A 12-year-old boy was referred to A+E with a ten day history of a facial rash. He had been treated by his GP with oral flucloxacillin for eight days prior but the rash had worsened. He had no significant past medical history. He lived with his parents who were from Pakistan, four siblings, his cat and four kittens. He had travelled to Pakistan on holiday four months earlier with no problems. On examination in the dermatology department he had an inflammatory eruption over the right periorbital area and dorsal nose. There were small pustules over the right eyebrow with surface scale and smaller lesions on the left temple and frontal hairline. He had marked cervical lymphadenopathy. A 4 mm punch biopsy was taken from the left temple along with skin scrapings.
Histological examination showed a deep suppurative folliculitis with fungal hyphae (Majocchi's granuloma). Skin scrapings confirmed trichophyton mentagrophytes on culture. Following discussion with microbiology he was commenced on 20 mg itraconazole daily. After 6 weeks of therapy the eruption had completely cleared and the lymphadenopathy had resolved.
Majocchi's granuloma is an uncommon deep dermatophyte infection of the dermis and subcutis. It does not respond to topical antifungal therapy and requires systemic therapy. Majocchi's granuloma is rare in immunocompetent people: in such cases it is usually secondary to trauma. There are two sub-types of trichophyton mentagrophytes: trichophyton mentagrophytes var interdigitale is anthropophilic and is specifically associated with humans; and trichophyton mentragrophytes var. mentagrophytes which is zoophilic. In the later case clinical disease is usually due to animal contact with mice, cats or rabbits.
In this case it was not possible to subtype t. mentagrophytes. The patient was referred to medical paediatrics for evaluation of his general health but he failed to attend three appointments. On closer questioning the patient advised that his pet cat regularly caught mice. It was felt that the cats were the likely source of his dermatophyte infection, and they were subsequently treated empirically for this by their vet. The patient remains well twelve months following treatment and has had no similar recurrence since then.