Kerion: an Unusual Presentation in the Otolaryngology Department

Abstract

A 19-year-old farmer was referred by his general practitioner as an emergency to our otolaryngology department complaining of marked breathlessness of a few hours duration. He gave a three-day history of painful swelling and hair loss in the beard area of the right side of the neck. His upper airway was compromised unless extension of the neck was maintained. Larynx and pharynx were normal. The acute symptoms settled with intravenous antibiotics and hydrocortisone. Culture of skin scrapings revealed a growth of Tricophyton verrucosum. The neck swelling subsided after a course of oral griseofulvin followed by terbinafine. Difficulty in breathing due to fungal infection of the neck has not been previously reported in the English literature.

Keywords: Dermatomycosis: Neck; Airway Obstruction

Introduction

Tinea (ringworm) is a common type of superficial (cutaneous) mycosis, which occurs in humans. Normally common in rural areas, of late it has become more frequent in urban areas. Infection can occur in all age groups. The causative agents vary from country to country and from continent to continent. Mycologically, dermatophytes which cause ringworm infection can be classified into Microsporum.Trichophyton and Epidermophyton species.

For clinical and epidemiological reasons, dermatophytes can be classified into geophilic species (inhabiting the soil and only rarely prove to be human pathogens), zoophilic species (having animal origins but may infect humans) and anthropophilic species (largely restricted to human skin) (Table 1).

TABLE I

MAIN SPECIES OF PATHOLOGIC FUNGI

In humans zoophilic fungi tend to cause more severe inflammation than anthropophilic ones. Such severe inflammatory reaction caused by zoophilic fungi in the scalp and beard area is called kerion, a word derived from the Greek for ‘honey comb’.1

Case report

A 19-year-old farmer presented with dyspnoea of a few hours duration. He gave a three-day history of painful swelling of the right side of the neck, for which his family physician had commenced him on oral penicillin and flucloxacillin. Three weeks earlier he had been prescribed clotrimazole cream for rashes in the beard area. He was a non-smoker.

On examination he was pyrexial (37.8C) and the right side of the neck revealed a boggy swelling (15 10cm) with inflammation, pustulation and lymphadenopathy (Figure 1). He also had similar but smaller swellings on the lower left side of the neck and over the upper thorax. He maintained his head in extension to avoid respiratory obstruction.

Fibre-optic endoscopie examination of larynx and pharynx was normal. There was no clinical evidence of para- or retropharyngeal abscess.

Ultrasound scan of the neck revealed a moderately large, ill- defined, echogenic and highly vascular lesion in the right submandibular and upper neck region associated with bilateral enlarged jugulodigastric lymph nodes, consistent with inflammatory pathology. A localized subcutaneous inflammatory lesion at the base of the left posterior triangle of the neck was also seen. There were no clear-cut features of abscess or matted lymph nodes. Tissue biopsy for definitive diagnosis was advised. The patient’s white cell count was 14.7 10^sup 9^/l (neutrophils 11.0 10^sup 9^/l) and C-reactive protein (CRP) was 72 mg/1. He was commenced on intravenous broad-spectrum antibiotics and also received one dose of hydrocortisone (100 mg).

FIG. 1

Kcrion (right side of the neck).

FiG. 2

Keratin invaded by spores of Trichophyton verrncoaitm. Special stain PASd (periodic acid Schiff with diastase) to demonstrate mucopolysaccharide coat of the fungus. Original magnification 400.

The dermatologist, whose help was sought, diagnosed kerion and advised that skin scrapings from the heard area be sent for fungal culture. The patient was commenced on oral griseotulvin 500 mg twice daily and ketaconazole cream for topical application. Skin scrapings revealed a heavy growth of Tricophyton verrucosiim. Over the next few days the inflammatory lesions in the neck gradually settled. The patient was discharged from hospital on the seventh day with advice to continue oral griseofulvin for six more weeks. At six weeks follow up in the out-patient department, it was found that there was still some residual neck swelling. However, the patient’s white cell count and CRP had returned to normal levels. The griseofulvin was discontinued and he was commenced on oral terbinafine 250 mg once daily for six weeks. The swellings of the neck had completely disappeared by the completion of this treatment, but residual rashes persisted. The patient was advised to use terbinafine cream topically. The rashes cleared completely after two months of this treatment.

Discussion

Tinea due to zoophilic fungi usually develops one to two weeks after contact with infected cattle skin, hair or fomites. The disease begins with a small papule or local red rash on the skin. Affected hair becomes brittle and breaks. The infection spreads outwards leaving a dry, scaly central area and red, sometimes raised, newly infected outer edge or ‘ring’. Lesions may or may not itch or be uncomfortable. Without treatment the lesions can linger for weeks to months.

The ‘ringworm” dermatophytes invade and live in the stratum corneum of skin, hair and nail, i.e. the dead keratinized tissues that they can digest (Figure 2). They cannot invade living tissue. Dermatophytosis has a wide range of clinical presentation2 including asymptomatic carrier states, noninflammatory patches of alopecia, alopecia with black dots, kerions with significant inflammation, alopecia resembling bacterial furunculosis, and a seborrhoeic dermatitis-like appearance. Forty to 60 per cent of infections caused by Trichophyton species result in inflammatory lesions, one- third of which are kerions.’ Kerions are common in agricultural workers.4 They are erythaematous, indurated, furunculoid, tender masses in which the hair follicles ooze sero-pus. The suppuration in the follicles causes loss of the hair and so the disease is self- limiting. We believe our patient developed hreathlessness due to massive inflammatory swelling of the right side of the neck, compressing the hypopharynx.

Microscopically, fungal invasion can be ectothrix, endothrix or favus. Trichophvton verrucosum causes large spored ectothrix infection.

In kerion. the inflammation is often so fierce that a bacterial infection is suspected. The other differential diagnoses are furunculosis, seborrhoeic dermatitis, carbuncle, alopecia areata, abscess, psoriasis, discoid eczema and pityriasis rosea. Bacteria are not a major factor in kerion. The immune system is responsible for the intense inflammatory reaction that produces the clinical findings of pustule formation and lymphadenopathy,^7 therefore the use of antibiotics for the treatment of kerion is questionable. Corticosteroids* will ‘tone down’ the immune response.

Diagnosis of tinea infection can be made by direct microscopic examination of an infected hair and/or by fungal culture. If skin scrapings from follicular orifices do not show spores and if a superficial skin scraping for fungal culture gives negative results, a biopsy should be performed.1 Part of the biopsy specimen must be placed on fungal culture media, for this may be the only source of a positive culture. If abscesses on the scalp and beard area are bacteriologically sterile, the pus should always be cultured for fungi.

As the established treatment for the condition, griseofulvin is fungistatic.” It prevents the fungus from growing into the hair once the drug is incorporated into the hair cells. A six-to-eight week treatment is generally considered the minimum requirement. Antifungal agents such as azoles (fluconazole, itraconazole and ketaconazole) and the allylamine terbinafine are also used in the treatment of kerion. Terbinafine is fungicidal in vitro and has been reported to give more rapid resolution of symptoms due to infections caused by Trichophyton species.9 Scarring and permanent hair loss is common in kerion. In such cases systemic antifungal agent such as griseofulvin or ketaconazole should be started immediately.1 Topical potions are of no help in treating a kerion.

Conclusion

Difficulty in breathing due to fungal infection of the neck has not been previously reported in the English literature. If pus from abscesses in the head and neck is bacteriologically sterile, fungal culture may be performed to rule out kerion caused by dermatophytosis.

Acknowledgements

The authors acknowledge the contributions of Dr G Harrison, Consultant Microbiologist, National Public Health Service of Wales, Carmarthenshire and Dr J K Murphy, Consultant, Department of Pathology, West Wales General Hospital, Carmarthen to the preparation of photomicrographs for this paper.

* This is a report of a patient with fungal infection in the neck

* The patient presented with airway problems and was treated successfully with antifungal therapy

* The authors state that such a condition has not been previously reported

References

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6 Brit AR, Wilt JC. Mycology, bacteriology and histopathology of suppurativc ringworm. Arch Dermatol Syphil 1954:69:441-8

7 Babel DE, Rogers AE, Beneke ES. Dermatophytosis of the scalp: incidence, immune response and epidemiology. Mycopathologia 1990:109:69-73

8 Urbanek M, Neill SM, Miller JA. Kerion – A case report. Clin Exp Dermatol 1995:20:413-14

9 Fuller EC. Smith CH. Cerio R. Marsden RA. Midgley G, Beard AE, el al. A randomized comparison of 4 weeks of terbinafine vs. 8 weeks of griseofulvin for the treatment of tinea capitis. BrJ Dcrmaiol 2001:144:321-7

K RAMACHANDRAN, FRCSI, DLO (LoN), M ARIF, FRCS (Eo), U UGOJI, FRCP*. B R DAVIS, FRCS

From the Departments of Otolaryngology & Head & Neck Surgery and * Dermatology, West Wales General Hospital, Carmarthen, Wales, UK.

Accepted for publication: 29 November 2004.

Address for correspondence:

Mr K Ramachandran,

Department of Otolaryngology & Head & Neck Surgery.

West Wales General Hospital,

Carmarthen SA31 2AF. UK.

E-mail: ramshyla@aol.com

Mr K Ramachandran takes responsibility for the integrity of the content of the paper.

Competing interests: None declared

Copyright Royal Society of Medicine Press Ltd. Feb 2005