Disseminated Deep Dermal Trichophyton Rubrum Infection in a Heart Transplant Recipient

Abstract

<h3>Introduction</h3> The dermatophyte Trichophyton rubrum (T. rubrum) is one of the most common causes of superficial cutaneous mycoses. Although these are often seen in immunosuppressed heart transplant recipients, reports of deep dermatophytoses are rare. Accounts of extensive T. rubrum are even scarcer. We report a case of disseminated deep T. rubrum infection in a heart transplant patient, successfully treated with itraconazole. <h3>Case Report</h3> A 62 year-old systemically well male one year post-cardiac transplantation presented with a 4-month history of painless discharging erythematous nodules. These ranged from 1 to 6 cm in diameter on his upper limbs, lower abdomen, perineum and upper thighs. Histology from skin biopsy showed deep dermal granulomatous inflammation with filamentous fungal hyphae. Mycological studies isolated T. rubrum. This was treated with oral itraconazole and careful dose reduction of tacrolimus. After one month, the patient described a reduction in size of nodules and absence of new lesions. Following three months of itraconazole, the patient achieved a near complete response. The infection remained adequately controlled two months after itraconazole cessation. <h3>Summary</h3> There have been 5 published reports of deep T. rubrum infection over the last 10 years in PubMed, MEDLINE and EMBASE¹. A condition distinct from superficial dermatophytosis, deep dermatophytosis occurs in immunosuppressed individuals with defective cell-mediated immunity². Cases in solid-organ transplant recipients have been described predominantly in kidney recipients³. Disseminated infection has been reported in various bodily sites with the presentation of papulo-nodular lesions⁴ alongside invasive and extensive forms³. Careful monitoring of immunosuppressant level is required to prevent complications when itraconazole (an enzyme inhibitor) is added⁵. Deep dermatophytosis such as T. rubrum should be included in the differential diagnosis of erythematous skin nodules in immunosuppressed patients.