Gorgas Case 2022-09 |
This is our last Case of the Week for 2022. We hope you have enjoyed the 2022 series of weekly live cases from Peru. We will continue to offer the Gorgas Diploma Course in February and March, and the Gorgas Advanced course in August next year, and we will be in touch at the beginning of next year’s case series. History: A 27-year-old male patient presented with a 9-year history starting with the appearance of multiple painful and pruriginous papules on his scalp. 7 years before presentation, a dermatologist prescribed a topical cream and oral pills, which he took for almost a year, but then suspended due to lack of improvement. Through the following years, the lesions persisted with small periods of inflammation and partial remittance; occasionally, other lesions would appear in other parts of his body, but these would resolve quickly. 1 week before presentation, the lesions abruptly ulcerated, forming a crusted, exudative, and painful erythematous plaque, and he also reported nightly subjective fevers. Epidemiology: Born and lives in Sicuani, in the highlands of Peru. He works in the mining industry. He is a frequent traveler, mostly to the Amazon. Past Medical History: In 2012 he had a skin abscess on the back of his neck following minor trauma. No other illnesses, currently not taking any medications. Physical Examination (on admission): Vital functions were within normal limits. Skin: crusted, diffusely erythematous verrucous plaque, with focal areas of alopecia and broken hair roots and exudative discharge in the occipital area of his scalp (Image A). No regional lymphadenopathy was noted. Rest of the exam was unremarkable. Laboratory Results: HIV and VDRL/RPR were non-reactive.
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Diagnosis: Kerion celsi Discussion: The differential diagnoses for a chronic inflammatory lesion in the scalp in our region include lobomycosis, botryomycosis, mycetoma, cutaneous tuberculosis, chromoblastomycosis, and dissecting cellulitis. However, the clinical presentation of our patient led us to a presumptive diagnosis of kerion celsi. Kerion refers to a severe inflammatory reaction to infection by zoophilic dermatophytes that cause tinea capitis. Commonly isolated dermatophytes include Microsporum canis and Trycophyton tonsurans, though the predominant pathogen varies from one geographical area to another. The diagnosis of kerion can be challenging; one proposed set of criteria include tenderness to palpation, perilesional alopecia, pustules and purulent drainage, and scaling as major criteria (Int J Dermatol. 2018 Jan;57(1):3-9. doi: 10.1111/ijd.13423). A definitive diagnosis can be made with fungal cultures, though there is a high rate of false negatives in kerion because samples may represent the inflammatory response, and results may take up to three weeks. Molecular testing for dermatophytes may provide a more timely diagnosis, but is not widely available. If untreated, kerion may lead to permanent scarring and alopecia. Empiric treatment is usually started with griseofulvin, though terbinafine is used if Tricophyton is isolated and itraconazole can be used for recurrent or severe lesions. There is no established role for adjuvant steroid therapy. Patients should be monitored closely for response, and the treatment regimen should be modified (increasing the dose or switching antifungal agents) accordingly. Our patient was started on empiric treatment with terbinafine, with marked improvement in the lesion (Image B). Fungal cultures are pending. He will continue to be monitored on an outpatient basis. |