Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
Observation Letter
87 (
2
); 249-252
doi:
10.25259/IJDVL_1036_18
CROSSMARK LOGO Buy Reprints
PDF

“Generalized exanthematous pustular dermatophytid” in a 4-year-old child: A misdiagnosed entity

Department of Dermatology Fattouma Bourguiba Hospital, Monastir, Tunisia
Department of Anatomopathology, Fattouma Bourguiba Hospital, Monastir, Tunisia
Corresponding author: Dr. Kamar Belhareth, Department of Dermatology, Fattouma Bourguiba HospitalMonastir, Tunisia. kmar.belhareth@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Belhareth K, Soua Y, Korbi M, Njima M, Youssef M, Belhadjali H, et al. “Generalized exanthematous pustular dermatophytid” in a 4-year-old child: A misdiagnosed entity. Indian J Dermatol Venereol Leprol 2021;87:249-52.

Sir,

A previously healthy 4-year-old child was referred to the dermatology department for an inflammatory, crusted, matted mass over the scalp progressing for 2 weeks [Figure 1].

Figure 1:: Inflammatory and crusted, matted mass on the scalp (kerion)

Direct microscopic examination of the hair sample from the affected area in 10% potassium hydroxide revealed an endothrix pilar invasion with the presence of septate hyaline hyphae. After 4 weeks, Trichophyton tonsurans was isolated from the culture using Sabouraud agar.

The diagnosis of a kerion was made. Three days after oral micronized griseofulvin initiation (22 mg/kg/d), the child presented with a generalized pustular eruption initially localized to the palms and soles which then rapidly spread over the entire body in the next few days. She had no fever and no other constitutional symptoms. On clinical examination, we found multiple, large, non-follicular pustules on a nonerythematous base especially on the palms and soles; also on her face, trunk and arms [Figures 2-4]. Intertriginous areas were spared. Blood analysis showed leucocytosis (12000/µl), neutrophilia (7000/µl) and a slight increase in C-reactive protein (20 mg/l). Bacteriological and mycological cultures of samples obtained from the pustular lesions were sterile. Biopsy revealed a subcorneal pustule containing a small amount of neutrophils. The dermis showed a moderate perivascular, lymphohistiocytic inflammatory infiltrate with the presence of some eosinophils [Figures 5 and 6]. A diagnosis of “generalized exanthematous pustular dermatophytid” was suspected. We opted to maintain griseofluvin at the same dose, and to add a high-potency topical steroid and systemic corticosteroids (dexamethasone sodium phosphate) (0.5 mg/kg/d) to the treatment protocol. The eruption resolved completely within 5 days of starting the treatment [Figure 7]. Systemic corticosteroids were stopped and griseofulvin was continued for 2 months.

Figure 2:: Multiple, large, non-follicular pustules on the palms
Figure 3:: Pustules on the soles
Figure 4:: Generalized pustular eruption on the trunk
Figure 5:: Subcorneal pustule containing neutrophils (H and E, ×40)
Figure 6:: Complete resolution of the eruption

The diagnosis of generalized exanthematous pustular dermatophytid was established based on the presence of a mycologically documented dermatophyte infection (kerion), the absence of dermatophytes in distant pustular lesions and the resolution of all symptoms after maintaining antifungal therapy and initiating systemic corticosteroid therapy.

This entity is a rarely reported form of dermatophytids, which are immunologically mediated dermatologic reactions secondary to dermatophyte infections commonly seen in patients with tinea pedis and typically described as a vesicular eruption. Dermatophytids secondary to kerion are less common. A recent prospective study revealed that 13 of 19 patients (68%) with kerion celsi developed dermatophytid reactions1. The main clinical manifestations of these reactions are: eczematous eruptions (36.8%), pruritic papules (15.8%), eczematous eruptions, excoriated papules and pustules (10.5%) and angioedema-like reaction (5.3%).1 According to literature, only four cases of generalized exanthematous pustular dermatophytid have been reported [features of all reported cases are summarized in Table 1].2,3 Three of those reported cases occurred within 2-3 days of griseofulvin intake and in one case, the eruption occurred spontaneously. All cases were characterized with a pustular eruption predominating initially in the cephalic region then spreading to the entire body. Fever was present in two cases and only one case was complicated with inflammatory chondritis. The palmoplantar onset of the rash, as noted in our case, had never been previously reported.

Table 1:: All reported cases of generalized exanthematous pustular dermatophytid secondary to kerion Reported cases
Reported cases Age (years) Sex Lesion/ Causative agent Clinical appearance Time to 'id' eruption Laboratory parameters Treatment
Liu et al., 20113 8 Female Multiples kerion/TM Widespread pustules, head+Fever 38.9 17 days after kerion Leucocytosis 20,300/mm3
Blood cultures (−)
Oral itraconazole (5 mg/kg/day) + low-dose
Dexamethasone (0.075 mg/kg/day)
Ronjat 20152 11 Male Kerion/TT Fever 39
Widespread pustules, head+Lymphadenopathy
Bilateral chondritis
2 months after kerion
2 days after Griseofulvin
Polynucleosis 7200/mm3
Monocytosis
1200/mm3
Eosinophilia 500/mm3
CRP: 28 mg/L
Oral corticosteroid 0.75 mg/kg/day + amoxicillin/clavulanic acid + griseofulvin (25 mg/kg/day)
Ronjat 20152 6 Male Kerion/TS Widespread pustules, head+ 6 weeks after kerion
2 days after Griseofulvin
Normal High-potency topical steroids + griseofulvin (20 mg/kg/day)
Ronjat 20152 6 Female Kerion/TM Widespread pustules, head+Eczematous eruption
Lymphadenopathy
8 weeks after kerion
3 days after Griseofulvin
Normal High-potency topical steroids + griseofulvin (19 mg/kg/day)
Our case 4 Female Kerion/TM Widespread pustules, palms and soles++ 2 months after kerion
3 days after Griseofulvin
Leucocytosis 12,000/mm3
CRP: 15 mg/L
Griseoulvin + high-potency topical steroids + oral corticosteroid (0.5mg/kg/day)

TM: Trichophyton mentagrophyte, TT: Trichophyton tonsuran, TS: Trichophyton soudanense, CRP: C-reactive protein

The most concerning differentials diagnosis of generalized pustular psoriasis was ruled out because of the clinical and pathological findings. The main differential diagnosis in our case was acute generalized exanthematous pustulosis. The lack of diffuse erythema, the absence of the involvement of intertriginous areas and the favorable evolution despite continued griseofluvin treatment made this diagnosis unlikely. Moreover, griseofulvin-induced acute generalized exanthematous pustulosis has not been previously reported. The typical histopathology of acute generalized exanthematous pustulosis shows spongiform subcorneal and/ or intraepithelial pustules, an edematous papillary dermis and perivascular infiltrates with neutrophils and some eosinophils. In some cases, necrotic keratinocytes and leucocytoclastic vasculitis can also be found. In our case, histopathological aspect was not different from acute generalized exanthematous pustulosis. We were unable to find any previous reports with histological description of generalized exanthematous pustular dermatophytid. Thus, we cannot conclude on the existence of a distinctive criteria to differentiate between these two entities. Further histological studies may be helpful to identify possible histologic characteristics of generalized exanthematous pustular dermatophytid.

The exact mechanism of generalized exanthematous pustular dermatophytid is still unknown. To the best of our knowledge, no case of terbinafine-associated generalized exanthematous pustular dermatophytid has been reported. Some authors have linked the flare of dermatophytid reaction after the administration of griseofulvin or terbinafine to the release of fungal antigens as a result of antimycotic therapy.4,5 Others suggest a local immunological response to systemically absorbed fungal antigen, especially some zoophilic species.3 The treatment of generalized exanthematous pustular dermatophytid is non-codified, due to the scarcity of reported cases. Oral corticosteroid treatment and/or high-potency topical steroids given as an adjunct to griseofulvin treatment (19 to 23 mg/kg/d) were used with a favorable resolution in the reported cases.2,3

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. , . Are dermatophytid reactions in patients with kerion celsi much more common than previously thought? A prospective study. Pediatr Dermatol. 2015;32:635-40.
    [CrossRef] [PubMed] [Google Scholar]
  2. , , , , . Generalized exanthematous pustular dermatophytid, a rare clinical presentation of dermatophytid reaction. Ann Dermatol Venereol. 2015;142:270-5.
    [CrossRef] [PubMed] [Google Scholar]
  3. , , . Severe kerion with dermatophytid reaction presenting with diffuse erythema and pustules. Mycoses. 2011;54:e650-2.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , , , , , et al. Erythema nodosum induced by kerion celsi of the scalp in a child: A case report and mini-review of literature. Mycoses. 2013;56:200-3.
    [CrossRef] [PubMed] [Google Scholar]
  5. , , . Dermatophytid in tinea capitis: Rarely reported common phenomenon with clinical implications. Pediatrics. 2011;128:e453-7.
    [CrossRef] [PubMed] [Google Scholar]

Fulltext Views
748

PDF downloads
82
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections