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CASE REPORT
Year : 2019  |  Volume : 64  |  Issue : 4  |  Page : 318-320
Zygomycosis of the scalp caused by Rhizopus oryzae presenting as kerion in an immunocompetent child


Department of Dermatology, SVS Medical College, Mahbubnagar, Telangana, India

Date of Web Publication5-Jul-2019

Correspondence Address:
Angoori Gnaneshwar Rao
F12, B8, Hig-II APHB, Baghlingampally, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_551_18

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   Abstract 


Deep mycosis of the scalp caused by Rhizopus oryzae mimicking kerion is rare. Herein, we report a case of such infection in a 5-year-old immunocompetent boy who presented with multiple painful boggy swellings with discharging sinuses on the scalp of 4 months' duration. Purulent discharge from the swelling cultured on Sabouraud's dextrose agar yielded R. oryzae species which was confirmed by molecular analysis by polymerase chain reaction. The child was managed with parenteral liposomal amphotericin-B which helped in clearance of infection.


Keywords: Amphotericin-B, kerion, polymerase chain reaction, Rhizopus oryzae, Sabouraud's dextrose agar


How to cite this article:
Rao AG, Reddy VS, Aparna K, Haqqani R, Jagadevapuram K, Gupta S, Fathima K, Tejal M, Muppirala D. Zygomycosis of the scalp caused by Rhizopus oryzae presenting as kerion in an immunocompetent child. Indian J Dermatol 2019;64:318-20

How to cite this URL:
Rao AG, Reddy VS, Aparna K, Haqqani R, Jagadevapuram K, Gupta S, Fathima K, Tejal M, Muppirala D. Zygomycosis of the scalp caused by Rhizopus oryzae presenting as kerion in an immunocompetent child. Indian J Dermatol [serial online] 2019 [cited 2019 Jul 17];64:318-20. Available from: http://www.e-ijd.org/text.asp?2019/64/4/318/262180





   Introduction Top


Mucorales and entomophthorales are the two orders of zygomycetes that are known to cause infection in humans. The majority of human illness is caused by the Mucorales and Rhizopus species. Other common causative agents are Rhizomucor, Mucor, and Absidia which are found in plants and soil.[1] Kerion is an inflammatory type of tinea capitis caused mostly by dermatophyte fungi. Herein, we report a case simulating kerion caused by deep mycosis.


   Case Report Top


A 5-year-old boy was brought to the dermatology department with multiple painful boggy swellings on the scalp for the past 4 months. Initially, mother noticed a painful swelling on the vertex which gradually increased in size and opened up to discharge pus. Subsequently, similar swellings were noticed on the entire scalp which progressed gradually ending up similarly. Parents denied the history of any injury to the scalp. He was treated with topical herbal medication without relief. Family history was negative for similar ailment. There was no history of contact with animals. On examination, there were multiple nodules and boggy swellings ranging from 1 to 2 cm in diameter surmounted by follicular pustules, interspersed with cicatricial alopecia almost involving the entire scalp [Figure 1]a. Swellings were tender and soft in consistency. Couple of the boggy swellings on the vertex showed hemorrhagic crusts [Figure 1]b and some showed multiple sinuses discharging pus. Cervical lymph nodes on both sides were enlarged, tender and discrete. No abnormality was detected on systemic examination. He was provisionally diagnosed as kerion and folliculitis decalvans was considered in the differential diagnosis. Routine hematological and biochemical investigations were unremarkable. Serology for human immune deficiency virus was nonreactive. Potassium hydroxide mount from the discharge was negative for fungal elements. Discharge material from pustules revealed Pseudomonas aeruginosa on culture, sensitive to gentamycin. Culture on Sabouraud's dextrose agar showed wooly grayish brown colonies [Figure 2]a. Lactophenol cotton blue preparation showed aseptate broad hyphae [Figure 2]b, sporangia, and sporangiospores [Figure 2]c and the mold was identified as Rhizopus species. Molecular analysis was carried out from the specimen by polymerase chain reaction (PCR) and sequencing using panfungal primers ITS1 and ITS4 and BLAST search of sequence showed 100% homology to that of Rhizopus oryzae.
Figure 1: (a) Multiple nodules and boggy swellings on the scalp with sinuses discharging pus. Patches of cicatricial alopecia between the swellings. (b) Boggy swellings showing hemorrhagic crusts

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Figure 2: (a) Wooly greyish brown colonies on Sabouraud's dextrose agar. (b) Lactophenol cotton blue preparation: aseptate broad hyphae, sporangiophores arising opposite to rhizoids (×400). (c) Sporangia and sporangiospores (×400). (d) Histopathology shows a dense collection of plasma cells, lymphocytes, and neutrophils along with few Langhans and foreign-body giant cells in the dermis (H and E, ×400)

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Lesional biopsy showed a dense collection of plasma cells, lymphocytes, and neutrophils along with few Langhans and foreign-body giant cells in the dermis [Figure 2]d. Periodic-acid–Schiff stain was negative for fungus. Chest skiagram, computed tomography (CT) of the skull and paranasal sinuses was unremarkable. Positive culture on Sabouraud's dextrose agar, characteristic morphology on lactophenol cotton blue preparation and molecular analysis by PCR corroborated in confirming the diagnosis of Zygomycosis caused by R. oryzae. Intravenous infusion of liposomal amphotericin B deoxycholate 7.5 mg/kg body weight/day was infused over 4 h daily for 7 days while carefully monitoring renal, liver, and hematological parameters. The considerable clinical improvement was noticed after 6 days and lesions healed 2 weeks following treatment.


   Discussion Top


Zygomycosis is a rapidly progressive lethal fungal infection in humans with mortality of 25%–62%.[2] The cutaneous form accounts for <10% of cases.[3] Primary disease is caused by direct implantation, whereas secondary disease results from dissemination from other affected sites.[4] Primary cutaneous zygomycosis usually affects the extremities in an immunocompromised individual. It may involve other regions of the body, such as, the nose, face, breast, chest, back, abdomen, buttocks, and perineum. Nonetheless, scalp involvement in the index case is noteworthy. It is usually, a nosocomially acquired infection. Risk factors include diabetic ketoacidosis, immune deficiency, hematologic malignancies, and prolonged steroid therapy.[1],[5] However, there was no such incriminating risk factor in the index case.

Although the clinical features were suggestive of kerion in the index case, the culture on Sabouraud's dextrose agar revealed wooly grayish colonies and characteristic morphology of Rhizopus on lactophenol cotton blue preparation and molecular analysis by PCR confirmed the diagnosis of zygomycosis due to R. oryzae.

Skin is the usual site of entry, and direct inoculation of the skin following penetrating trauma leads to the establishment of infection.[6] Contact with soil or vegetation containing fungi increases the chance of acquiring the infection.[7] The child's parents denied a history of injury; however, the index case being a child is prone to trauma, might have sustained a minor injury which could have facilitated implantation of fungal spores resulting in subsequent infection. Furthermore, topical application of herbal medicine possibly contaminated with fungal spores could have compounded in establishing the infection in the child.

Cutaneous zygomycosis may present as localized or disseminated disease (24%). The onset of cutaneous zygomycosis may be progressive or fulminant depending on immunity of the host and virulence of the fungi. Incidentally, pathology was localized to the scalp in this case which might be attributable to immunocompetency in the child. Mortality varies from 10% for a localized disease to 94% for disseminated disease. Therapeutic agents such as amphotericin B, isavuconazole, and posaconazole are used in the management of zygomycosis. Incidentally, the child responded satisfactorily to liposomal amphotericin B. Prognosis seems to be favorable for the child since the deep mycosis is patchy and localized to the scalp without any systemic involvement.

R. oryzae infection presenting as kerion is rare and literature search failed to reveal reports of such presentation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Pak J, Tucci VT, Vincent AL, Sandin RL, Greene JN. Mucormycosis in immunochallenged patients. J Emerg Trauma Shock 2008;1:106-13.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Khatiwada P, Giri A, Khatiwoda P. Mucormycosis in diabetes mellitus. J Adv Int Med 2012;1:73-5.  Back to cited text no. 2
    
3.
Umbert IJ, Su WP. Cutaneous mucormycosis. J Am Acad Dermatol 1989;21:1232-4.  Back to cited text no. 3
    
4.
Skiada A, Rigopoulos D, Larios G, Petrikkos G, Katsambas A. Global epidemiology of cutaneous zygomycosis. Clin Dermatol 2012;30:628-32.  Back to cited text no. 4
    
5.
Perusquía-Ortiz AM, Vázquez-González D, Bonifaz A. Opportunistic filamentous mycoses: Aspergillosis, mucormycosis, phaeohyphomycosis and hyalohyphomycosis. J Dtsch Dermatol Ges 2012;10:611-21.  Back to cited text no. 5
    
6.
Spellberg B, Edwards J Jr., Ibrahim A. Novel perspectives on mucormycosis: Pathophysiology, presentation, and management. Clin Microbiol Rev 2005;18:556-69.  Back to cited text no. 6
    
7.
Chakrabarti A. Cutaneous zygomycosis: Major concerns. Indian J Med Res 2010;131:739-41.  Back to cited text no. 7
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    Figures

  [Figure 1], [Figure 2]



 

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