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Tinea Corporis Bullosa Due to Trichophyton schoenleinii: Case Report

Article  in  Mycopathologia · May 2012

DOI: 10.1007/s11046-012-9553-8 · Source: PubMed

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Tinea Corporis Bullosa Due to
Trichophyton schoenleinii: Case Report

Mihai Mareş, Valentin Năstasă, Ingrid

Cezara Apetrei & Gabriela Cristina
Suditu

Mycopathologia

ISSN 0301-486X
Volume 174
Number 4

Mycopathologia (2012) 174:319-322

DOI 10.1007/s11046-012-9553-8

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 Author's personal copy
Mycopathologia (2012) 174:319–322
DOI 10.1007/s11046-012-9553-8

Tinea Corporis Bullosa Due to Trichophyton schoenleinii:

Case Report
Mihai Mareş • Valentin Năstasă •
Ingrid Cezara Apetrei • Gabriela Cristina Suditu

Received: 25 February 2012 / Accepted: 23 April 2012 / Published online: 11 May 2012
Ó Springer Science+Business Media B.V. 2012

Abstract We report the first case of tinea corporis
bullosa due to Trichophyton schoenleinii in a 41-year-
old Romanian woman, without any involvement of the
scalp and hair. The species identification was per-
formed using macroscopic and microscopic features of
the dermatophyte and its physiological abilities.
Epidemiological aspects of the case are also discussed.
The general treatment with terbinafine and topical
applications of ciclopiroxolamine cream have led to
complete healing, with the lesions disappearing in
2 weeks.
M. Mareş (&)
Department of Mycology and Mycotoxicology, Ion
Ionescu de la Brad University, 8 Aleea Sadoveanu, P4,
1st floor, 700489 Iaşi, Romania
e-mail: mycomedica@gmail.com
V. Năstasă
Department of Pharmacology, Ion Ionescu de la Brad
University, 8 Aleea Sadoveanu, P4, 1st floor, 700489 Iaşi,
Romania
I. C. Apetrei
Romanian Society of Medical Mycology and
Mycotoxicology, 10 Stefan cel Mare şi Sfânt Avenue,
700063 Iaşi, Romania
G. C. Suditu
Dermatology Outpatient Department, ‘‘Nicolina’’ Medical
Center, 1 Hatman Şendrea Street, 2nd floor, 700613 Iaşi,
Romania
Keywords Tinea corporis bullosa
Trichophyton
schoenleinii
Epidemiology
Romania
Introduction
The dermatophyte Trichophyton schoenleinii is an
anthropophilic fungus usually reported as etiological
agent of favus or tinea favosa—a scalp illness
characterized by the presence of scutula [1, 2]. This
disease is essentially chronic and contagious, causing
permanent hair loss in the affected area [3].
Since its discovery by Johannes Lukas Schönlein in
1839, this fungal species was suddenly implied in
numerous outbreaks of tinea capitis worldwide, being
the most prevalent dermatophyte until the middle of
last century [4]. Nowadays, typical infections with
T. schoenleinii mainly occur in Africa, Asia, and the
Middle East, with only few cases being reported in
Europe and only related to immigration or travels in
endemic areas [5, 6]. In the second half of the
twentieth century, the incidence of T. schoenleinii
infections decreased continuously, with the introduc-
tion of griseofulvin in 1958 having a decisive contri-
bution to the eradication of favus in Europe [7]. In
addition to overt favus lesions, sporadic and unusual
clinical findings may occur during infection: onycho-
mycosis [8], tinea corporis favosa [3], and keratitis [9].
We report the first case of tinea corporis bullosa due
to T. schoenleinii in a 41-year-old Romanian woman,
without any involvement of the scalp and hair.

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320 Mycopathologia (2012) 174:319–322

Case Report appeared after 2 weeks, both on SDA and MYC

plates, have been identified as T. schoenleinii. They
A 41-year-old woman presented in our outpatient grew slowly, deep into the medium, whitish to cream
department with multiple vesiculobullous lesions, colored, waxy in appearance, later becoming velvety,
3–10 mm in diameter, on the internal side of her left central heaped and folded, with irregular, feathered
knee. Inspection of the area surrounding the lesions margins (Fig. 2). The reverse of colonies was unpig-
revealed an overt inflammatory aspect of the skin and mented. Microscopy showed antler-like hyphae with
several erosive, small circular zones, covered with dichotomous branching (Fig. 3) and nail head tips
adherent crusts consecutive to the dehiscence of the (favic chandeliers), and many chlamydospores
vesicles and bullae’s wall and dehydration of their (Fig. 4). No macro- or microconidia were observed.
fluid (Fig. 1). The woman worked as nurse in a county Additional physiological tests were performed and
hospital (internal medicine ward), she was an obese their results indicated T. schoenleinii-compatible
person (BMI, 31.2), and she suffered from arterial features: growth with alkalization on Bromcresol
hypertension, being under specific treatment. The purple casein glucose agar, hair perforation negative,
patient has declared that she never travelled outside good growth on all seven Trichophyton Agars
the country and she did not know about other illness to (Becton–Dickinson, USA).
suffer from. Also, the patient did not use any topical or
general corticosteroids treatment before the medical
consultation.
From skin lesions, multiple samples were taken,
and the specimens were used to obtain smears and wet
mounts. Microscopy revealed numerous inflammatory
cells and septated hyphae on May-Grünwald-Giemsa
stained smears and septated, seldom branched hyphae
on KOH 20 % wet mounts, respectively. The speci-
mens were also plated onto solid media—Tryptone
Soy Agar (TSA) enriched with 5 % sheep blood
(Biokar, France), Sabouraud Dextrose Agar (SDA)
with chloramphenicol (Biokar, France), and Mycobi-
otic Agar (MYC) (bioMérieux, France), in order to
detect any microbial growth.
After one-week incubation, no bacterial or yeast Fig. 2 Characteristic T. schoenleinii colonies after 3 weeks
cultures were recorded. The only colonies that incubation on Mycobiotic Agar

Fig. 3 Antler-like hyphae with dichotomous branching; wet

Fig. 1 Vesiculobullous lesions before and after dehiscence mount with blue lactophenol (9400)

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Mycopathologia (2012) 174:319–322
Fig. 4 Chlamydospores and branched hyphae; wet mount with
blue lactophenol (9400)
Other vesiculobullous diseases such as pemphigus
vulgaris, epidermolysis bullosa, and dermatitis herpet-
iformis were excluded based on medical history, exclu-
sive localization on the skin, and serum assays [10].
The treatment with oral terbinafine 250 mg/day for
3 weeks and topical applications of ciclopiroxolamine
1 % cream led to complete cure of the lesions with no
relapse. The mycological examination performed one
week after the treatment was done indicated no more
viable fungal elements.
Discussion
According to de Hoog et al., the differential diagnosis
must be made with T. mentagrophytes [11]. Both
species—T. schoenleinii and the neotype of T. ment-
agrophytes—belong to the Arthroderma simii Com-
plex, having the same distribution area and strong
phylogenetic relationships based on ITS sequencing
[12–14]. Our isolate did not show any type of
conidiation, the hair perforation test was negative,
and the colonies presented typical swollen hyphae,
especially in submerged margins. Due to these
features, the isolate was identified as T. schoenleinii.
The skin lesion—tinea corporis bullosa—is a rare
manifestation of the dermatophytic infections. Until
now, only four cases have been reported [15–18], with
none of them being produced by T. schoenleinii. It is
still unclear how the dermatophytes can induce
atypical manifestations, but some host conditions are
possibly related to an upregulation of their enzymatic
321
activity. Enzymes such as extracellular keratinase,
collagenase, elastase, and lipase are involved in the
dermatophytoses pathogenesis [19, 20].
Our patient is living in a town from northeast
Romania where the immigration is quite null. More-
over, her family and she never travelled outside the
country. From epidemiological point of view, the
contamination source for T. schoenleinii infections is
represented by the ill individuals, with this fungus
being an anthropophilic one. For our case, such a
source cannot be considered because this species
disappeared from Romania since the early 1970s.
Since the patient was not able to correlate the onset of
the lesions with a previous inter-personal contact, we
supposed that an inanimate contaminated substrate
could represent the source of infection. This is a very
plausible fact, taking into consideration the long-term
viability of T. schoenleinii spores in epilated hair
(up to 4 years and 9 month) [21].
Acknowledgments This work was supported by the Ministry
of Education and Research from Romania—CNCSIS-
UEFISCDI, project number PN II-RU 159/2010.
Conflict of interest None.
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