Path Quiz Case-100 : Diagnosis -

           Dermatophyte Infection

                  Dermatophytosis

    Dr Sampurna Roy MD  

 Path Case 100: Case history and images:

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 Image Link1 ;  Image Link2  ;

Image Link3 ; Image Link4 .

Skin infections -(Histopathological patterns)

The most important superficial mycoses is dermatophytosis, a clinical entity caused by a group of related filamentous fungi - Dermatophytes, of the genera Epidermophyton , Microsporum  and  Trichophyton.

DIseases produced by the dermatophytes occur worldwide and are known as tineas, or ringworm.

The clinical appearances are variable and depend on a number of factor:  i)  Species of fungus ii)  Site of infection iii) Immunological status of the patient  iv)  Use of topical steroid.

Atypical presentation following use of topical steroids have been called 'tinea incognito'.

Subtypes:

1) Tinea Capitis: ( tinea of the head , scalp, eye-brow, and eyelash).   Kerion is a boggy violaceous inflammatory area of dermal suppuration and folliculitis. Favus is a chronic infection of the scalp and rarely of the glaborous skin which is usually acquired in childhood.

2) Tinea Faciei : Rare variant presenting as a facial erythema with scaling

3) Tinea corporis (of the body)- The term 'radiation port dermatophytosis'- is used for cases of tinea corporis localized to irradiated skin.

4) Tinea cruris (of the groin)- Occurs exclusively in males. Have been noted in patients with AIDS. Diaper dermatitis is a variant which predominantly affects infants.

5) Tinea Pedis (of the foot)- Common in swimmers.

6) Onychomycosis: Fungal infection of the nail ;  Presents as thickening, discoloration, and deformity of the nails.  Fungal organisms are present in the deeper portions of the nail plate and in the hypertrophic nail bed. PAS- stain is used to demonstrate the fungal elements.

Clinical Images: click here

Majocchi's granuloma:  Common in females ; Often occurs in immunocompromised patients ; Presents as nodular and plaque-like lesions of the lower leg ; Microscopic features are of granulomatous perifolliculitis ;  The nodular granulomatous lesions in the dermis contain individual dermatophyte hyphae.

Microscopic features: Image Link (Dermatlas)

Dermatophyte infection may display a wide range of microscopic features.

Changes in stratum corneum include: i) Presence of neutrophils; ii) Compact orthokeratosis ; iii) Presence of 'Sandwitch Sign' - characterized by  hyphae 'sandwitched in' between an upper normal basket weave stratum corneum and lower layer of abnormal stratum corneum -(compact orthokeratotic or parakeratotic in type).

Epidermis may show:  mild spongiosis ; prominent spongiotic vescicles (palms and soles) ; Rarely subcorneal or intraepidermal pustules ;Chronic cases show variable acanthosis.

Dermis may show sparse perivascular mixed inflammatory infiltrate or a heavy dermal infiltrate with involvement of hair follicle. Perifollicular   neutrophils or a mixed inflammatory infiltrate may be present.

Dermatophytes are identified in the tissue as branched, septate hyphae and spores. They usually stain with hematoxylin and eosin but are best demonstrated with special stains for fungi.

Special stain for fungi:  Gomori-Methenamine Silver(GMS) ; Periodic Acid- Schiff (PAS) ;Gridley fungus ; GMS with H&E counterstain(GMS/H&E).

Hyphae and arthroconidia invade the stratum corneum, hair follicle and hair shafts. The pattern of hair invasion may be ectothrix , endothrix or endoectothrix .

Occasionally, rupture of a hair follicle and release of fungal elements into the dermis elicits acute suppurative inflammation that eventually becomes granulomatous. 

Aggregates of hyphae embedded in and surrounded by abundant Splendore - Hoeppli material in the dermis and subcutaneous tissue may be misinterpretated by some pathologists as grains and granules found in Mycetoma .  The aggregates actually consist of clustered dermatophyte hyphae (pseudogranules) each ensheathed by Splendore - Hoeppli material .

Note: The presence of hyphae in the very thin compactly orthokeratotic zone in the lowermost part of the stratum corneum of a section stained by hematoxylin and eosin is diagnostic of dermatophytosis.

          

Abstracts:

Dermatophytoses in monterrey, mexico.Mycoses. 2006 Mar ;49(2):119-23

Dermatophytosis: the management of fungal infections.Skinmed. 2005 ;4 (5):305-10.

Prevalence of dermatophytosis in University of Nigeria Teaching Hospital, Enugu, Nigeria: any change in pattern? Niger J Clin Pract. 2005;8(2):83-5

Onychomycosis in children: a survey of 46 cases.Mycoses.2005;48(6):430-7.

Utility of histopathologic analysis in the evaluation of onychomycosis.
J Am Podiatr Med Assoc. 2005;95(3):258-63.

Histopathological diagnosis of onychomycosis by periodic acid-Schiff-stained nail clippings. Br J Dermatol. 2003 ;148(4):749-54

Usefulness of histological examination for the diagnosis of onychomycosis. Dermatology. 2001;202(4):283-8

Routine histologic examination for the diagnosis of onychomycosis: an evaluation of sensitivity and specificity. Cutis. 1998;61(4):217-9

Pathopedia-India.com:

Contents ; Introduction of Pathology ; An outline of Diagnostic Techniques available in Pathology ; Cellular Injury ; Diagram showing Structural Changes in Reversible and Irreversible Cell Injury ; Autolysis; Heterolysis ; Necrosis; Coagulation (Coagulative) necrosis ; Caseative (Caseous) necrosis ; Liquefaction necrosis ; Fat necrosis ; Fibrinoid necrosis ; Apoptosis ; Gangrene ; Hyaline Change ; Atrophy ; Hypertrophy ; Hyperplasia ; Metaplasia ; Aplasia ; Hypoplasia ;Cellular Accumulations ; Accumulation of Glycogen, complex lipids and carbohydrates ; Pigments ; Melanin ; Pigments derived from Hemoproteins; Hemosiderin and Hemosiderosis ; Primary Hemochromatosis ; Hematin; Bilirubin; Lipofuscin; Mineral Dusts ; Silica ; Urate ; Amyloid ; Inflammation ; Inflammatory cells in acute and chronic inflammation ; Acute Inflammation; Types of Acute Inflammation; Chemical Mediators ; Chronic Inflammation; Wound Healing ; Circulatory Anatomy, Physiology and Regulation; Normal Fluid Balance; Edema; Morphology of Edema; Diagram showing Capillary System and Mechanisms of Edema Formation; Hyperemia and Congestion; Hemostasis and Thrombosis; Embolism; Fat Embolism; Air Embolism ; Decompression Sickness ; Amniotic Fluid Embolism ; Diagram showing Sources of Arterial Emboli ; Diagram showing Sources of Venous Emboli ; Infarction ; Diagram showing common sites of Systemic Infarction  from Arterial Emboli; Shock; Pathology of Shock; Diagram showing Complications of Shock; Hemorrhage;


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