P3.T388: The Dermato-Fight: A Curious Rash Following Tropical Travel

Introduction: Dermatologic disorders are a common problem in returning travelers. Skin lesions can present with a varied and diverse range of conditions. Due to the extensive differential and unfamiliarity, travel-related rashes are challenging to accurately diagnose. Here we present a case of Majocchi's Granuloma in an adolescent traveler initially misdiagnosed as a bacterial cellulitis to raise awareness of this rare dermatophyte infection.

Case Description: An 18-year-old previously healthy male presented with a persistent bilateral rash on the medial aspects of his lower legs. The rash began on the right ankle following local trauma while traveling in the Philippines 4 months earlier. There was spread to the left ankle in a mirroring distribution several weeks after the initial abrasion. The affected areas have become increasingly erythematous and pruritic. He has been covering the areas with bandages and treating with topical steroid creams.

He initially presented to an urgent care for evaluation where a culture was obtained and grew methicillin sensitive Staphylococcus aureus. He was treated with amoxicillin-clavulanate followed by ciprofloxacin, but there was no improvement. He has denied fever or other features concerning for a systemic infection, did not recall any insect bites or other atypical travel exposures, and spent most of his trip in large cities. His complete blood count was significant for an elevated absolute eosinophil count (710) while chemistry and inflammatory markers were normal. Upon consultation with Pediatric Infectious Disease the infection was recognized, treatment with oral terbinafine (250mg once daily) was initiated, and, at follow up two weeks later, the rash was much improved (Figure). The rash completely resolved following 6 weeks of therapy.

Discussion: The spread of this rash to the opposing leg raised concern for an infectious etiology. Most infectious rashes with this description are caused by cutaneous leishmaniasis, nontuberculous mycobacteria, or dermatophytes. Leishmaniasis has a narrow worldwide distribution that does not include the Philippines. Nontuberculous mycobacteria often have a more nodular appearance. Majocchi’s granuloma is an inflammatory and granulomatous infection caused mainly by dermatophytes, most frequently Trichophyton rubrum, and usually affects the lower extremities. It is more common in young adults with preceding local trauma, in warm and humid environments, and can be exacerbated by topical steroids. Treatment requires systemic therapy as topical antifungals are ineffective. The characteristics, evolution, and response to treatment in our patient is consistent with Majocchi’s granuloma. Greater awareness of this condition would facilitate early recognition and appropriate management.

Conclusion: Majocchi’s granuloma is an uncommon infection caused by dermatophytes that can appear similar to more commonly encountered rashes. Pediatricians should consider this possibility in children and adolescents with an appropriate history, especially a potential inoculating injury, and skin lesions that do not respond to topical steroids or antifungals or oral antibiotics.