RSS-Feed abonnieren
DOI: 10.1055/s-0043-112665
Trichophyton rubrum-Syndrom und Tinea incognita unter immunsuppressiver Behandlung mit Leflunomid und Fumarsäureestern bei Patienten mit rheumatoider Arthritis und Psoriasis vulgaris
Trichophyton rubrum Syndrome and Tinea incognita under Immunosuppressive Treatment with Leflunomide and Fumaric Acid Esters in Patients with Rheumatoid Arthritis and Psoriasis vulgarisPublikationsverlauf
Publikationsdatum:
31. August 2017 (online)
![](https://www.thieme-connect.de/media/derma/20170809/lookinside/thumbnails/889_10-1055-s-0043-112665-1.jpg)
Zusammenfassung
Ein 70-jähriger Patient mit rheumatoider Arthritis (Anti-CCP-Antikörper positiv), Nikotinabusus und Arteriosklerose wurde immunsuppressiv mit Leflunomid 20 mg und Prednisolon 50 mg täglich behandelt. Am Körperstamm traten großflächige, ekzematisierte, randbetonte, zentrifugal wachsende erythrosquamöse Läsionen auf. Die Haut der rechten Hand und beider Füße war trocken, schuppend und atrophisch. Außerdem bestanden gelbbraune Onychodystrophien aller Fingernägel der rechten Hand sowie aller Zehennägel. Das Blankophor®-Präparat aus Hautschuppen war positiv, kulturell und mit PCR ließ sich Trichophyton (T.) rubrum nachweisen. Die ausgeprägte Tinea corporis wurde mit einer Antimykotika- und Glukokortikoid-haltigen Creme behandelt, wegen der Tinea unguium kam Terbinafin zur Anwendung.
Ein 68-jähriger Psoriatiker erhielt bereits seit 1979 Fumarsäureester zur systemischen antipsoriatischen Therapie. Seit einigen Monaten entwickelten sich an Flanken, Rücken, gluteal, an den Waden, prätibial und an den Oberschenkeln blass-rote erythrosquamöse Plaques im Sinne einer Tinea corporis incognita. Das Nativpräparat war positiv, kulturell und mit PCR gelang aus insgesamt 6 Lokalisationen der Nachweis von T. rubrum. Da eine systemische antimykotische Behandlung abgelehnt wurde, kam Terbinafin-Creme im Wechsel mit Clotrimazol- + Betamethason-Creme zur Anwendung.
Die großflächige und generalisierte Tinea corporis mit Onychomykose erfüllte bei beiden Patienten die Kriterien eines sog. T. rubrum-Syndroms. Dieses, aber auch die Tinea incognita, entwickeln sich in der Regel infolge einer Autoinokulation von einer vorbestehenden Tinea pedis et unguium. Disponierender Faktor für das T. rubrum-Syndrom, aber auch für die Tinea incognita, ist nicht selten eine immunsupprimierende Therapie, hier durch Glukokortikoide, Leflunomid sowie Fumarsäureester.
Abstract
A 70-year-old patient with rheumatoid arthritis (anti-CCP antibodies positive), nicotine abuse, and arteriosclerosis received an immunsuppressive therapy by leflunomide 20 mg and prednisolone 50 mg, both daily. The trunk showed extensive areas of eczematization with edge emphatic rubefaction and centrifugal growing lesions. The skin of the right hand and of both feet was dry, scaling, and atrophic. Moreover, yellow brown and hypertrophic onychodystrophy of all fingernails of the right hand and all toe nails of both feet were apparently. The Blankophor® preparation was positive, by cultivation and with PCR Trichophyton (T.) rubrum was detected from skin scrapings. The pronounced tinea corporis was treated topically with a combined antifungal and glucocorticoid containing cream, for the tinea unguium and tinea corporis terbinafine was started.
A 68-year-old psoriatic patient received already since 1979 fumaric acid esters for systemic antipsoriatic therapy. Over the last few months, at the flanks, the back, in the gluteal area, both lower legs, and at the thighs he developed pale red plaques which could be interpreted as tinea corporis incognita. The native preparation of skin scrapings was positive, and again by culture and by PCR it was possible to detect T. rubrum. Because the oral antifungal therapy was rejected topical antifungal treatment using terbinafine cream and clotrimazole plus betamethasone containing cream was started.
The extensive area and generalized tinea corporis and onychomycosis fulfilled the criteria of a so called T. rubrum syndrome. Both the dermatomycosis in the patient with rheumatoid arthritis, and the tinea incognita of the psoriatic patient have been developed after an autoinoculation from a prior existing tinea pedis and tinea unguium. An immunosuppressive treatment – here by glucocorticoids, leflunomide, and fumaric acid esters – represents a disposing factor both for the T. rubrum syndrome, and also for the tinea incognita.
-
Literatur
- 1 Nenoff P, Krüger C, Schaller J. et al. Mykologie – ein Update. Teil 2: Dermatomykosen: Klinisches Bild und Diagnostik. J Dtsch Dermatol Ges 2014; 12: 749-779
- 2 Kick G, Korting HC. The definition of Trichophyton rubrum syndrome. Mycoses 2001; 44: 167-171
- 3 Piñeiro L, Larruskain J, Idigoras P. et al. Trichophyton rubrum syndrome: the tip of the iceberg and a preventable outcome. Mycoses 2010; 53: 186
- 4 Peixoto I, Maquine G, Francesconi VA. et al. Dermatophytosis caused by Trichophyton rubrum as an opportunistic infection in patients with Cushing disease. An Bras Dermatol 2010; 85: 888-890
- 5 de Sousa MdaG, Santana GB, Criado PR. et al. Chronic widespread dermatophytosis due to Trichophyton rubrum: a syndrome associated with a Trichophyton-specific functional defect of phagocytes. Front Microbiol 2015; 6: 801
- 6 Zisova LG, Dobrev HP, Tchernev G. et al. Tinea atypica: report of nine cases. Wien Med Wochenschr 2013; 163: 549-555
- 7 Jewell JR, Myers SA. Topical therapy primer for nondermatologists. Med Clin North Am 2015; 99: 1167-1182
- 8 Seitz AT, Paasch U, Simon JC. et al. Tinea incognito. J Dtsch Dermatol Ges 2013; 11: 1090-1093
- 9 Kim WJ, Kim TW, Mun JH. et al. Tinea incognito in Korea and its risk factors: nine-year multicenter survey. J Korean Med Sci 2013; 28: 145-151
- 10 Amano H, Kishi C, Yokoyama Y. et al. Microsporum canis infection mimics pemphigus erythematosus. Indian J Dermatol 2013; 58: 243
- 11 Liu ZH, Shen H. Tinea incognito in an old patient with bullous pemphigoid receiving topical high potency steroids. J Mycol Med 2015; 25: 245-246
- 12 Kye H, Kim DH, Seo SH. et al. Polycyclic annular lesion masquerading as lupus erythematosus and emerging as tinea faciei incognito. Ann Dermatol 2015; 27: 322-325
- 13 Barth D, Tauchnitz-Hiemisch R, Nenoff P. et al. Is leflunomide therapy a predisposition factor for cryptococcosis?. Mycoses 2016; 59: 29 (Abstract)
- 14 Yoo HG, Yu HM, Jun JB. et al. Risk factors of severe infections in patients with rheumatoid arthritis treated with leflunomide. Mod Rheumatol 2013; 23: 709-715
- 15 Woyciechowsky TG, Dalcin DC, dos Santos JW. et al. Paracoccidioidomycosis induced by immunosuppressive drugs in a patient with rheumatoid arthritis and bone sarcoma: case report and review of the literature. Mycopathologia 2011; 172: 77-81
- 16 Stankovic K, Sève P, Hot A. et al. Aspergillosis in systemic diseases treated with steroids and/or immunosuppressive drugs: report of 9 cases and review of the literature. Rev Med Interne 2006; 27: 813-827
- 17 Dimitrova P, Ivanovska N. Host resistance to Candida albicans infection of mice with collagen-induced arthritis treated with leflunomide. Res Microbiol 2006; 157: 525-530
- 18 Dimitrova P, Ivanovska N. Influence of leflunomide on gastrointestinal Candida albicans infection induced in naive and arthritic newborn mice. Int Immunopharmacol 2006; 6: 1682-1689
- 19 Kobayashi M, Soude E, Takahashi E. et al. A case of nail candidiasis with severe deformities treated with oral fluconazole. Nihon Ishinkin Gakkai Zasshi 2008; 49: 217-220
- 20 Bicer A, Tursen U, Cimen OB. et al. Prevalence of dermatophytosis in patients with rheumatoid arthritis. Rheumatol Int 2003; 23: 37-40
- 21 Yamamoto T, Ohkubo H, Nishioka K. Skin manifestations associated with rheumatoid arthritis. J Dermatol 1995; 22: 324-329
- 22 Meinhof W, Hornstein OP, Scheiffarth F. Multiple subkutane Trichophyton-rubrum-Abszesse. Pathomorphose einer generalisierten superfiziellen Tinea bei gestörter Infektabwehr. Hautarzt 1976; 27: 318-327
- 23 Nieuwkamp DJ, Murk JL, van Oosten BW. PML in Dutch MS Patients Consortium et al. PML in a patient without severe lymphocytopenia receiving dimethyl fumarate. N Engl J Med 2015; 372: 1474-1476
- 24 Akao M, Kuroda K. Antifungal activity of fumaric acid in mice infected with Candida albicans . Chem Pharm Bull (Tokyo) 1991; 39: 3077-3078
- 25 Zhu KJ, Cen JP, Lin AH. et al. Modulatory effect of fumaric acid esters on superoxide-anion generation in human phagocytes. Yao Xue Xue Bao 2007; 42: 1215-1217
- 26 Zhu K, Mrowietz U. Enhancement of antibacterial superoxide-anion generation in human monocytes by fumaric acid esters. Arch Dermatol Res 2005; 297: 170-176
- 27 Zisova L, Valtchev V, Sotiriou E. et al. Onychomycosis in patients with psoriasis – a multicentre study. Mycoses 2012; 55: 143-147