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\begin{document}

\title{Tinea capitis caused by Trichophyton violaceum in an immunocompetent
elderly patient: a case report and review of literature}



\author[1]{Mehdi Gheisari}%
\author[1]{Khatere Zahedi}%
\author[1]{Nabaa Al-Zubaidi}%
\affil[1]{Shahid Beheshti University of Medical Sciences}%


\vspace{-1em}



  
  \date{May 24, 2024}


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\textbf{Introduction}

Tinea capitis is a common infection of the scalp and hair caused by
dermatophyte fungi that principally affects children\textsuperscript{1}.
It is an uncommon infection in adults and generally occurs in
postmenopausal women and immunocompromised patients. Adult tinea capitis
may have atypical clinical presentations\textsuperscript{2}
\textsuperscript{34}. The causative pathogens in children and adults
belong to two genera: \emph{Trichophyton} and\emph{Microsporum}
\textsuperscript{5}\emph{.} The clinical manifestations characterized by
an erythematous and scaly plaques, itching, suppurative swelling with
purulent discharge, areas of alopecia and regional lymphadenopathy. It
is often misdiagnosed as a bacterial infection, leading to unnecessary
antibiotic prescription or surgical intervention. Treatment delay may
result in permanent hair loss\textsuperscript{6} \textsuperscript{7}.
The diagnosis of tinea capitis is made by fungal culture (gold
standard), microscopy, wood's lamp and trichoscopy\textsuperscript{5}
\textsuperscript{8}.

\textbf{Case report}

A 75-year-old female presented with a three-month history of pruritic
purulent and crusted lesions over the scalp. She had been treated with
multiple oral antibiotics and a topical cream consisting of clobetasol
and salicylic acid for one month without any improvement. The patient
had no medical history other than hypertension. She was in a good
general condition and had not received any immunosuppressant drug. There
was not any similar disease in other family members. Physical
examination showed multiple erythemato-edemathous papules and plaques
with yellow crust, pustule formation, and hair loss involving the vertex
and occipital area of the scalp (Fig 1). There were no other lesions in
any other parts of the skin, nails and mucosa. Values of serum blood
chemistry were in the normal range. The patient's immune profile was
normal. The direct exam with 20\% KOH showed an endothrix infection and
the mycological culture showed the growth of \emph{Trichophyton
Violaceum} . Bacterial culture was negative. Skin biopsy of the scalp
lesions showed an acute superficial and deep folliculitis with
intrafollicular mycelial fungal infection consistent with tinea capitis
(endothrix), on hematoxylin and eosin staining (Fig 2A \& 2B).
PAS-stained slides showed endothrix septate hyphae invading the hair
shafts (Fig 2C). Fluorescent microscopy showed endothrix infection by
green fluorescent, septate hyphae and spores (Fig 2D). The patient was
treated with prednisolone 15mg daily for one month and oral itraconazole
400 mg daily, which was gradually tapered to 100 mg daily at the last
two months. Also, the patient and all family members were treated with
2.5\% selenium sulfide shampoo. There was complete clearance of the
lesions and acceptable hair regrowth (Fig 3).

\textbf{Discussion}

The amount of fungistatic saturated fatty acids in sebum increases at
puberty and therefore dermatophyte colonization of the scalp disappears
in this age\textsuperscript{9}. This is thought to explain the rarity of
tinea capitis in adults. Although the disease was once thought to be
rare in adulthood, studies have been increasingly reporting tinea
capitis among adults especially in immunocompromised patients,
menopausal and elderly women\textsuperscript{2} \textsuperscript{34}.
Our patient was a 75-year-old menopause female, but not
immunocompromised. In most of the reported cases, including our case,
the diagnosis was delayed. This delay is probably due to both the rarity
of this infection in adults and its atypical clinical presentation. The
disease may resemble bacterial folliculitis, folliculitis decalvans,
dissecting cellulitis, pityriasis amiantace and its related etiologies,
and scaring alopecia like lupus erythematosus\textsuperscript{10}. In
many studies the correct diagnoses were established by tissue
culture\textsuperscript{23}. Although, for some authors, griseofulvin
remains the treatment of choice for tinea capitis in children and
adults, both terbinafine and itraconazole are considered acceptable
alternatives\textsuperscript{2} \textsuperscript{3} \textsuperscript{4}.
Due to the numerous reports describing treatment-resistant
dermatophytosis, which has emerged as a global public health
threat,\textsuperscript{11} \textsuperscript{12} \textsuperscript{1314}
we started the treatment with high dose itraconazole as 400 mg daily.
Also, we prescribed prednisone 15mg daily at the first month because of
the severe inflammation. Our patient responded well to this treatment
and there was complete clearance of the lesions with acceptable hair
regrowth.

We reviewed tinea capitis case reports in adults indexed in PubMed
between 2018 and 2023. To be included in the review, articles had to be
available in the English language. Inclusion criteria included patient
age [?]18 years, diagnosis of tinea capitis, no history of
immunosuppression or receiving any immunosuppressant drugs, no history
of other medical conditions or history of other dermatophytosis
infection in other parts of the skin, no history of gardening,
pet-keeping, contact with domestic animals or other individuals with the
same manifestations or dermatophytosis infection and no history of
contact with objects containing fomites, including brushes, combs,
bedding, clothing, toys, furniture, and telephones (Table 1).

We found a total of 11 cases. Of these cases, the prevalence was higher
in women (8/11) and the average age was 48.36. Three cases did not have
a mycological culture and didn't mention the dermatophyte isolated.
Trichophyton tonsurans was the most common dermatophyte, followed by
Trichophyton violaceum. Most cases were treated with oral terbinafine
250 mg daily. One patient was treated with oral griseofulvin 500 mg
every 12 hours and another one with oral itraconazole 200 mg twice
daily. Most patients received combination therapy consisting of oral and
topical antifungal agents. All patients reported were cured successfully
without any side effects. Two cases had disseminated lesions on the
face\textsuperscript{15}, extremities and nails\textsuperscript{1516}
years after the scalp manifestations. One case caused by Trichophyton
tonsurans suffered subsequent herpes zoster infection, which shows that
tinea capitis may be a risk factor for varicella zoster virus
reactivation\textsuperscript{17}.

\textbf{Conclusion}

Herein, we report a case of tinea capitis in a 75-year-old
immunocompetent female and review the literature on this rare entity
from 2018 to 2023. Despite the rarity of the disease in adults, tinea
capitis should be included in the differential diagnosis of the
inflammatory scalp lesions in adult or elderly patients, even in
immunocompetent individuals. A KOH examination (and/or fungal culture)
should be performed, to provide early and accurate treatment to minimize
complications and sequelae of the disease.

\textbf{References}

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