Mycopathologia (2015) 179:293–297
DOI 10.1007/s11046-014-9834-5
Chronically Recurrent and Widespread Tinea Corporis Due
to Trichophyton rubrum in an Immunocompetent Patient
Q. T. Kong • X. Du • R. Yang • S. Y. Huang
H. Sang • W. D. Liu
•
Received: 17 June 2014 / Accepted: 13 November 2014 / Published online: 7 December 2014
Ó Springer Science+Business Media Dordrecht 2014
Abstract A 31-year-old immunocompetent male
who presented with a 4-year history of extensive
erythematous and scaly plaques involving the abdomen, gluteal and inguen regions with concomitant
tinea pedis and onychomycosis is described. Diagnosis was based on positive mycological examination
and positive histopathologic examination. Species
identification was performed by growth on Sabouraud
dextrose agar and by sequencing of the internal
transcribed spacer regions of the rDNA region. The
pathogen identified was Trichophyton rubrum. The
same fungal species was cultured from his abdominal,
gluteal, foot and toenail. A combination therapy with
systemic terbinafine and topically applied terbinafine
cream was successful. A 1-year follow-up did not
show any recurrence of infection.
Introduction
Keywords Chronically Widespread Tinea
corporis Trichophyton rubrum Immunocompetent
A 31-year-old male was presented to our department
with a 4-year history of recurrent extensive erythematosquamous lesions involving the trunk, gluteal,
inguinal and crural regions with concomitant tinea
pedis and onychomycosis. The patient stated that the
erythematous lesions with slightly scale and pruritus
began 7 years earlier on the gluteal and inguinal and
the eruptions had disappeared promptly with topical
application of 2 % ketoconazole cream. However, he
had a 4-year history of repeated recurrence of similar
erythra on the gluteal and inguinal. The lesions spread
to trunk, lower extremities rapidly after he use a folk
prescription. He underwent a 2-week therapy period
therapy with systemic terbinafine and miconazole
Q. T. Kong X. Du R. Yang S. Y. Huang H. Sang (&)
Jinling Hospital, Department of Dermatology,
Nanjing University, School of Medicine,
Nanjing 210002, People’s Republic of China
e-mail: [email protected]
W. D. Liu
Institute of Dermatology, Chinese Academy of Medical
Sciences, Peking Union Medical College,
Nanjing 210042, People’s Republic of China
Chronic, widespread and invasive cutaneous dermatophytoses due to Trichopyhton rubrum are common in
immunocompromised patients. In immunocompetent
individuals, however, chronic widespread dermatophytoses are more often associated with foot, hand and
nail dermatophyte infections and rarely tinea cruris
and corporis. We describe a 31-year-old immunocompetent male who presented with a 4-year history of
extensive erythematous and scaly plaques involving
the abdominal, gluteal and inguen regions with
concomitant tinea pedis and onychomycosis.
Case Report
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cream at a local hospital and achieved complete
remission, but his rashes developed again after drug
discontinuance. In this period, he had used topical
corticosteroids on the lesions and traditional Chinese
medicine. He had not received any treatment in the last
2 years. He has been healthy except the persistent
rashes and denied susceptibility to repeated bacterial
or viral infections. There was neither an indication of
diabetes nor evidence of using immunosuppressive
drugs and corticosteroids. No contact with domesticated or wild animals was reported. There was no
history of fungal skin infection in his family.
Physical cutaneous examination revealed diffuse
erythema on his abdominal, back, gluteal and inguen
regions with well-defined borders and scale (Fig. 1).
There was also onychauxis on his toenails (Fig. 2).
The mucosae were not affected. His laboratory tests
including biochemical and serological tests and
radiological examinations were all within normal
limits.
Skin biopsies were taken from his abdomen. The
histological picture (Fig. 3) showed epidermal hyperkeratinization. The upper dermis presented a sparse
perivascular lymphocytic infiltrate. The PAS stain
confirmed the presence of few hyphae in the horny
layer. Septate and branching hyphae were observed on
direct microscopic examination (KOH preparation) of
Fig. 1 Clinical presentation of the patient
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Mycopathologia (2015) 179:293–297
Fig. 2 Onychauxis of the patient’s toenails
scales obtained by scraping the plaques on the
abdominal, gluteal, foot and toenail. Skin-scraping
cultures on Sabouraud dextrose agar with chloramphenicol and cycloheximide at 26 °C for 14 days
yielded downy white-coloured colonies with crimson
pigment on the reverse. Teardrop-shaped microconidias along septate hyphae were established after
staining with lactophenol cotton blue on microscopic
examination. Genomic DNA was extracted from the
three fungal cultures using Biopsin Fungus Genomic
DNA Extraction Kit (Bioer Technology, China)
Mycopathologia (2015) 179:293–297
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Fig. 3 Histological features of the skin biopsy from the abdominal, a HE 9100, b PAS 9400
according to the manufacturer’s protocol. The universal fungal primer pair was used for amplification:
ITS1 (50 -TCCGTAGGTGAACCTGCGG-30 ) and
ITS4 (50 -TCCTCCGCTTATTGATATGC-30 ). The
PCR assay was performed, and the PCR product was
directly sequenced using both the ITS1 primer and
ITS4 primer. The resultant nucleotide sequences were
aligned to produce consensus for analysis. The consensus sequence of the isolate aligned with 99 %
sequence similarity to multiple sequences of T.
rubrum available in the GenBank database. Moreover,
we identified the genotype of the four isolated strains
using primers TrNTSF-2(50 -ACCGTATTAAGCT
AGCGCTGC-30 ) and TrNTSR-4 (50 -TGCCACTTCGATTAGGAGGC-30 ) [1] and random amplified
polymorphic DNA methods. Amplification products
were separated by electrophoresis in 1.5 % agarose
gels and photographed. The results showed that the
four isolated strains were the same fungal species
(Fig. 4). The fungal culture and PCR approach
resulted in the identification of T. rubrum. The
sequences of the isolates from abdomen and toenail
in this publication have been submitted to Genbank
(accession numbers KP012333, KP012334). And the
Fig. 4 Amplification of the TRS-1 subrepeat element for
clinical isolates. (1) The isolate from abdominal, (2) inguen,
(3) gluteal and (4) toenail
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two isolates have been deposited in the Institute of
Dermatology, Chinese Academy of Medical Sciences,
Chinese Medical Fungi Culture Collection Center,
Nanjing, China under accession number CMCC (T1j
and T1k, respectively). In vitro antifungal susceptibility testing was performed in accordance with CLSIM38-P. The most sensitive antifungal drug against our
strain was terbinafine, followed by itraconazole.
Therefore, treatment was started with oral terbinafine
(250 mg/day) as well as local therapy with terbinafine
cream once a day for 1 month.
After treatment, the skin lesions had cleared up
(Fig. 5) and mycological examination was negative.
Treatment with oral terbinafine was maintained during
12 weeks. A follow-up examination 1 year later
showed no recurrence of symptoms.
Discussion
Trichophyton rubrum is the most common cause
worldwide for superficial dermatophytosis. Chronic
and widespread infections often occur in immunocompromised patients, such as those with AIDS. There
have been a few reports of widespread tinea corporis in
Mycopathologia (2015) 179:293–297
immunocompetent patients caused by T. rubrum,
which may persist for several years [2–4]. Our case
presented here is unique in that the patient was
immunocompetent and had a 7-year history of chronic
recurrent multiple of corporis despite intermittent
topical and system antifungal treatment.
The lesions of our patient began 7 years earlier on
the gluteal and inguinal, followed by spread to trunk,
lower extremities and toenail gradually, and repeated
recurrence. However, he did not get a professional
diagnosis and treatment. From his medical history, he
had used topical corticosteroids on the lesions and
traditional Chinese medicine. This may be one of the
most causes of our patient’s lesions progression.
Regard to chronic, widespread and recurrent cutaneous dermatophytoses, it is important to identify the
isolation pathogen from patients. The fungus was
identified as T. rubrum based on both macroscopic
features of colonies, microscopic characteristics on
lactophenol cotton blue staining and PCR approach
results. Moreover, the isolation of T. rubrum from his
toenail is the same species from his abdomen, gluteal
and foot. Therefore, the chronic recurrent tinea
corporis in this case is likely due to repeated autoinfection with pathogenic dermatophytes from the
Fig. 5 Almost complete healing of the lesions 1 month after the treatment
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Mycopathologia (2015) 179:293–297
patient’s toenail, which served as a reservoir for the
pathogen. Moreover, Mannans in the cell walls of
dermatophytes have immuno-inhibitory effects. In T.
rubrum, the mannans may also decrease epidermal
proliferation, thereby decreasing the likelihood of the
fungus being sloughed off prior to invasion. This
mechanism is thought to contribute to the chronicity of
infections caused by T. rubrum [5].
In a long period of treatment, the pathogen may be
resistance to antifungal agents. Therefore, drug sensitivity test is important to choose antifungal agents.
The isolation was identified as T. rubrum; according to
the results of drug sensitivity test, systemic terbinafine
was given and our patient showed rapid improvement
and clearing of the cutaneous lesions.
In conclusion, we have described a rare form of
chronic and widespread tinea infection caused by T.
rubrum in an immunocompetent patient. The observations in our case indicate the importance of surveying the nails as a potential source of pathogenic
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dermatophytes in patients with recurrent and widespread tinea corporis.
Acknowledgments This work was supported by the National
Natural Science Foundation of China (Grant No. 81371782).
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