31

CASE REPORT

TINEA CORPORIS AND TINEA CRURIS CAUSED BY
TRICHOPHYTON MENTAGROPHYTES TYPE GRANULAR IN
ASTHMA BRONCHIALE PATIENT

Arif Risdianto, Dirmawati Kadir, Safruddin Amin


Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin
Sudirohusodo Hospital Makassar


























ABSTRACT
Tinea corporis is a fungal infection of the skin dermatophytes
glabrosa except the hands, feet and groin, while tinea cruris is a
common infection in the groin area, genitals, pubic area, perineum and
perianal skin, which causes the fungus most often derived from the
genus Trichophyton, Microsporum and Epidermophyton.
It was reported one case of tinea corporis and tinea cruris caused by
Trichophyton mentagrophytes type granular on a man of 54 years old.
Diagnosis was established based on clinical features, direct microscopic
examination with kalium hidroxyde (KOH) 10% and culture in vitro.
Patients was treated with oral ketokonazole and myconazole2% cream
with clinical and mycologycal improvement.

Keywords: tinea corporis, tinea cruris, trichophyton mentagrophytes
type granular


















Address for correspondence : Arif Risdianto, dr., Department of Dermatovenereology Medical Faculty of Hasanuddin University / Wahidin
Sudirohusodo Hospital Makassar , Blok Z /7 Perum Citra Sudiang Indah Jl. Sukhoi Makassar, South Sulawesi, Indonesia 90242,
arif_risdianto@yahoo.com

32

Arif Risdianto tinea corporis and tinea cruris caused by trichophyton mentagrophytes type granular in asthma bronchiale patient

INTRODUCTION
Dermatophytosis is a superficial fungal
infection caused by dermatophyte fungi on
keratin-containing tissues, such as the
stratum corneum, hair and nails.
(1, 2)

Fungal infection that often causes
dermatophytosis is a genus Tricophyton,
Microsporum and Epidermophyton.
(3, 4)
Tricophyton mentagrophytes, Tricophyton
rubrum and Microsporum canis are the
causative agent of tinea corporis and tinea
cruris most frequently.
(5)
Dermatophytosis
infection is thought to have attacked 20-
25% of the population worldwide, and its
incidence continues to rise.
(6, 7)

Tinea corporis is a dermatophyte fungal
infection of the skin glabrosa except the
palms, feet and groin, while tinea cruris is
a common infection on the groin area,
genitals, pubic area, perineum and
perianal skin. Clinically be found only tinea
corporis or tinea cruris, but can also be
found both.
(1, 5, 8)
Transmission can be
through direct contact with an individual or
an infected animal or indirectly through
objects containing squama infected.
(9)

Covered clothes and high humidity
associated with the frequency and severity
of eruptions dermatophytosis.
(1, 5)

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 may merge to form a
pattern or polycyclic girata. Lesions of
tinea corporis can also serpigininous and
annular (ringworm-like). Tinea cruris which
appears in the form of multiple
erythematous papules demarcated, with a
more elevated edges. Usually itchy or
painful case of maceration and secondary
infection.
(1, 5, 10)

Investigations to establish the
diagnosis of a dermatophyte infection can
be done by direct microscopic examination
with potassium hydroxide (KOH) and
cultured in vitro.
(10, 11)
Direct microscopic
examination showed long and branched
hyphae which is characteristic of the
dermatophyte infection but the level of
specificity and sensitivity is less. Cultured
in vitro by using Saboraud Dextrosa Agar
(SDA) can be used to determine the
characteristics of the macroscopic and
microscopic organisms is diagnostically
specific techniques but takes a long
time.
(11, 12)

Treatment of dermatophyte
infections usually respond well to topical
antifungal within 2-4 weeks. If patients
have extensive lesions or fail with topical
treatments, anti-fungal preparations can
be administered orally, among others,
griseofulvin, ketoconazole, itraconazole
and terbinafin.
(12, 13)

Reported one case of tinea corporis and
tinea cruris in a man aged 54 years old
caused by Trichophyton mentagrophytes
granular type that responds well to oral
ketoconazole and topical miconazole 2%
cream.
CASE REPORT
A man aged 54 years old , came to
dermatology clinic Salewangan hospital,
Maros with complaints itchy red patches
on the chest, back, buttocks since 1 year
ago. Originally appeared in the form of red
spots on the chest area, getting larger
became red patches and scales on top
then spread to the upper back and
buttocks . These complaints were often
perceived recurrent. Itching is felt
especially when sweating. A history of
drug treatment in the form of itching CTM
and betamethasone ointment purchased
at a pharmacy, but no clinical
improvement. Patients admitted often
wear a jacket every day. History contact
with pets denied. History therapy for
asthma, patient took prednisone since 24

33

IJ DV Vol.2 No.2 2013



34

Arif Risdianto tinea corporis and tinea cruris caused by trichophyton mentagrophytes type granular in asthma bronchiale patient

years ago . History of the same disease in
the family denied. Denied a history of
diabetes mellitus.
On physical examination seem
mild pain, compos mentis, nutrition
enough impression, with blood pressure
140/85 mm Hg, pulse 84 beats / min and
breathing 20 times / min. Dermatological
status on the region of anterior thoracic
and cervical posterior looks erythematous
plaques, demarcated, erythematous
papules on the edge of lesions. At the
center of the lesion are experiencing the
healing area (central healing) and
squama. At the gluteus and supra pubic
region looks hyperpigmentation plaques,

35

IJ DV Vol.2 No.2 2013


demarcated, erythematous papules on
the edge of lesions . At the center of the
lesion are experiencing the healing area
(central healing), and squama. (Figure 1)
Diagnosis was tinea corporis and tinea
cruris.
Direct microscopic examination of
skin scrapings by using 10% KOH solution
gives an overview long and branched
hyphae (Figure 2). Based on anamnesis,
physical examination, and examination of
skin scrapings with KOH 10%, patient
was diagnosed tinea corporis and tinea
cruris.
Culture examination conducted
with specimens of skin scrapings on media
Saboroud's Dextrose Agar (SDA). Macros-
copically visible presence of white to
creamy-colored colonies with a pile of
cotton surfaces such as fine and coarse
granular. (Figure 3 a,b,c,d) On micros-
copic examination by using Lactophenol
Cotton Blue (LCB) of culture appears
microconidia are clustered, rarely macro-
conidia shaped like a cigar, sometimes
there is a spiral hyphae. (Figure 4 a,b)
Description of macroscopic and micros-
copic colonies according to the dermato-
phyte species Trichophyton mentagro-
phytes granular type. Final diagnosis was
tinea corporis and tinea capitis caused by
Trichophyton mentagro-phytes granular
type.
Management therapy oral ketoco-
nazole 200 mg per day and topical
miconazole 2% cream applied twice a day.
On day 10 therapy , clinical pictures
showed hypopigmentation and hyper-
pigmentation macules and no scales.
Topical therapy with miconazole 2% be
continued. Re-examination of KOH 10%,
long and branched hyphae not found
.(Figure 5 a,b,c,d).
On day 14 therapy , clinical pic-
tures showed macular hypopigmentation
and hyperpigmentation. Re-examination
of KOH 10% long and branched hyphae
not found, therapy discontinued.(Figure 6
a,b,c,d).
DISCUSSION
Diagnosis of tinea corporis and
corporis caused by Trichophyton menta-
grophytes granular type was established
based on the patient history, physical
examination and direct microscopic
examination with 10% KOH preparations
using skin scrapings followed specimens
culture examination to determine the
cause of dermatophytosis species.
In the history of a male patient 54
years with complaints of itching on the
chest, back, buttocks and above the pubic
experienced since 1 year ago, white
scales, often recurrent. Itching is felt
especially when sweating and patients
admitted often wore jacket. In accordance
with the literature that tinea corporis and
tinea cruris generally provide complaint
and intensified itching when sweating.
High humidity, excessive perspiration and
clothing that covered a predisposing factor
for the emergence of dermatophyte
infection.
(5, 8, 14)
Patients often have a
history of taking prednisone for asthma
hospital since the age of 20 years and
often recurred. Immunosuppression drugs
may increase the risk of dermatophyte
infection.
(15)
In one study by Woodfolk
indicates that there is a very strong
relationship between asthma with
dermatophyte infections especially those
caused by the genus Trichophyton. This
study showed that Trichophyton infections
may trigger the development of asthma
and other allergic diseases or otherwise
through the mechanism of immediate
hypersensitivity and delayed hypersen-

36

Arif Risdianto tinea corporis and tinea cruris caused by trichophyton mentagrophytes type granular in asthma bronchiale patient

sitivity. Jones mentions the theory that
exposure to fungal antigen can induce an
allergic inflammatory response in the
respiratory tract.
(16, 17)
In another study
showed that asthma-up with dermatophyte
infection especially by the genus
Trichophyton, after treatment with oral
anti-fungal medication then asthma has
improved.
(18)

On physical examination, thoracic
region gluteus and supra pubic showed
erythematous plaques, hyperpigmentation,
demarcated, erythematous papules on the
edge, central healing and squama. This is
consistent with the literature which states
that tinea corporis and tinea cruris can be
acute or chronic. Acute abnormalities that
can give a picture of macular and erythe-
matous plaques with erosion and some-
times there is excoriation, and there is a
central healing. When the disease is
chronic then effloresensi visible only along
hyperpigmented macules or plaques scaly.
(1, 4, 8, 14)b
Fungal cultures in vitro was
conducted to determine the cause of
dermatophytosis species. Source of
specimens derived from skin scrapings,
planted in Saboraud's dextrose agar
(SDA) at 25 - 30 C, and the colony will
grow normally within 7-28 days.
(1, 10, 19, 20)

In this case, it appears the macroscopic
colonies are white to creamy colored with
a a pile of cotton surfaces such as fine and
coarse granules. On microscopic
examination by using Lactophenol Cotton
Blue (LCB) of culture appears the
microconidia are clustered, rarely
macroconidia shaped like a cigar,
sometimes there is a spiral hyphae.
Description of macroscopic and micros-
copic colonies according to the dermato-
phyte species Trichophyton mentagro-
phytes granular type.
(1, 21, 22)
Tinea corporis
is most often caused by the species T.
mentagrophytes, T. rubrum, and M. canis
and fungal species most commonly
causes tinea cruris is T. rubrum, T.
mentagrophytes and E. floccosum.
(1, 4)
In
this patient, tinea cruris is suspected that
autoinoculation result of tinea corporis.
This is consistent with the literature that
tinea corporis often occurs concurrently
with other dermatophyte infections such as
tinea capitis and tinea pedis.
(23)
In one
study in the Section of Urology in Turkey
says that there are about 7.7% of patients
with tinea capitis is always accompanied
by tinea corporis and 33.3% were caused
by Trichophyton mentagrophytes.
(24)
Therapy in this case oral
ketoconazole 200 mg once daily for 2
weeks and miconazole 2% cream and
obtained clinical improvement and
mycological improvement. 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.
(4, 25)

Ketoconazole is an antifungal azole class,
broad-spectrum and can be given to
patients who do not respond to topical
therapy. Mechanism of action of this drug
to inhibit ergosterol biosynthesis by
menginhibisi enzyme cytochrome P-450,
C-14--dimethylase responsible transform
lanosterol to ergosterol resulting in fungal
cell walls become permeable and the
destruction of the fungus occurs.
(25-27)
After
10 days of therapy, no complaints of
itching and red spots dissappeared as
well as negative KOH examination.
Imidazole group is quite effective topical
treatment for dermatophyte infec-tions.
Preparations are often used mico-nazole,
ketoconazole, clotrimazole, oxico-nazole,
and econazole. This recommend-dation
topical imidazole twice a day and is
usually used for 2 weeks for tinea corporis
and tinea pedis for 4 weeks. The
mechanism works by inhibiting the

37

IJ DV Vol.2 No.2 2013


synthesis of ergosterol fungi that result in
defects in the fungal cell membrane.
(25, 28,
29)
In this case was given topical therapy
miconazole 2% cream.
Non-medicamentosa management
and prevention of relapse of disease is
very important, such as reducing the
predisposing factors, namely temperature,
humidity and occlusion by advocating
wearing loose clothing and materials that
easily absorb sweat, dry off after a shower
and sweating, losing weight if obese, wash
contaminated clothing and avoid allergens
trigger asthma.
(8, 10, 13)

REFERENCES
1. Verma S, Heffernan MP. Superficial
fungal infection: dermatophytosis, onicho-
mycosis, tinea nigra, piedra. In: Wolff K,
Goldsmith LA, Katz SI, Gilchrest BA,
Paller AS, Leffell DJ, editors. Fitzpatric's
Dermatology in General Medicine. 7th ed.
New York: McGraw-Hill; 2008. p. 1807-21.
2. Krajewska-Kuak E, Moss E, ukaszuk C,
Niczyporuk W, Bartoszewicz M, Roszkow-
ska4 I. Common difficulties in the diagno-
sis and therapy of tinea in patients diag-
nosed in dermatology hospital in the years
1981~2000. Kor J Med Mycol2003;8(3):
103-9.
3. Chong AH, Sinclair RD. Diagnosing su-
perficial mycoses. Am J Clin Dermatol
2000;1(2):125-31.
4. Gupta AK, Tu LQ. Dermatophytes: diag-
nosis and treatment. J Am Acad Dermatol
2006;54:1050-5.
5. Gupta AK, Chaudhry M, Elewski B. Tinea
corporis, tinea cruris, tinea nigra, and
piedra. Dermatol Clin2003;21:395-400.
6. Ameen M. Epidemiology of superficial
fungal infections. Clinics in Dermatol2010;
28:197-201.
7. Bassiri-Jahromi S, Khaksari AA. Epide-
miological survey of dermatophytosis in
Tehran, Iran, from 2000 to 2005.
IJDVL2009;75(2):142-8.
8. Goedadi M, Suwito H. Tinea korporis dan
tinea kruris. In: Budimulja U, Kuswadji,
Bramono K, Menaldi SL, editors. Derma-
tomikosis superfisial. Jakarta: Balai Pe-
nerbit FKUI; 2004. p. 31-5.
9. Adiguna MS. Epidemiologi
dermatomikosis di Indonesia. In:
Budimulja U, Kuswadji, Bramono K,
Menaldi SL, editors. Dermatomikosis
superfisial. Jakarta: Balai Penerbit FKUI;
2004. p. 1-6.
10. Hay RJ, Ashbee HR. Mycology. In: Burns
T, Breathnach S, Cox N, Griffiths C,
editors. Rook's textbook of dermatology.
8th ed. Oxford: Wiley-Blackwell; 2010. p.
36.1-.15.
11. Garg J, Tilak R, Garg A, Prakash P, Gulati
AK, Nath G. Rapid detection of
dermatophytes from skin and hair. BMC
Research Notes2009;2(60):1-6.
12. Hainer BL. Dermatophyte infections. Am
Fam Physician2003;67:101-8.
13. Gupta AK, Cooper EA. Update in
antifungal therapy of dermatophytosis.
Mycopathologia2008;166:353-67.
14. Straten MRV, Hossain MA, Ghannoum
MA. Cutaneous infections
dermatophytosis, onychomycosis, and
tinea versicolor. Infect Dis Clin N
Am2003;17:87-112.
15. Creed R, Morrison LK, Ravanfar P,
Mendoza N, Tyring S. Skin complications
of HIV infection. Expert Rev
Dermatol2009;4(5):509-21.
16. Woodfolk JA. Allergy and Dermatophytes.
Clin Microbiol2005;18:30-43.
17. Woodfolk JA, Wheatley LM, Piyasena RV,
Benjamin DC, Platts-Mills TAE. Tricho-
phyton antigens associated with IgE
antibodies and delayed type hypersen-
sitivity. The J Of Bio Chemistry 2008;
273:1-5.


38

Arif Risdianto tinea corporis and tinea cruris caused by trichophyton mentagrophytes type granular in asthma bronchiale patient

18. W.Ward G, A.Woodfolk J, Hayden ML,
Jackson S, Platts-Mills TAE. Treatment of
late-onset asthma with fluconazole. J
Allergy Clin Immunol2009;104:541-6.
19. Sharma R, Jasuja ND, Sharma S. Clinical
and mycological study of dermatophytosis
in Jaipur (India). Int J of Pharmacy and
Pharmaceutical Sciences2012;4(3).
20. Thomas B. Clear choices in managing
epidermal tinea infections. The J of Fam
Practice2003;52:850-62.
21. Oyeka CA. Trichophyton mentagrophytes
a keratinophilic fungus. Revista
Iberoamericana de Micologa2000:1-6.
22. Frey D, Oldfield RJ, Bridger RC. In: Frey
D, Oldfield RJ, Bridger RC, editors. A
colour atlas of pathogenic fungi. Holland:
Wolfe Medical Publications Ltd; 1979.
23. Ziemer M, Seyfarth F, Elsner P, Hipler U-
C. Atypical manifestations of tinea
corporis. Mycoses2007;50:31-5.
24. Ardogan IA, Ates A, Izol V, Ilkit M. Tinea
cruris in routine urology practice. Urol
Int2005;74:346-8.
25. Minnebruggen GV, Franois EJA,
Cammue BPA, Thevissen K, Vroome V,
Borgers M, et al. A General overview on
past, present and future antimycotics. The
Open Mycology J2010;4:22-32.
26. Palacio Ad, Garau M, Gonzalez-Escalada
A, Calvo T. Trends in the treatment of
dermatophytosis. Revista Iberoamericana
de Micologa2000:148-59.
27. Gupta AK, Cooper EA. Update in
antifungal therapy of dermatophytosis.
Mycopathologia2008;166:357-67.
28. Weinstein A, Berman B. Topical treatment
of common superficial tinea infections. Am
Fam Physician2002;65:2095-113.
29. Erbagci Z. Topical Therapy for
Dermatophytoses Should Corticosteroids
be Included? Am J Clin
Dermatol2004;5(6):375-84.