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Joao Brissos1, Catarina Gouveia2, Conceição Neves2, Luís Varandas2

1 Department of Pediatrics, Hospital Dona Estefânia, Lisboa, Portugal
2 Department of Pediatric Infectious Diseases, Hospital Dona Estefânia, Lisboa, Portugal

BMJ Case Rep 2013.

Description: A healthy 3-year-old boy presented to our emergency department with a 2-week history of inflammatory scalp lesions. Physical examination revealed diffuse erythematous lesions, with focal areas of alopecia and several pustular patches with extensive suppurative discharge (figures 1 and 2). Cervical lymphadenopathy and fever were also noted. Tinea capitis with secondary bacterial infection was diagnosed and fluconazol, intravenous flucloxacillin and clindamycin were given. Surgical drainage was performed due to multiple scalp abscesses. Trichophyton mentagrophytes was isolated from scalp brushings. A 5-month course of fluconazol was necessary for clinical cure. His mother had the same fungal infection (forearm skin lesion) and family reported guinea pig exposure for the past months. Tinea capitis is the most frequent fungal infection in children. Zoophilic dermatophytes are responsible for severe inflammatory reactions probably due to their poor adaptation to the human host. Kerion celsi is an acute purulent inflammatory process of scalp, probably due to a T-cell-mediated hypersensitivity reaction to the dermatophyte. Griseofulvin is the first therapeutic choice since late 1950s, but is not available in certain European countries. Newer antifungal agents (terbinafine, itraconazole and fluconazole) seem to have similar efficacy rates. Treatment duration should be individualized according to severity and clinical response. Adjunctive treatment is controversial but data does not support antibiotics nor surgery for routine use. Tinea capitis and particularly kerion celsi, have a high potential for misdiagnosis. Several cases are incorrectly diagnosed as bacterial infection. Delay in treatment led to more extensive, severe inflammation and consequently to scarring and alopecia in our case.
Learning points:
- Tinea capitis is a superficial fungal infection of the scalp and is one of the most common dermatophytosis of childhood.
- The most inflammatory presentation is kerion, which is considered to be an exaggerated cell-mediated response to the fungus, often confused with a bacterial infection.
- Tinea capitis treatment in infants is still on debate, regarding newer oral antifungal agents. Duration of treatment should be individualized according to the