Tinea Corporis Bullosa Secondary to Trichophyton Verrucosum: A Newer Etiological Agent with Literature Review.

Sir,

A 45-year-old female presented with multiple itchy patchy skin lesions with scaling all over the body since 2 months. It was followed by itchy fluid-filled lesions with raw areas and crusting on bilateral thighs, chest, back, and abdomen since one month. She had a history of contact with cows and buffalos. There was no history of trauma, insect bite, or recent intake of medicine. On cutaneous examination, there were multiple bullous lesions filled with clear fluid, which ruptured within 2–3 days to leave behind erosions and crust over an erythematous background, involving approximately 50% of the body surface area (BSA) [Figure 1]. The surrounding area was associated with multiple erythematous, polycyclic plaques with scaling which were severely pruritic. These lesions were symmetrically distributed on the chest, axillae, back, buttocks, arms, and legs. There was no mucosal, palm, sole, and nail involvement.

Figure 1

Multiple bullous lesions (Red arrow) with crusting and erosions (Green arrow) on erythematous plaque and multiple polycyclic lesions with scaling on the surrounding areas

Family and past history were unremarkable. Nikolsky and bulla spread signs were negative. Both Tzanck smear and potassium hydroxide preparation revealed hyphal elements. All other hematological and biochemical investigations were within normal limits. Serology for HIV, hepatitis B (HBV), and hepatitis C (Hep C) were negative.

Histopathology showed subepidermal bulla with fungal hyphae present in the stratum corneum [Figure 2]. Direct-immunofluorescence (DIF) from perilesional skin was negative. Dermatophytes in stratum corneum were also confirmed on periodic acid–Schiff (PAS) stain. Fungal culture on Sabouraud dextrose agar (SDA) was positive for Trichophyton verrucosum. As the patient had already taken tablet fluconazole without any response, she was started on tablet terbinafine and clotrimazole cream. After 1 month of treatment, there was recurrence, so she was started on capsule itraconazole 100 mg twice daily with topical luliconazole cream for 2 months, which led to complete clearance of lesions.

Figure 2

(a) Histopathology reveals subepidermal bulla with inflammatory infiltrate in the upper dermis (H and E, ×40) (b) Fungal hyphae in stratum corneum (marked with a green arrow) (H and E, ×100) (c) Direct immunofluorescence of perilesional skin was negative (x100)

Dermatophytic infection may rarely be present with unusual manifestations, one of them is tinea corporis bullosa. On extensive search of English literature, we found only 11 cases of tinea corporis bullosa. It was first reported by Costello in 1952.[12] Then, in 1970, Cullen and Loannides reported 3 cases.[2] Terragni et al. coined the term “tinea corporis bullosa” for such a rare presentation.[3] The literature review is given in Table 1.[3456] Previously, it was called tinea corporis bullosa annularis in which vesicobullous lesions were limited to the borders of the plaque. But, in our case, the bullous lesions were distributed all over the plaque, which is different from other previously described cases and is similar to the case described by Padhiyar et al.[4]

Table 1

Characteristics of patients diagnosed with Tinea corporis bullosa

Author	Year	Age/Sex	Causative organism	Similarity with other Autoimmune diseases	Treatment
Bennion SD[3]	1989	20 yr/Female	Trichophyton rubrum	-	Treated topically with clotrimazole cream for 2 weeks with complete resolution
Terragni et al.[3]	1993	63 yr/Female	Microsporum canis	-	Not mentioned
Veraldi et al.[4]	1996	27 yr/Female	Microsporum canis	-	Griseofulvin (500 mg/day) for 40 days with complete regression of lesions
Azfar et al.[4]	2009	14 yr/Male	Trichophyton tonsurans	-	Not mentioned
Mares et al.[5]	2012	41 yr/Female	Trichophyton schoenleinii	-	Terbinafine 250 mg/day for 3 weeks and topical application of 1% ciclopirox olamine cream led to complete healing within 2 weeks
Aalfs and Jonkman[6]	2012	48 yr/Female	Microsporum canis	Mimicking Linear IgA bullous dermatosis	Terbinafine 250 mg/day for 4 weeks with topical ketoconazole cream with complete disappearance of lesions
Padhiyar et al.[4]	2018	29 yr/Female	Trichophyton mentagrophyte	Mimicking bullous pemphigoid	Itraconazole 100 mg twice daily and topical luliconazole for 11/2 months leads to a clinical and mycological cure

In our case, the causative organism was Trichophyton verrucosum. This organism is distributed globally and is usually associated with dermatophyte infection of cattle,[7] also called “cattle ringworm disease.” Transmission to the human is rare and is more frequent among humans who are in close contact with animals, especially cows. In our case, the patient had a long history of contact with animals, such as cows and buffalo. It is a zoophilic dermatophyte, which may produce an inflammatory response in the affected areas. This inflammatory response may lead to hypersensitivity reactions to the dermatophyte, which might be implicated in bulla formation accompanied by dermal infiltrate.[3] This may be the reason for the unique characteristic widespread distribution of the bullous lesions all over the affected areas in our patient.

There are two important facts in our case. First, after a detailed search of the literature, this may be the first case of tinea corporis bullosa due to T. verrucosum. Secondly, dermatophytic infections caused by T. verrucosum are usually localized. There are only a few case reports of extensive tinea corporis caused by T. verrucosum, of which the first patient was HIV positive,[8] the second patient had a history of use of corticosteroids,[9] and the third patient was a 3-year-old boy.[7] Our patient did not have any history of immunosuppression or the use of steroids. Thus, probably this may be the first report of extensive tinea corporis due to T. verrucosum in an adult immunocompetent patient.

Keeping in view of the recent alarming increase in the incidence of dermatophytosis in our country, it is mandatory that the dermatologist fraternity be made aware of the unusual presentations of dermatophytosis secondary to T. verrucosum.

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Conflicts of interest

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