of the patient’s father and on the scalp and limbs
of the patient’s 3-year-old sister were documented. Previous
contact with wild rabbits was reported. Laboratory tests
showed neutrophilic leucocytosis (white blood cells
12 460 per µL [normal range 4000–10 000], neutrophils
Figure: Kerion celsi
6530 per µL [normal range 2100–7000], lymphocytes
3100 per µL [normal range 1000–3300], monocytes 1370 per
µL [normal range 200–800], eosinophils 620 per µL [normal
range 10–500]) and an increased inflammation index
(C-reactive protein 1·03 mg/dL [normal range <0·50]). A
swab sample was taken from the scalp lesions, and Gram
stain and bacterial culture of the buffer were negative. A
scalp specimen was collected for mycological examination
and, after 5 days in Sabouraud agar, Trichophyton tonsurans
was isolated. The lesion resolved after a 1-month course of
systemic itraconazole (oral, 50 mg twice daily) and a 6-week
course of topical econazole (1% cream, three times a day).
Kerion celsi is a severe inflammatory form of tinea capitis
that is characterised by a T-cell-mediated hypersensitivity
reaction against dermatophyte fungi. In Europe,
Microsporum canis is the most common cause (80% of
cases), although an increased number of cases caused by
Trichophyton spp (particularly T tonsurans) have been
described since 2015, possibly facilitated by immigration
from west Africa.
The standard treatment for kerion celsi is griseofulvin
(20–25 mg/kg per day of microsize tablets or 10–15 mg/kg
per day of ultramicrosize tablets for 6–8 weeks).
Itraconazole and terbinafine are newer available
therapeutic alternatives with the same efficacy as
griseofulvin. Concomitant topical therapies, such as
shampoos or fungicidal creams or lotions, might help in
removing scales and spores.
Kerion celsi is often unrecognised or confused with
other lesions (eg, pyogenic abscesses). A sample of a scalp
lesion should be taken to avoid misdiagnosis, unnecessary
invasive procedures (eg, surgical drainage), and delayed
treatment.
Contributors
GL and CG wrote the manuscript, collected figures, and reviewed the
literature. PLC and LB provided specialist consultations (surgical and
immunological). AM wrote and revised the manuscript.
Declaration of interests
We declare no competing interests.
© 2018 Elsevier Ltd. All rights reserved.