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Revival of generalized favus

  • Xiu-Jiao Xia
    Affiliations
    Department of Dermatology, Hangzhou Third People's Hospital, Affiliated Hangzhou Dermatology Hospital, Zhejiang University School of Medicine, West Lake Rd 38, Hangzhou, 310009, China
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  • Hui-Lin Zhi
    Affiliations
    Department of Dermatology, Hangzhou Third People's Hospital, Affiliated Hangzhou Dermatology Hospital, Zhejiang University School of Medicine, West Lake Rd 38, Hangzhou, 310009, China
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  • Ze-Hu Liu
    Correspondence
    Corresponding author: Ze-Hu Liu, Department of Dermatology, Hangzhou Third People's Hospital, Affiliated Hangzhou Dermatology Hospital, Zhejiang University School of Medicine, West Lake Rd 38, Hangzhou, China. Tel: 86-571-87827181, Fax: 86-571-87814481.
    Affiliations
    Department of Dermatology, Hangzhou Third People's Hospital, Affiliated Hangzhou Dermatology Hospital, Zhejiang University School of Medicine, West Lake Rd 38, Hangzhou, 310009, China
    Search for articles by this author
Open AccessPublished:May 27, 2022DOI:https://doi.org/10.1016/j.ijid.2022.05.053

      Keywords

      An immunocompetent 70-year-old woman from a rural village complained of painful lesions of the scalp, adjacent area of the face, and trunk evolving for 2 months. Examination revealed extensive cicatricial alopecia and extensive scaling and crusted plaques (Figure 1). These plaques presented as concave cup-shaped, whitish, isolated, or confluent scutula of 0.5-5 cm diameter involving the scalp, face (Figure 2), and trunk (Figure 3), with an unpleasant mousy odor.
      Figure 1
      Figure 1Vertex of the scalp showing an extensive an extensive cicatricial alopecia and concave cup-shaped, whitish, isolated, and confluent scutula.
      Figure 2
      Figure 2Extensive concave cup-shaped, whitish, isolated, or confluent scutula involving the face, ear, and neck.
      Figure 3
      Figure 3Concave cup-shaped, whitish, isolated, or confluent scutula with erythematous base on the trunk.
      Direct microscopic examination of infected hairs in 10% potassium hydroxide showed endothrix invasion with the presence of hyphae (Figure 4) and a huge number of hyphae and spores in the crust as revealed by periodic acid-Schiff staining (Figure 5) and calcofluor white staining (Figure 6). Fungal culture of infected hair and crusts on Sabouraud glucose agar yielded whitish, waxy heaped, and irregularly folded colonies. Microscopic examination of cultures revealed antler-like filaments with favic characteristic chandelier structures, and few intercalate chlamydospores. The isolate was further confirmed as Trichophyton schoenleinii by internal transcribed spacer-polymerase chain reaction sequencing. Laboratory examination showed significant hypoalbuminemia (24 g/l). The diagnosis of generalized favus because of T. schoenleinii was confirmed. A clinical and mycological cure was achieved after treatment with an oral terbinafine tablet (250 mg/d) for one month.
      Figure 4
      Figure 4Direct microscopy of ill-hairs revealed the presence of endothrix hyphae, which grow in parallel to the long axis of the hair shaft (original magnification × 400).
      Figure 5
      Figure 5Huge number of hyphae and spores with concavity revealed in the crust stained with periodic acid-Schiff staining (original magnification × 400).
      Figure 6
      Figure 6Large number of hyphae and spores with central cleft could be detected in the crust stained with calcofluor white staining (original magnification × 400).
      Tinea capitis favosa is a chronic inflammatory dermatophyte infection of the scalp (
      • Ilkit M.
      Favus of the scalp: an overview and update.
      ), which affects patients with anthropophilic Trichophyton schoenleinii, T. violaceum, T. verrucosum, zoophilic T. mentagrophytes var. quinckeanum, Microsporum canis, and geophilic Nannizzia gypsea (
      • Xia XJ
      • Zhang Y
      • Zhong Y
      • Sang B
      • Li QP
      • Wang M
      • et al.
      Novel in vivo observations of scrotal Nannizzia gypsea infection.
      ). Generalized favus is uncommon (
      • Iwasa K
      • Ogawa K
      • Azukizawa H
      • Tanabe H
      • Iwanaga T
      • Anzawa K
      • et al.
      Revival of favus in Japan caused by Trichophyton schoenleinii.
      ), which was seen in geographic regions with extreme poverty, poor hygiene, and malnutrition (
      • Ilkit M.
      Favus of the scalp: an overview and update.
      ). The patient admitted to fasting for several months, leading to malnutrition with significant hypoalbuminemia. The white appearance of skin lesions results from incoherent reflections of light on their many surfaces among the abundant hyphae and separated keratinocytes (
      • Liu ZH
      • Xia XJ
      • Zhang Y
      • Zhong Y
      • Sang B
      • Li QP
      • et al.
      Favus of scrotum because of Trichophyton rubrum in immunocompetent patients: a clinical, mycological and ultrastructural study.
      ). The concave, cup-shaped appearance of favus results from peripheral well-preserved hyphae with central dead and degenerating mycelium and debris (
      • Ilkit M.
      Favus of the scalp: an overview and update.
      ).

      Declaration of Competing Interest

      The authors have no competing interests to declare.

      Author contributions

      Drs. Xia, Zhi, Liu: acquisition and interpretation of data, Drs. Xia, Zhi, Liu: preparation of the manuscript, Drs. Xia, Zhi, Liu: conceived the study concept, supervised data acquisition and interpretation, Dr Liu: took care of the patient, Drs. Xia, Zhi, Liu: completion of the manuscript.

      Funding

      This work was supported by the Hangzhou Science and Technology Bureau, China (grant no. 202004A17).

      Ethical approval

      Written informed consent was obtained from the patient for publication of this case report and accompanying images.

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