Case for Diagnosis
Inflammatory Tinea Faciei Mimicking Sweet's Syndrome
Tinea faciei inflamatoria que simula un síndrome de Sweet
a University of Miami, Miller School of Medicine, Department of Dermatology and Cutaneous Surgery, 1600 NW 10th Ave, RMSB, Room 2023A (R250), Miami, FL 33136, United States
b Veterans Affairs Medical Center Miami (VAMC), University of Miami, Miller School of Medicine, Department of Dermatology and Cutaneous Surgery, United States
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A la derecha (C, D) se aprecia detalle del infiltrado en la dermis profunda, donde se observan células redondeadas, de núcleos grandes con cromatina laxa, y abundantes mitosis, acompañados de linfocitos normales. (HE, A-B: x40, C-D: x400).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Requena, V. Traves, B. Llombart, C. Guillén" "autores" => array:4 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Requena" ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Traves" ] 2 => array:2 [ "nombre" => "B." "apellidos" => "Llombart" ] 3 => array:2 [ "nombre" => "C." 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Alonso-Llamazares" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M.H." "apellidos" => "Viera" "email" => array:1 [ 0 => "mviera2@med.miami.edu" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "S.M." "apellidos" => "Costales" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Regalado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Alonso-Llamazares" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "University of Miami, Miller School of Medicine, Department of Dermatology and Cutaneous Surgery, 1600 NW 10th Ave, RMSB, Room 2023A (R250), Miami, FL 33136, United States" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Veterans Affairs Medical Center Miami (VAMC), University of Miami, Miller School of Medicine, Department of Dermatology and Cutaneous Surgery, United States" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tinea faciei inflamatoria que simula un síndrome de Sweet" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 600 "Ancho" => 795 "Tamanyo" => 275377 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin and Eosin Stain (HE), 4 X magnifications. Superficial and deep dense perivascular and periappendageal mixed inflammatory infiltrate with the presence of neutrophils within the hair follicles.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Medical history</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 53-year-old female with a 2-month history of a painful pruritic eruption on the face. The patient had previously presented with abrupt onset of multiple edematous pseudovesicular papules on the face and shoulders preceded by a febrile upper respiratory infection (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B). A diagnosis of Sweet's syndrome had been presumed pending pathologic confirmation. Initially, the condition was treated empirically with triamcinolone 0.1% cream twice daily and prednisone starting with 60<span class="elsevierStyleHsp" style=""></span>mg daily and gradual tapering. No improvement was observed and new lesions developed. Therefore, and after receipt of the pathology report (see below), hydroxychloroquine 200<span class="elsevierStyleHsp" style=""></span>mg twice daily was added to the corticosteroid regimen with suspicion of either Jessner lymphocytic infiltrate, lupus tumidus, or polymorphic light eruption. No response was observed after one-month of treatment.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Physical examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed multiple well-defined edematous pseudovesicular papules and plaques symmetrically distributed on the chin and both cheeks with underlying erythema and a few scattered lesions on the shoulders.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Microscopic examination</span><p id="par0015" class="elsevierStylePara elsevierViewall">Microscopic examination revealed perivascular and periadnexal lymphocytic infiltrate with papillary edema. A biopsy from lesional skin was submitted for direct-immunofluorescence with negative results. Examination of a biopsy obtained 1 month later revealed the above-mentioned changes, together with a mixed inflammatory infiltrate containing neutrophils in the hair follicle (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">What is Your Diagnosis?</span></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnosis was inflammatory <span class="elsevierStyleItalic">tinea faciei</span> caused by <span class="elsevierStyleItalic">Microsporum canis</span>. Periodic acid–Schiff staining revealed the presence of a small number of hyphae in the stratum corneum and hair follicles (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Culture identified these as <span class="elsevierStyleItalic">M. canis</span>.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Treatment</span><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment with griseofulvin 500<span class="elsevierStyleHsp" style=""></span>mg/d resulted in complete resolution of the lesions within 1 month.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Comment</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Tinea faciei</span> is a superficial dermatophyte infection localized to the glabrous skin of the face. <span class="elsevierStyleItalic">M. canis</span> is an organism that causes dermatophytosis (ringworm) mostly in dogs and cats. In humans, it is an infrequent zoonosis, usually associated with severe inflammatory reactions. Our patient was cohabiting with a dog at the time of presentation. Falahati et al. isolated <span class="elsevierStyleItalic">M. canis</span> in 6.5% of patients with dermatophyte infections in a study in Iran.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In the USA, <span class="elsevierStyleItalic">Trichophyton tonsurans</span> is the predominant dermatophyte isolated and only a few cases of <span class="elsevierStyleItalic">tinea faciei</span> caused by <span class="elsevierStyleItalic">M. canis</span> have been reported in American schools.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The prevalence differs depending on the geographic area. In Italy, <span class="elsevierStyleItalic">M. canis</span> is the main causal organism in children with dermatophyte infections of the face. In Mexico, it was isolated in 38.2% of patients with <span class="elsevierStyleItalic">tinea capitis</span>, but only a few cases of <span class="elsevierStyleItalic">tinea faciei</span> caused by this organism have been reported.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> The clinical presentation of <span class="elsevierStyleItalic">tinea faciei</span> can closely resemble that of other dermatoses, leading to misdiagnoses and delayed treatments as occurred in the present case.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> It can mimic atopic dermatitis, impetigo, lupus erythematosus, and periorificial dermatitis. Steroid-modified <span class="elsevierStyleItalic">tinea (tinea incognito)</span> may be observed when the condition has been misdiagnosed and the lesions have been erroneously treated with topical corticosteroids. Our patient initially presented with abrupt onset of a facial skin eruption. The acute onset of the lesions and their association with a febrile respiratory infection was clinically suggestive of Sweet's syndrome. Several authors have reported cases of inflammatory tinea masquerading as reactive dermatoses. For instance, tinea barbae caused by <span class="elsevierStyleItalic">Trichophyton mentagrophytes</span> can mimic contact dermatitis or acneiform dermatitis. Inflammatory tinea capitis has been reported to induce lupus erythematous-like eruptions.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Shanon et al. reported 3 patients with tinea faciei simulating discoid lupus erythematosus.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Dermatophytosis usually follows a chronic non-inflammatory clinical course and is mostly limited to the superficial keratin structures. Subcutaneous involvement is rare and involves atypical clinical manifestations such as pustular psoriasiform trichophytia, trichophytosis mimicking pseudolymphoma or Sweet's syndrome, and impetiginized herpetiform trichophytosis in which a definitive diagnosis is generally confirmed by biopsy. Exceptional cases have been reported of tinea corporis bullosa caused by <span class="elsevierStyleItalic">M. canis</span> in which the clinical presentation was characterized by multiple annular bullous lesions.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the present case, the clinical picture resembled Sweet's syndrome, but subsequent treatment with oral and topical corticosteroids only worsened the condition. Despite repeated biopsies, diagnosis was challenging, and only appropriate histopathological examination with special stains and tissue cultures allowed the diagnosis to be confirmed, isolating <span class="elsevierStyleItalic">M. canis</span> as the pathogenic organism. The lesions resolved completely after 1 month of treatment with griseofulvin.</p><p id="par0045" class="elsevierStylePara elsevierViewall">This case illustrates the need to consider an infectious etiology in what would otherwise be presumed to be cases of reactive dermatosis refractory to corticosteroid therapy.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical history" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Microscopic examination" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Treatment" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Comment" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 7 => 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" => 1250 "Ancho" => 833 "Tamanyo" => 152956 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Facial lesions (A-Lateral; B-Inferior) multiple symmetrically distributed edematous papules on bilateral cheeks and chin.</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" => 600 "Ancho" => 795 "Tamanyo" => 275377 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin and Eosin Stain (HE), 4 X magnifications. Superficial and deep dense perivascular and periappendageal mixed inflammatory infiltrate with the presence of neutrophils within the hair follicles.</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" => 500 "Ancho" => 602 "Tamanyo" => 131982 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Periodic acid-Schiff (PAS) 40X magnification. Hyphae located to the corneal layer confirmed by PAS stain.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of dermatophytoses in an area south of Tehran, Iran" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Falahati" 1 => "L. Akhlaghi" 2 => "A.R. Lari" 3 => "R. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 13 | 7 | 20 |
| 2024 Octubre | 73 | 34 | 107 |
| 2024 Septiembre | 98 | 20 | 118 |
| 2024 Agosto | 104 | 41 | 145 |
| 2024 Julio | 98 | 27 | 125 |
| 2024 Junio | 98 | 33 | 131 |
| 2024 Mayo | 69 | 33 | 102 |
| 2024 Abril | 78 | 17 | 95 |
| 2024 Marzo | 86 | 23 | 109 |
| 2024 Febrero | 71 | 30 | 101 |
| 2024 Enero | 53 | 28 | 81 |
| 2023 Diciembre | 79 | 14 | 93 |
| 2023 Noviembre | 135 | 25 | 160 |
| 2023 Octubre | 91 | 15 | 106 |
| 2023 Septiembre | 66 | 24 | 90 |
| 2023 Agosto | 62 | 13 | 75 |
| 2023 Julio | 104 | 31 | 135 |
| 2023 Junio | 85 | 17 | 102 |
| 2023 Mayo | 42 | 15 | 57 |
| 2023 Abril | 104 | 15 | 119 |
| 2023 Marzo | 125 | 32 | 157 |
| 2023 Febrero | 84 | 29 | 113 |
| 2023 Enero | 86 | 27 | 113 |
| 2022 Diciembre | 60 | 42 | 102 |
| 2022 Noviembre | 71 | 26 | 97 |
| 2022 Octubre | 97 | 37 | 134 |
| 2022 Septiembre | 96 | 44 | 140 |
| 2022 Agosto | 53 | 43 | 96 |
| 2022 Julio | 45 | 33 | 78 |
| 2022 Junio | 40 | 34 | 74 |
| 2022 Mayo | 51 | 43 | 94 |
| 2022 Abril | 62 | 34 | 96 |
| 2022 Marzo | 53 | 52 | 105 |
| 2022 Febrero | 43 | 44 | 87 |
| 2022 Enero | 42 | 62 | 104 |
| 2021 Diciembre | 30 | 49 | 79 |
| 2021 Noviembre | 49 | 40 | 89 |
| 2021 Octubre | 46 | 63 | 109 |
| 2021 Septiembre | 40 | 41 | 81 |
| 2021 Agosto | 37 | 46 | 83 |
| 2021 Julio | 26 | 44 | 70 |
| 2021 Junio | 41 | 49 | 90 |
| 2021 Mayo | 97 | 60 | 157 |
| 2021 Abril | 75 | 95 | 170 |
| 2021 Marzo | 69 | 36 | 105 |
| 2021 Febrero | 40 | 31 | 71 |
| 2021 Enero | 31 | 15 | 46 |
| 2020 Diciembre | 29 | 16 | 45 |
| 2020 Noviembre | 27 | 21 | 48 |
| 2020 Octubre | 24 | 7 | 31 |
| 2020 Septiembre | 29 | 25 | 54 |
| 2020 Agosto | 20 | 21 | 41 |
| 2020 Julio | 29 | 18 | 47 |
| 2020 Junio | 29 | 37 | 66 |
| 2020 Mayo | 42 | 26 | 68 |
| 2020 Abril | 20 | 27 | 47 |
| 2020 Marzo | 31 | 29 | 60 |
| 2020 Febrero | 4 | 10 | 14 |
| 2020 Enero | 4 | 2 | 6 |
| 2019 Diciembre | 4 | 1 | 5 |
| 2019 Noviembre | 4 | 1 | 5 |
| 2019 Octubre | 0 | 4 | 4 |
| 2019 Septiembre | 0 | 10 | 10 |
| 2019 Agosto | 4 | 11 | 15 |
| 2019 Julio | 4 | 14 | 18 |
| 2019 Junio | 4 | 23 | 27 |
| 2019 Mayo | 4 | 24 | 28 |
| 2019 Abril | 2 | 9 | 11 |
| 2019 Marzo | 2 | 10 | 12 |
| 2019 Febrero | 7 | 4 | 11 |
| 2019 Enero | 6 | 1 | 7 |
| 2018 Diciembre | 2 | 4 | 6 |
| 2018 Noviembre | 2 | 2 | 4 |
| 2018 Octubre | 3 | 2 | 5 |
| 2018 Septiembre | 12 | 2 | 14 |
| 2018 Agosto | 1 | 3 | 4 |
| 2018 Julio | 0 | 4 | 4 |
| 2018 Junio | 0 | 2 | 2 |
| 2018 Mayo | 1 | 13 | 14 |
| 2018 Abril | 0 | 2 | 2 |
| 2018 Marzo | 1 | 7 | 8 |
| 2018 Febrero | 54 | 18 | 72 |
| 2018 Enero | 50 | 6 | 56 |
| 2017 Diciembre | 65 | 10 | 75 |
| 2017 Noviembre | 48 | 4 | 52 |
| 2017 Octubre | 46 | 6 | 52 |
| 2017 Septiembre | 39 | 13 | 52 |
| 2017 Agosto | 438 | 13 | 451 |
| 2017 Julio | 46 | 14 | 60 |
| 2017 Junio | 60 | 20 | 80 |
| 2017 Mayo | 56 | 15 | 71 |
| 2017 Abril | 53 | 19 | 72 |
| 2017 Marzo | 63 | 11 | 74 |
| 2017 Febrero | 33 | 5 | 38 |
| 2017 Enero | 40 | 23 | 63 |
| 2016 Diciembre | 51 | 15 | 66 |
| 2016 Noviembre | 47 | 9 | 56 |
| 2016 Octubre | 74 | 23 | 97 |
| 2016 Septiembre | 63 | 9 | 72 |
| 2016 Agosto | 41 | 9 | 50 |
| 2016 Julio | 33 | 10 | 43 |
| 2016 Junio | 11 | 12 | 23 |
| 2016 Mayo | 6 | 0 | 6 |
| 2016 Abril | 9 | 2 | 11 |
| 2016 Marzo | 5 | 0 | 5 |
| 2016 Febrero | 8 | 9 | 17 |
| 2016 Enero | 10 | 0 | 10 |
| 2015 Diciembre | 10 | 11 | 21 |
| 2015 Noviembre | 13 | 14 | 27 |
| 2015 Octubre | 8 | 10 | 18 |
| 2015 Septiembre | 9 | 6 | 15 |
| 2015 Agosto | 11 | 0 | 11 |
| 2015 Julio | 153 | 1 | 154 |
| 2015 Junio | 106 | 10 | 116 |
| 2015 Mayo | 221 | 21 | 242 |
| 2015 Abril | 106 | 14 | 120 |
| 2015 Marzo | 110 | 4 | 114 |
| 2015 Febrero | 95 | 1 | 96 |
| 2015 Enero | 98 | 0 | 98 |
| 2014 Diciembre | 58 | 0 | 58 |
| 2014 Noviembre | 38 | 0 | 38 |
| 2014 Octubre | 51 | 0 | 51 |
| 2014 Septiembre | 33 | 0 | 33 |
| 2014 Agosto | 53 | 0 | 53 |
| 2014 Julio | 40 | 0 | 40 |
| 2014 Junio | 40 | 0 | 40 |
| 2014 Mayo | 63 | 0 | 63 |
| 2014 Abril | 54 | 0 | 54 |
| 2014 Marzo | 78 | 16 | 94 |
| 2014 Febrero | 99 | 25 | 124 |
| 2014 Enero | 97 | 15 | 112 |
| 2013 Diciembre | 116 | 22 | 138 |
| 2013 Noviembre | 86 | 12 | 98 |
| 2013 Octubre | 80 | 12 | 92 |
| 2013 Septiembre | 96 | 8 | 104 |
| 2013 Agosto | 51 | 12 | 63 |
| 2013 Julio | 66 | 22 | 88 |
| 2013 Junio | 67 | 15 | 82 |
| 2013 Mayo | 66 | 8 | 74 |
| 2013 Abril | 82 | 24 | 106 |
| 2013 Marzo | 76 | 20 | 96 |
| 2013 Febrero | 56 | 40 | 96 |
| 2013 Enero | 4 | 4 | 8 |
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