Primary Care and Specialty Care Delays in Diagnosing Trichophyton verrucosum Infection Related to Cattle Exposure

Abstract

ABSTRACT The objective of this study was to identify exposure risks, body site of presentation, length of time from symptom onset to definitive diagnosis, initial and eventual treatment courses, and the number of medical visits between initial assessment and definitive diagnosis for patients with culture-proven Trichophyton verrucosum (T. verrucosum) skin infection, and to report the specialties of physicians making the initial assessment and the eventual correct diagnosis. Chart data were abstracted from patients diagnosed with culture-proven T. verrucosum in the Marshfield Clinic system from May 1996 to August 2009. Fifty-one patients were identified and included in the study. Of the 51 patients studied, 39 had a documented history of cattle exposure. The average length of time from symptom onset to diagnosis was 41.5 days. Prior to a culture-positive T. verrucosum diagnosis, 35 patients were treated with topical medications, 10 received oral antibiotics, and 6 received no initial treatment. After a culture-positive T. verrucosum diagnosis was obtained, all documented treatments were either oral or topical antifungal medications. In 68.6% of cases, the physician making the initial assessment was different than the physician making the final diagnosis. Health care providers who care for patients in rural populations presenting with recalcitrant inflammatory skin lesions should include occupational and exposure histories and include cutaneous fungal infections in the differential diagnosis of chronic inflammatory skin lesions, particularly in patients with a history of contact with cattle. Fungal cultures may aid in the definitive diagnosis when cattle ringworm is suspected. Increased awareness of the condition among all care providers may decrease the number of medical visits required, avoid unnecessary drug therapy, shorten the time to make the correct diagnosis, and hasten the onset of appropriate antifungal therapy.