Revival of generalized favus

Abstract

An immunocompetent 70-year-old woman from a rural village complained of painful lesions of the scalp, adjacent area of the face, and trunk evolving for 2 months. Examination revealed extensive cicatricial alopecia and extensive scaling and crusted plaques (Figure 1). These plaques presented as concave cup-shaped, whitish, isolated, or confluent scutula of 0.5-5 cm diameter involving the scalp, face (Figure 2), and trunk (Figure 3), with an unpleasant mousy odor.Figure 2Extensive concave cup-shaped, whitish, isolated, or confluent scutula involving the face, ear, and neck.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Concave cup-shaped, whitish, isolated, or confluent scutula with erythematous base on the trunk.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Direct microscopic examination of infected hairs in 10% potassium hydroxide showed endothrix invasion with the presence of hyphae (Figure 4) and a huge number of hyphae and spores in the crust as revealed by periodic acid-Schiff staining (Figure 5) and calcofluor white staining (Figure 6). Fungal culture of infected hair and crusts on Sabouraud glucose agar yielded whitish, waxy heaped, and irregularly folded colonies. Microscopic examination of cultures revealed antler-like filaments with favic characteristic chandelier structures, and few intercalate chlamydospores. The isolate was further confirmed as Trichophyton schoenleinii by internal transcribed spacer-polymerase chain reaction sequencing. Laboratory examination showed significant hypoalbuminemia (24 g/l). The diagnosis of generalized favus because of T. schoenleinii was confirmed. A clinical and mycological cure was achieved after treatment with an oral terbinafine tablet (250 mg/d) for one month.Figure 4Direct microscopy of ill-hairs revealed the presence of endothrix hyphae, which grow in parallel to the long axis of the hair shaft (original magnification × 400).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Huge number of hyphae and spores with concavity revealed in the crust stained with periodic acid-Schiff staining (original magnification × 400).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Large number of hyphae and spores with central cleft could be detected in the crust stained with calcofluor white staining (original magnification × 400).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Tinea capitis favosa is a chronic inflammatory dermatophyte infection of the scalp (Ilkit, 2010Ilkit M. Favus of the scalp: an overview and update.Mycopathologia. 2010; 170: 143-154Crossref PubMed Scopus (42) Google Scholar), which affects patients with anthropophilic Trichophyton schoenleinii, T. violaceum, T. verrucosum, zoophilic T. mentagrophytes var. quinckeanum, Microsporum canis, and geophilic Nannizzia gypsea (Xia et al., 2018Xia XJ Zhang Y Zhong Y Sang B Li QP Wang M et al.Novel in vivo observations of scrotal Nannizzia gypsea infection.Br J Dermatol. 2018; 179: 499-501PubMed Google Scholar). Generalized favus is uncommon (Iwasa et al., 2019Iwasa K Ogawa K Azukizawa H Tanabe H Iwanaga T Anzawa K et al.Revival of favus in Japan caused by Trichophyton schoenleinii.J Dermatol. 2019; 46: 347-350Crossref PubMed Scopus (2) Google Scholar), which was seen in geographic regions with extreme poverty, poor hygiene, and malnutrition (Ilkit, 2010Ilkit M. Favus of the scalp: an overview and update.Mycopathologia. 2010; 170: 143-154Crossref PubMed Scopus (42) Google Scholar). The patient admitted to fasting for several months, leading to malnutrition with significant hypoalbuminemia. The white appearance of skin lesions results from incoherent reflections of light on their many surfaces among the abundant hyphae and separated keratinocytes (Liu et al., 2019Liu ZH Xia XJ Zhang Y Zhong Y Sang B Li QP et al.Favus of scrotum because of Trichophyton rubrum in immunocompetent patients: a clinical, mycological and ultrastructural study.Mycopathologia. 2019; 184: 433-439Crossref PubMed Scopus (3) Google Scholar). The concave, cup-shaped appearance of favus results from peripheral well-preserved hyphae with central dead and degenerating mycelium and debris (Ilkit, 2010Ilkit M. Favus of the scalp: an overview and update.Mycopathologia. 2010; 170: 143-154Crossref PubMed Scopus (42) Google Scholar). An immunocompetent 70-year-old woman from a rural village complained of painful lesions of the scalp, adjacent area of the face, and trunk evolving for 2 months. Examination revealed extensive cicatricial alopecia and extensive scaling and crusted plaques (Figure 1). These plaques presented as concave cup-shaped, whitish, isolated, or confluent scutula of 0.5-5 cm diameter involving the scalp, face (Figure 2), and trunk (Figure 3), with an unpleasant mousy odor. Direct microscopic examination of infected hairs in 10% potassium hydroxide showed endothrix invasion with the presence of hyphae (Figure 4) and a huge number of hyphae and spores in the crust as revealed by periodic acid-Schiff staining (Figure 5) and calcofluor white staining (Figure 6). Fungal culture of infected hair and crusts on Sabouraud glucose agar yielded whitish, waxy heaped, and irregularly folded colonies. Microscopic examination of cultures revealed antler-like filaments with favic characteristic chandelier structures, and few intercalate chlamydospores. The isolate was further confirmed as Trichophyton schoenleinii by internal transcribed spacer-polymerase chain reaction sequencing. Laboratory examination showed significant hypoalbuminemia (24 g/l). The diagnosis of generalized favus because of T. schoenleinii was confirmed. A clinical and mycological cure was achieved after treatment with an oral terbinafine tablet (250 mg/d) for one month. Tinea capitis favosa is a chronic inflammatory dermatophyte infection of the scalp (Ilkit, 2010Ilkit M. Favus of the scalp: an overview and update.Mycopathologia. 2010; 170: 143-154Crossref PubMed Scopus (42) Google Scholar), which affects patients with anthropophilic Trichophyton schoenleinii, T. violaceum, T. verrucosum, zoophilic T. mentagrophytes var. quinckeanum, Microsporum canis, and geophilic Nannizzia gypsea (Xia et al., 2018Xia XJ Zhang Y Zhong Y Sang B Li QP Wang M et al.Novel in vivo observations of scrotal Nannizzia gypsea infection.Br J Dermatol. 2018; 179: 499-501PubMed Google Scholar). Generalized favus is uncommon (Iwasa et al., 2019Iwasa K Ogawa K Azukizawa H Tanabe H Iwanaga T Anzawa K et al.Revival of favus in Japan caused by Trichophyton schoenleinii.J Dermatol. 2019; 46: 347-350Crossref PubMed Scopus (2) Google Scholar), which was seen in geographic regions with extreme poverty, poor hygiene, and malnutrition (Ilkit, 2010Ilkit M. Favus of the scalp: an overview and update.Mycopathologia. 2010; 170: 143-154Crossref PubMed Scopus (42) Google Scholar). The patient admitted to fasting for several months, leading to malnutrition with significant hypoalbuminemia. The white appearance of skin lesions results from incoherent reflections of light on their many surfaces among the abundant hyphae and separated keratinocytes (Liu et al., 2019Liu ZH Xia XJ Zhang Y Zhong Y Sang B Li QP et al.Favus of scrotum because of Trichophyton rubrum in immunocompetent patients: a clinical, mycological and ultrastructural study.Mycopathologia. 2019; 184: 433-439Crossref PubMed Scopus (3) Google Scholar). The concave, cup-shaped appearance of favus results from peripheral well-preserved hyphae with central dead and degenerating mycelium and debris (Ilkit, 2010Ilkit M. Favus of the scalp: an overview and update.Mycopathologia. 2010; 170: 143-154Crossref PubMed Scopus (42) Google Scholar). The authors have no competing interests to declare. Drs. Xia, Zhi, Liu: acquisition and interpretation of data, Drs. Xia, Zhi, Liu: preparation of the manuscript, Drs. Xia, Zhi, Liu: conceived the study concept, supervised data acquisition and interpretation, Dr Liu: took care of the patient, Drs. Xia, Zhi, Liu: completion of the manuscript.