Rare Case of Scrotal Candida albicans Infection in an Elderly Man Induced by Urinary Leakage.

Sir,

An 80-year-old man presented with pruritic erythema on his scrotum for 2 months. In August 2017, he underwent a radical prostatectomy as treatment for prostate cancer in a local hospital. However, the urethral sphincter was damaged which resulted in the patient leaking urine repeatedly after the operation. The patient solved this difficulty by wearing plastic bags every day. In January 2021, the patient developed pruritic scrotal erythema and the lesion gradually extended. In February 2021, he visited our hospital.

Cutaneous examination revealed a bright erythema symmetrically distributed on the dorsal side of the penis and on both sides of the scrotal suture. The erythema covered an area of approximately 18 × 7 cm. The skin lesion was well defined, and the surface was moist with slightly powdery scales in the folds of the penis [Figure 1]. No similar lesions were found on any other part of the patient's body. No signs of angular cheilitis or glossitis were detected by examination. While the patient was taking antihypertensive drugs, he was otherwise healthy. The results of a routine complete blood cell count and a complete metabolic panel performed on the patient's blood were all within normal limits. An HIV test was negative.

Figure 1

A bright erythema symmetrically distributed on the dorsal side of the penis and on both sides of the scrotal suture

A skin biopsy specimen revealed the presence of many elongated fungal hyphae in the stratum corneum and periodic-acid Schiff staining confirmed that result [Figure 2a and 2b]. Direct microscopic examination of dander scraped from the scrotum revealed a significant number of slender, branching, and septate hyphae with a diameter of 2–4 μm. Cultures on Sabouraud agar grew characteristic creamy colonies after 7 days of incubation at 25°C [Figure 2c]. The isolated strains were grown on chromogenic medium for 48 h. These strains displayed a green color, which proved to be Candida albicans [Figure 2d].

Figure 2

(a) Histopathology shows acanthosis and the superficial layers of the epithelium are infiltrated by large numbers of neutrophils (H and E, ×100). (b) Periodic-acid Schiff staining confirmed abundant yeast-like and pseudohyphal forms (×200). (c) Cultures on Sabouraud agar grew characteristic creamy colonies. (d) The isolated strains exhibit a green color on chromogenic medium

The diagnosis of cutaneous candidiasis was made and we prescribed miconazole cream twice a day for 2 weeks and advised him to use adult diapers. After a 1-month follow-up visit, the lesion showed total recovery. There was no sign of recurrence.

Candida is a yeast-like fungus with budding and filamentous (pseudohyphal and hyphal) forms. There are several species, but C. albicans is by far the most common human pathogen.[1]

Candida infection involving mucocutaneous sites can be categorized as follows: oral candidiasis, cutaneous candidiasis, candidal vulvovaginitis, candidal balanitis, chronic mucocutaneous candidiasis, subcutaneous candidal abscess, and disseminated candidiasis. Cutaneous candidiasis tends to be confined to skin folds in the obese and to the genital mucous membranes. However, scrotal infections by dermatophytes and candidiasis are rare.[1] This result is attributed to capric acid, one of the fatty acids in the epidermal barrier, that is particularly abundant in scrotal skin and is thought to act as an antifungal factor.[2] Systemic diseases, hormones, antibiotics, and immunosuppressive drugs can reduce the body's resistance and increase the likelihood of development of candidiasis.[3] The major contributor to the invasion and rapid reproduction of C. albicans is a large amount of local sweat maceration, coupled with high temperature and humidity in young patients.[4] The case reported here is a rare case of scrotal C. albicans infection in an elderly man. The predisposing factors present in this patient were longstanding urine leakage and wearing plastic bags every day, which resulted in local cutaneous occlusion and maceration. Perkins et al.[5] reported that one case of 73-year-old man developed the extremely rare condition of Fournier gangrene after urinary incontinence by C. albicans infection. Therefore, we should keep in mind that patients with chronic urinary retention or urinary extravasation of various etiologies are often colonized with fungal species, specifically Candida. In terms of treatment, topical antifungal drugs have shown good therapeutic effects.

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Conflicts of interest

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