Case and Research Letter
Majocchi Granuloma of the Breast: A Rare Clinical Entity
Granuloma de Majocchi: Una rara entidad
U. Khanna
, T. Kumar Dhali, P. D'Souza, S. Chowdhry
Corresponding author
Department of Dermatology, ESIPGIMSR Basaidarapur, New Delhi, 15, India
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B, Histologic findings: detailed view of perivascular plasma cells (hematoxylin-eosin, original magnification ×40). C, Positive immunohistochemical staining for <span class="elsevierStyleItalic">Treponema pallidum</span>.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "N. Jiménez-Gómez, Á. Hermosa-Gelbard, R. Carrillo-Gijón, P. Jaén" "autores" => array:4 [ 0 => array:2 [ "nombre" => "N." "apellidos" => "Jiménez-Gómez" ] 1 => array:2 [ "nombre" => "Á." "apellidos" => "Hermosa-Gelbard" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Carrillo-Gijón" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Jaén" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S000173101630014X" "doi" => "10.1016/j.ad.2016.02.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S000173101630014X?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016301457?idApp=UINPBA000044" "url" => "/15782190/0000010700000007/v2_201704140340/S1578219016301457/v2_201704140340/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1578219016301445" "issn" => "15782190" "doi" => "10.1016/j.adengl.2016.06.013" "estado" => "S300" "fechaPublicacion" => "2016-09-01" "aid" => "1389" "copyright" => "Elsevier España, S.L.U. and AEDV" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2016;107:607-10" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 753 "formatos" => array:3 [ "EPUB" => 49 "HTML" => 541 "PDF" => 163 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letter</span>" "titulo" => "Benign Cutaneous Plexiform Hybrid Tumor of Perineurioma and Cellular Neurothekeoma" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "607" "paginaFinal" => "610" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tumor benigno cutáneo plexiforme híbrido de perineuroma y neurotecoma celular" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 996 "Ancho" => 2006 "Tamanyo" => 716326 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, In the superficial dermis, a circumscribed nonencapsulated nodule is observed that does not make contact with the epidermis. Hematoxylin and eosin (H&E), original magnification<span class="elsevierStyleHsp" style=""></span>×2. B, Plexiform architectural pattern. The neoplastic cells form round and irregular nests in a predominantly myxoid stroma. No neural or vascular structures are visible within these nests. H&E, original magnification<span class="elsevierStyleHsp" style=""></span>×10.<span class="elsevierStyleHsp" style=""></span>C, The majority of the neoplastic cells have ovoid nuclei with inconspicuous nucleoli and eosinophilic cytoplasm with poorly defined borders. These cells are intimately associated with distinct spindle-shaped cells with delicate, elongated, hyperchromatic nuclei. D, Diffuse positivity for MiTF in the nuclei of the neoplastic cells. Original magnification<span class="elsevierStyleHsp" style=""></span>×10. E, Focal positivity for claudin-1 in the neoplastic cells. Original magnification<span class="elsevierStyleHsp" style=""></span>×10. F, Positivity for CD163 in numerous interstitial cells between the nests. Original magnification<span class="elsevierStyleHsp" style=""></span>×10.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Areán, A. Córdoba, L. Requena, Ma.L. Álvarez" "autores" => array:4 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Areán" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Córdoba" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Requena" ] 3 => array:2 [ "nombre" => "Ma.L." 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Khanna, T. Kumar Dhali, P. D'Souza, S. Chowdhry" "autores" => array:4 [ 0 => array:4 [ "nombre" => "U." "apellidos" => "Khanna" "email" => array:1 [ 0 => "urmi23khanna@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "T." "apellidos" => "Kumar Dhali" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "D'Souza" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Chowdhry" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Dermatology, ESIPGIMSR Basaidarapur, New Delhi, 15, India" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Granuloma de Majocchi: Una rara entidad" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 600 "Ancho" => 800 "Tamanyo" => 75893 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Complete resolution of the plaque after finishing treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Deep penetration of the skin by dermatophytic agents may provoke a granulomatous inflammatory skin reaction. This was first described by Majocchi.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> Majocchi granuloma is characterized clinically by papular, pustular, or nodular inflammatory lesions occurring typically on the limbs or face,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> though isolated cases affecting the vulva or scrotum have been published.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> We report a unique presentation of Majocchi granuloma in the breast; there are no previous reports of involvement of this location.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 28-year-old female presented with a slightly painful, raised reddish lesion that had developed in her left breast over the previous 3 months. She gave no history of trauma and did not describe constitutional symptoms. The lesion had increased in size after the repeated application of mud to the area over 2 months. Treatment with a potent topical corticosteroid (betamethasone valerate, 0.122% wt/wt) was then applied twice daily for a month.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical examination revealed a single erythematous plaque with areas of scarring. A yellowish discharge emanated from multiple openings in an area beneath the left nipple measuring approximately 5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). On palpation the plaque was firm and indurated and was slightly tender; there was no underlying breast lump. Diascopy findings were nonspecific. Gram stain of the discharge showed the presence of gram-positive cocci and abundant neutrophils. No acid-fast bacilli (AFB) were seen on direct smear. Potassium hydroxide (KOH) mount and fungal culture of skin scrapings and of the discharge was negative. Ultrasonography of the breasts was normal, though a single lymph node of 20<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>mm with a preserved hilum was observed in the left axilla. Chest X-ray was normal and the Mantoux skin test produced a wheal of 8<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mm. Routine blood tests were within normal limits. The patient was treated with oral cefuroxime 500<span class="elsevierStyleHsp" style=""></span>mg twice a day plus topical 2% mupirocin cream but showed no improvement after 2 weeks of treatment. We performed skin biopsy based on a differential diagnosis of hidradenitis suppurativa, lupus vulgaris, or subcutaneous fungal infection. Hematoxylin and eosin staining of the sample revealed a mixed cell, granulomatous inflammatory reaction in the dermis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Ziehl-Neelsen and periodic acid Schiff (PAS) stains to detect AFB and fungi were both negative. Mycobacterial culture of the tissue sample was negative, but fungal culture on Sabouraud dextrose agar with chloramphenicol produced growth of heaped up, folded violaceous colonies of waxy consistency after 3 weeks, suggestive of <span class="elsevierStyleItalic">Trichophyton violaceum</span>. Lactophenol cotton blue mount showed the presence of tangled, irregular branched hyphae with chlamydospores. With a final diagnosis of Majocchi's granuloma, the patient was treated with 250<span class="elsevierStyleHsp" style=""></span>mg of oral terbinafine once daily plus topical 2% sertaconazole cream twice daily. The lesion resolved completely within 8 weeks and there was no evidence of recurrence after 6 months of follow-up (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In 1883, Majocchi<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> described a phenomenon in which dermatophytes, which usually remain limited to the stratum corneum, become more aggressive and invade the superficial dermis. Majocchi granuloma typically develops when a dermatophyte infection extends down a hair follicle in the setting of localized immunosuppression (most commonly a potent topical steroid) or systemic immunosuppression. The result is a granulomatous response in the dermis.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> The commonly implicated organisms are <span class="elsevierStyleItalic">Trichophyton</span> species (<span class="elsevierStyleItalic">rubrum</span>, <span class="elsevierStyleItalic">mentagrophytes complex</span>, <span class="elsevierStyleItalic">violaceum</span>) as well as some nondermatophyte species such as <span class="elsevierStyleItalic">Aspergillus</span> and <span class="elsevierStyleItalic">Phoma</span>.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> Although historically <span class="elsevierStyleItalic">T. violaceum</span> has been the most commonly identified organism, Majocchi granuloma now a days is usually due to <span class="elsevierStyleItalic">T rubrum</span>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Two clinical forms of Majocchi granuloma, follicular and subcutaneous nodular, have been described.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> The follicular type usually develops after trauma, repeated shaving of hair-bearing areas, or topical corticosteroid treatment, and in cases of long-standing immunosuppression.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">5,6</span></a> The subcutaneous nodular type occurs in immunocompromised hosts. Our patient developed the follicular type, probably caused by endothrix-type infection due to anthropophilic <span class="elsevierStyleItalic">T. violaceum</span> secondary to the use of a potent topical steroid under occlusion, which could have led to deep penetration of the fungus. In modern medicine, systemic antifungals such as griseofulvin,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> itraconazole,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> and terbinafine<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> are the mainstays of therapy as they are safe and effective. The duration of therapy should be of at least 4–8 weeks, and treatment should be continued until all lesions have cleared. In the reports in literature, nearly all lesions resolve without scarring within 6 weeks of starting antifungal. The response of Majocchi granuloma to oral terbinafine can be explained on the basis of its pharmacokinetics.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> Terbinafine is the preferred oral therapy for treating Majocchi granuloma not only for its superior efficacy in eliminating dermatophytes, but also because of its greater selectivity for the skin structures involved in Majocchi granuloma and fewer drug interactions than azole antifungals like itraconazole.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> We used terbinafine for its good antidermatophyte activity, adequate penetration into common sites of dermatophyte infection (stratum corneum and the hair follicle), lower rates of recurrence, low rate of drug interactions (its metabolism does not involve cytochrome P450), and its cost effectiveness when long-term therapy is warranted to prevent relapse.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> A diagnosis of Majocchi granuloma should always be considered in papular-pustular plaques, especially when the patient describes factors associated with local or systemic immunosuppression. Negative results of KOH examination or fungal culture of skin scrapings or of the purulent discharge do not exclude a diagnosis of Majocchi granuloma, which should be confirmed either by tissue culture or by PAS staining of histopathology samples. Although the detection of fungal spores or hyphae using special stains on histopathology samples will confirm the diagnosis, these structures may sometimes escape detection, as in our case.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> Fungal spores and hyphae are usually detected within hairs or hair follicles and in dermal granulomas. Our inability to detect the fungal elements may have been due to the absence of hair follicles and the poorly defined granulomas in our biopsy specimen. To the best of our knowledge, this is the first reported case of Majocchi granuloma of the breast.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 705 "Ancho" => 849 "Tamanyo" => 134271 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Papular-pustular plaque on the left breast with central scarring and a purulent discharge visible at the periphery.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 675 "Ancho" => 900 "Tamanyo" => 291478 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Acanthosis of the epidermis with a mixed cell inflammatory infiltrate in the superficial and mid dermis. Hematoxylin and eosin, original magnification ×100.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 600 "Ancho" => 800 "Tamanyo" => 75893 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Complete resolution of the plaque after finishing treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Sepra una nuova tricofizia (granuloma tricofitico), studi clinici micologici" "tituloTraducido" => "A new Trichophyton granuloma: clinical and mycological studies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 17 | 8 | 25 |
| 2024 October | 222 | 43 | 265 |
| 2024 September | 154 | 29 | 183 |
| 2024 August | 194 | 61 | 255 |
| 2024 July | 121 | 38 | 159 |
| 2024 June | 142 | 44 | 186 |
| 2024 May | 124 | 37 | 161 |
| 2024 April | 112 | 30 | 142 |
| 2024 March | 139 | 28 | 167 |
| 2024 February | 146 | 31 | 177 |
| 2024 January | 152 | 29 | 181 |
| 2023 December | 200 | 20 | 220 |
| 2023 November | 273 | 42 | 315 |
| 2023 October | 246 | 35 | 281 |
| 2023 September | 173 | 33 | 206 |
| 2023 August | 121 | 20 | 141 |
| 2023 July | 114 | 42 | 156 |
| 2023 June | 97 | 24 | 121 |
| 2023 May | 125 | 24 | 149 |
| 2023 April | 116 | 19 | 135 |
| 2023 March | 107 | 20 | 127 |
| 2023 February | 88 | 24 | 112 |
| 2023 January | 56 | 36 | 92 |
| 2022 December | 53 | 32 | 85 |
| 2022 November | 29 | 28 | 57 |
| 2022 October | 34 | 23 | 57 |
| 2022 September | 26 | 28 | 54 |
| 2022 August | 23 | 34 | 57 |
| 2022 July | 21 | 36 | 57 |
| 2022 June | 50 | 34 | 84 |
| 2022 May | 95 | 39 | 134 |
| 2022 April | 90 | 36 | 126 |
| 2022 March | 74 | 50 | 124 |
| 2022 February | 48 | 29 | 77 |
| 2022 January | 70 | 39 | 109 |
| 2021 December | 52 | 36 | 88 |
| 2021 November | 80 | 54 | 134 |
| 2021 October | 69 | 56 | 125 |
| 2021 September | 66 | 42 | 108 |
| 2021 August | 53 | 39 | 92 |
| 2021 July | 48 | 39 | 87 |
| 2021 June | 74 | 24 | 98 |
| 2021 May | 60 | 43 | 103 |
| 2021 April | 138 | 82 | 220 |
| 2021 March | 106 | 32 | 138 |
| 2021 February | 75 | 32 | 107 |
| 2021 January | 57 | 18 | 75 |
| 2020 December | 58 | 17 | 75 |
| 2020 November | 42 | 17 | 59 |
| 2020 October | 33 | 7 | 40 |
| 2020 September | 61 | 14 | 75 |
| 2020 August | 41 | 17 | 58 |
| 2020 July | 36 | 25 | 61 |
| 2020 June | 28 | 23 | 51 |
| 2020 May | 20 | 19 | 39 |
| 2020 April | 17 | 16 | 33 |
| 2020 March | 24 | 13 | 37 |
| 2020 February | 6 | 1 | 7 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 4 | 0 | 4 |
| 2019 November | 4 | 0 | 4 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 4 | 0 | 4 |
| 2019 May | 5 | 1 | 6 |
| 2019 April | 2 | 5 | 7 |
| 2019 March | 2 | 0 | 2 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 2 | 0 | 2 |
| 2018 November | 1 | 0 | 1 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 3 | 0 | 3 |
| 2018 February | 15 | 2 | 17 |
| 2018 January | 25 | 6 | 31 |
| 2017 December | 46 | 8 | 54 |
| 2017 November | 25 | 3 | 28 |
| 2017 October | 26 | 8 | 34 |
| 2017 September | 23 | 6 | 29 |
| 2017 August | 28 | 8 | 36 |
| 2017 July | 39 | 21 | 60 |
| 2017 June | 26 | 8 | 34 |
| 2017 May | 35 | 7 | 42 |
| 2017 April | 42 | 7 | 49 |
| 2017 March | 13 | 11 | 24 |
| 2017 February | 14 | 5 | 19 |
| 2017 January | 14 | 10 | 24 |
| 2016 December | 18 | 14 | 32 |
| 2016 November | 17 | 19 | 36 |
| 2016 October | 16 | 16 | 32 |
| 2016 September | 1 | 0 | 1 |
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