Majocchi’s Granuloma due to Trichophyton rubrum This is GMS stain and culture of a skin biopsy from a patient’s leg. 66M. 4 mo after heart Tx: painless leg nodules that spread distally x 5 weeks. No pain. No fever. PE unremarkable except lesions in left leg / foot + tinea pedis Biopsy: GMS fungal elements in dermis. Culture: Trichophyton rubrum Histopath shows fungal elements (GMS) - not sufficient for identification. Important: Send specimen for culture identification!!! Treatment: Itraconazole Rx What is Majocchi granuloma? - Pathology: inflammatory / granulomatous fungal infection of the dermis / subcutaneous tissues - mainly caused by dermatophytes (>95%) - Occurs in immunocompetent and compromised hosts! - Location: mostly lower extremities but can occur anywhere - Risks: Trauma such as shaving and scratching - most common - allows fungus invasion, Topical steroids and conditions with immunosuppression, Preexisting dermatophytosis, Animal contact Majocchi granuloma pathogens: - Dermatophytes >95%: T. rubrum, T. mentagrophytes, T. violaceum, T. tonsurans, Microsporum, Epidermophyton - Non-dermatophytes: Aspergillus, Phoma Majocchi granuloma in transplant: - Indolent course: nodules, papules, plaques, pustules, abscess - Lower extremity most common; dissemination rare - Preexisting tinea common - T. rubrum most common pathogen - Systemic Rx: terbinafine, Itraconazole Majocchi granuloma Treatment: - Topical Rx - does not penetrate deeper dermis! Not recommended as sole Rx. - Systemic Rx is recommended - Options: Terbinafine, Itraconazole, Others Majocchi granuloma Pearls: 1. Fungal infection of dermis and subQ; most common T. rubrum and other dermatophytes 2. Competent and compromised hosts 3. Localized mostly to lower extremity; rare dissemination 4. Dx: pathology and culture 5. Rx: Oral antifungal Rx recommended Mayo Clinic Infectious Diseases @MayoClinicINFD #Majocchis #Granuloma #Trichophyton #rubrum #clinical #photo #microscopy
