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
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Department of Dermatology, ESIPGIMSR Basaidarapur, New Delhi, 15, India
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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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 7 | 7 | 14 |
| 2024 Octubre | 81 | 39 | 120 |
| 2024 Septiembre | 74 | 17 | 91 |
| 2024 Agosto | 83 | 46 | 129 |
| 2024 Julio | 70 | 26 | 96 |
| 2024 Junio | 82 | 37 | 119 |
| 2024 Mayo | 66 | 32 | 98 |
| 2024 Abril | 76 | 38 | 114 |
| 2024 Marzo | 78 | 29 | 107 |
| 2024 Febrero | 74 | 44 | 118 |
| 2024 Enero | 59 | 23 | 82 |
| 2023 Diciembre | 62 | 15 | 77 |
| 2023 Noviembre | 44 | 37 | 81 |
| 2023 Octubre | 61 | 39 | 100 |
| 2023 Septiembre | 58 | 28 | 86 |
| 2023 Agosto | 55 | 28 | 83 |
| 2023 Julio | 87 | 39 | 126 |
| 2023 Junio | 43 | 18 | 61 |
| 2023 Mayo | 94 | 29 | 123 |
| 2023 Abril | 79 | 20 | 99 |
| 2023 Marzo | 69 | 25 | 94 |
| 2023 Febrero | 64 | 20 | 84 |
| 2023 Enero | 63 | 23 | 86 |
| 2022 Diciembre | 75 | 38 | 113 |
| 2022 Noviembre | 51 | 42 | 93 |
| 2022 Octubre | 54 | 28 | 82 |
| 2022 Septiembre | 61 | 41 | 102 |
| 2022 Agosto | 70 | 45 | 115 |
| 2022 Julio | 41 | 38 | 79 |
| 2022 Junio | 48 | 40 | 88 |
| 2022 Mayo | 49 | 34 | 83 |
| 2022 Abril | 51 | 57 | 108 |
| 2022 Marzo | 43 | 56 | 99 |
| 2022 Febrero | 42 | 26 | 68 |
| 2022 Enero | 56 | 46 | 102 |
| 2021 Diciembre | 43 | 50 | 93 |
| 2021 Noviembre | 44 | 50 | 94 |
| 2021 Octubre | 58 | 50 | 108 |
| 2021 Septiembre | 32 | 35 | 67 |
| 2021 Agosto | 68 | 28 | 96 |
| 2021 Julio | 31 | 32 | 63 |
| 2021 Junio | 28 | 18 | 46 |
| 2021 Mayo | 51 | 45 | 96 |
| 2021 Abril | 124 | 96 | 220 |
| 2021 Marzo | 92 | 40 | 132 |
| 2021 Febrero | 76 | 23 | 99 |
| 2021 Enero | 43 | 20 | 63 |
| 2020 Diciembre | 48 | 19 | 67 |
| 2020 Noviembre | 27 | 24 | 51 |
| 2020 Octubre | 24 | 11 | 35 |
| 2020 Septiembre | 44 | 16 | 60 |
| 2020 Agosto | 23 | 13 | 36 |
| 2020 Julio | 42 | 17 | 59 |
| 2020 Junio | 45 | 36 | 81 |
| 2020 Mayo | 30 | 29 | 59 |
| 2020 Abril | 25 | 22 | 47 |
| 2020 Marzo | 38 | 25 | 63 |
| 2020 Febrero | 4 | 2 | 6 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 2 | 0 | 2 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Septiembre | 4 | 0 | 4 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 5 | 0 | 5 |
| 2019 Mayo | 4 | 1 | 5 |
| 2019 Abril | 2 | 4 | 6 |
| 2019 Febrero | 2 | 0 | 2 |
| 2019 Enero | 1 | 0 | 1 |
| 2018 Diciembre | 2 | 2 | 4 |
| 2018 Noviembre | 2 | 0 | 2 |
| 2018 Octubre | 4 | 0 | 4 |
| 2018 Septiembre | 1 | 0 | 1 |
| 2018 Julio | 2 | 0 | 2 |
| 2018 Mayo | 1 | 0 | 1 |
| 2018 Febrero | 10 | 5 | 15 |
| 2018 Enero | 13 | 7 | 20 |
| 2017 Diciembre | 19 | 8 | 27 |
| 2017 Noviembre | 11 | 9 | 20 |
| 2017 Octubre | 10 | 6 | 16 |
| 2017 Septiembre | 10 | 8 | 18 |
| 2017 Agosto | 7 | 5 | 12 |
| 2017 Julio | 8 | 10 | 18 |
| 2017 Junio | 12 | 12 | 24 |
| 2017 Mayo | 7 | 17 | 24 |
| 2017 Abril | 12 | 14 | 26 |
| 2017 Marzo | 9 | 20 | 29 |
| 2017 Febrero | 8 | 11 | 19 |
| 2017 Enero | 6 | 15 | 21 |
| 2016 Diciembre | 21 | 32 | 53 |
| 2016 Noviembre | 15 | 21 | 36 |
| 2016 Octubre | 26 | 30 | 56 |
| 2016 Septiembre | 7 | 4 | 11 |
| 2016 Agosto | 8 | 8 | 16 |
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