CASE REPORT

TINEA CORPORIS CAUSED BY MICROSPORUM AUDOUINII

ABSTRACT
Tinea corporis is a superficial dermatophyte fungal infection of the trunk, leg and arm region. These infections are by the caused by species of Trichophyton, Epidermophyton and Microsporum. One case of tinea corporis et causa Microsporum audouinii in a 61 years old woman was reported. Diagnosis was established based on history, physical examination, direct microscopic examination with potassium hydroxide (KOH 10%) and culture. The patient was treated with oral ketoconazole and topical treatment contains a combination of Salicyl acid 3%, 6% benzoic acid and vaseline 30gr (AAV1). Eight days after therapy, the patient showed clinical and mycological improvement. Key words: Microsporum audouini, ketoconazole, tinea corporis

Address for correspondence : Mungky Sukarnadi, dr., Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin Sudirohusodo Hospital Makassar, 11 Komp. TNI AL Dewakang Jl. Koptu Harun Makassar, South Sulawesi, Indonesia 90245, smungky@yahoo.com

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tinea corporis caused by microsporum audouinii

INTRODUCTION Dermatophytosis is a superficial infection caused by dermatophyte fungi on keratincontaining tissues such as nails, hair and stratum corneum of the skin. Tinea corporis is a superficial fungal infection caused by dermatophytes on regional bodies, legs, and arms. ( 1-3 ) Dermatophyte fungi are classified based on habitat or source of infection, ie geophilic, zoophilic, and anthropophilic. Three fungi most commonly found in cases of tinea corporis is Trichophyton rubrum, Trichophyton mentagrophytes and Epidermophyton floccosum. Trichophyton rubrum, Microsporum canis and Trichophyton mentographytes a common cause in the United States. Some species have a predilection for certain body parts, such as Microsporum audouinii typical cause of tinea capitis and Trichopyton rubrum which generally causes tinea pedis, but they also can cause tinea corporis. ( 1 , 4-6 ) The incidence of dermatophyte infection according to a survey World Health Organization (WHO) that approximately 20% of people worldwide are infected, especially tinea corporis (70%), followed by tinea cruris, tinea pedis and onychomycosis. ( 7 ) Incident dermatomycosis in Indonesia shows the highest incidence of dermatophytosis followed by pityriasis versicolor and candidiasis skin. ( 8 ) Clinical picture of tinea corporis varied, can be demarcated erythematous plaques with more rising edge and the center of the lesion tends to heal (central healing). Adjacent lesions can coalesce to form polycyclic pattern. Lesions of tinea corporis can also serpiginous and annular (ringworm-like). ( 1 )

Diagnosis of tinea corporis can be established based on history, physical examination and investigation by direct microscopic examination and culture. ( 1 , 9 , 10 ) Patient with tinea corporis usually responds well to topical antifungal treatment within 2-4 weeks. Various preparations allilamin, imidazole, and available in several forms. Patient with extensive lesions or fail with topical treatments, anti-fungal preparations can be administered orally, such as griseofulvin, ketoconazole, itraconazole and terbinafin. ( 1 , 11 , 12 ) Microsporum audounii is a dermatophyte fungus anthropophilic group most likely to cause tinea capitis, although rarely reported to cause tinea corporis. ( 4 , 5 , 13 ) In this paper, we reported a case of tinea corporis in a woman 61 years old caused by Microsporum audouinii CASE REPORT A woman aged 61 years old, occupation a housewife came to dermatovenereology clinic Wahidin Sudirohusodo hospital with chief complaint red spots on the upper left arm since 1 year ago. Patient also complained of itchy, and while sweating itchy getting worse . Initially lesion showed reddish patches scaly and became larger. Previous history of similar complaints (+). History of its own lubrication purchased at pharmacies (not known the title), but not improved. Family history of similar disease undeniable. Denied a history of diabetes mellitus. Denied a history of allergy. Physical examination on the region of the left brachial showed erythema plaques with elevated edges and fine scales . (Figure 1.AB)

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On microscopic examination using staining Lactophenol Cotton Blue (LCB) of culture looks macroaleurospora and bizarre branching. (Figure 4.AB)

Figure 1. Erythematous plaques with elevated edges and fine scales on the the left brachial region

Direct microscopic examination of skin scrapings of the lesion with KOH 10% solution showed insulated length and branching hyphae. (Figure 2)

Figure 4A. Macroaleurospora 4B. Branching Bizarre

Figure 2. Long, septate and branching hyphae on KOH 10% examination

Culture examination conducted by the specimen scrapings of skin lesions on media Saboroud's Dextrose Agar (SDA). Macroscopic picture looks a brownish red colonies with elevated surfaces and edges are white gray, bottom looks brownish yellow colonies. (Figure 3.AB)

Final diagnosis is established tinea corporis caused by Microsporum audouinii. Management of this case oral ketoconazole 200 mg per day, and topical therapy contains 3% salicylic acid , benzoic acid 6% and vaseline 30gr (AAV1) applied two times a day. On day 8 therapy, clinical improvement appeared in the form of macular hypopigmentation with complaint of itching diminished. (Figure 5). Direct microscopic examination with 10% KOH showed negative result and continued therapy.

Figure 3A. SDA culture day 21 showed a brownish red colonies with elevated surfaces and edges are white gray. 3B. Bottom side showed brownish yellow colonies.

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Mungky Sukarnadi

tinea corporis caused by microsporum audouinii

In our case, on day 21 macroscopically showed maroon colonies with elevated surface and gray white edge, the bottom side showed brownish yellow colonies. Microscopic picture looks macroaleurospora and bizarre branching. Culture results according to Microsporum audouinii. ( 15 ) Microsporum audouinii an anthropophilic dermatophyte fungi spesises which is one of the most frequent causes of dermatophytes (61.5%) in tinea capitis, especially in children who are in Latin America and South Africa, but this species can also infect the skin and nails. ( 13 ) Reported a young woman from Germany with tinea corporis due to Microsporum audouinii accompanied by tinea capitis.( 16) Systemic antifungal therapy is indicated if the lesions are extensive or fails to topical treatment, recurrent or chronic, or if the skin condition gets worse. ( 11 , 12 ) Ketoconazole is an antifungal systemic broad spectrum imidazole group and is fungistatic. Mechanism of action of ketoconazole that inhibit the biosynthesis of ergosterol, the main sterol which serves to maintain the integrity of the fungal cell membrane, by inhibiting the enzyme cytochrome P-450 lanosterol 14 demetilase an enzyme essential for fungal cell membrane ergosterol synthesis. ( 4 , 7 , 12 ) In a study to compare strength between itraconazole and fluconazole and the ketoconazole and fluconazole obtained similar results with a cure rate of approximately 90% for all three drugs. ( 17 ) In this case , patient was treated ketoconazole 200 mg per day. On day 8 therapy, lesions looks macular hypopigmentation, itching diminished and negative KOH examination. Other oral anti-fungal medication that can be given to tinea corporis is fluconazole, itraconazole, griseofulvin, and terbinafin. On a compa42

Figure 5. On the day 8 therapy showed macular hypopigmentation.

DISCUSSION In this case report, patient diagnosed tinea corporis caused by Microsporum audouinii based on history, physical examination and investigations using direct microscopic examination followed by culture examination to determine the cause of the species. Tinea corporis is a disease that causes itching and complaints intensified when the patient sweats. Clinical picture of tinea corporis vary, and may be macular erythematous plaque with an active edge and accompanied squama, with the center of the cure (central healing). ( 1 ) In this case, patient complaints of itching erythematous plaques with elevated edges and fine scales on the left brachial region. Microscopic examination of skin scrapings specimens using 10% KOH solution is a simple diagnostic method to see length hyphae, branched hyphae, and arthospora Scales collected by scrape edge of an active lesion, then dropped 10-20% KOH solution. ( 1 , 4 , 5 , 14 ) In this case KOH 10% examination showed length and branching hyphae. Fungal culture is used to confirm the diagnosis and identify pathogenic species. Culture media is a selective medium for the isolation of dermatophytes, and then stored at a temperature of 26 0 C

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rative study of adults showed fluconazole 150 mg per week for 4 to 6 weeks, itraconazole 100 mg per day for 15 days and terbinafin 250 mg per day for 2 weeks is as effective by administering griseofulvin 200 mg per day for 2 to 6 weeks. ( 1 ) Research conducted comparing Clayton and Connor clotrimazole cream and Whitfield's ointment was not found significant differences and showed negative mycological results after 4 weeks of treatment. Whitfield's ointment is fungistatic and keratolytic. ( 18 , 19 ) In this case, topical treatment with AAV1/Whitfield 's ointment was applied two times a day. Non-medicamentous management by reducing the predisposing factors, suggest to wear loose clothing and absorb sweat, dry off after shower and sweating. ( 2 ) REFERENCES
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