A 62-year-old female patient presented to our hospital with a complaint of a lump on her left forearm for 5 months, and the condition had been aggravated for the last month. The lump was not painful or itchy. The patient had her left forearm bitten by a dog 5 months prior. At that time, she was treated at a pet hospital and injected with a rabies vaccine. The wound healed very slowly but failed to heal completely, leaving a small red nodules. In the month prior, the red nodules had increased significantly in size without pain or itching, and there was a small amount of pus after squeezing. She self treated with an oral cephalosporin for one week. No topical treatments, including topical steroids, were used. Her condition did not improve, so she came to our hospital for treatment. She had no history of any other disease.
Physical examination revealed a 3 x 3.5 cm sized lump on her left forearm, with a clear boundary, a few scales and scabs on the surface, and no tenderness (Fig. 1a). Her trunk and limbs were free of tinea corporis, tinea pedis and onychomycosis.
Laboratory investigations showed normal liver, kidney, immune function test results and T lymphocyte subsets were normal. The results of human immunodeficiency virus (HIV) were negative. Fungal microscopy was negative. PAS staining was positive for hyphae (Fig. 2).
A fungal culture was performed in a 27℃ incubator and showed the fungi growing slowly with a variable texture. The surfaces of colonies were velvety (Fig. 3a). White colonies could be seen in small cultures (Fig. 3b). A large number of small conidia of different shapes were seen in small cultures, and the ends of individual small conidia enlarged, like balloons (Fig. 4). The results showed only the growth of Trichophyton tonsurans.
Histological examination showed excessive keratinization of the epidermis and epithelioma-like hyperplasia of the spinous layer (Fig. 5). Dense lymphocytes and neutrophils infiltrated the superficial dermis. The above characteristics are consistent with infectious granulomatous changes. Molecular identification showed that the fungus was 99.7% similar to AB094063.1 Trichophyton tonsurans in GenBank, and was eventually diagnosed as Trichophyton tonsurans through ITS molecular diagnosis (ITS1, ITS4).
The patient was given itraconazole 100 mg twice daily. At the same time, the patient was given moxibustion treatment, which used a burning moxa to stimulate the lumps twice a day for 20 minutes each time. At the beginning of the moxibustion, the lumps were swollen and exuded pus (Fig.1b), and there was pain, but it was tolerable. After 2 weeks of treatment, the lumps began to be absorbed. After 40 days, the lumps were further absorbed and there was no exudation of pus on their surfaces. The treatment lasted for a total duration of 2 months until the lesions of Majocchi’s granuloma were completely absorbed and changed to scars (Fig.1c). There was not any recurrence of Majocchi’s granuloma after the treatment at a 3-months follow-up.