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Joe R. Monroe, PA-C, MPAS, DEPARTMENT EDITOR
A persistent “fungal infection” on the face
Joe R. Monroe, PA-C, MPAS
The author practices in the dermatology department of the Springer Clinic, Tulsa, Okla, and is the founder and president-elect of the Society of Dermatology Physician Assistants. He has indicated no relationships to disclose relating to the content of this article.
A 52-year-old African American woman was seen in the dermatology clinic for evaluation
of a “fungal infection” of facial skin that had persisted despite the
use of several OTC and prescription antifungal creams. Oral terbinafine, 250 mg
daily for 2 weeks, also had not the slightest beneficial effect.
The patient revealed in the history that the rash
had been present off and on for more than a year. During this time, she had also
had significant problems with recurrent “sinus infections,” shortness
of breath, and unexplained fever and malaise. There had been no recent foreign travel,
and no one else in her family was ill. The patient denied smoking. She admitted
to having several dogs at home, but these were the same outside pets she had had
for years, and she had little contact with them.  Examination revealed large, nontender
erythematous plaques on the sides of the patient’s face, but no scale was evident
(see Figure 1). Diffuse, nontender adenopathy was found in anterior cervical nodal
locations. A punch biopsy of the plaques was done, and the results showed noncaseating
granulomatous changes.
The patient almost certainly has
• Cutaneous tuberculosis
• Fungal infection
• Mycosis fungoides
• Sarcoidosis Discussion
The correct answer is sarcoidosis, a multisystem
disease of unknown origin with a predilection for African American women. Thought
to be a reaction to an unknown antigen, sarcoidosis can affect virtually any organ.
At least 50% of affected patients eventually demonstrate skin findings, which offer
a readily available opportunity to confirm the diagnosis when biopsy results show
noncaseating granulomatous changes. Laboratory abnormalities include an elevated
ACE level along with hypercalcemia, hypercalciuria, or both. This patient was referred
to a pulmonologist, who treated her successfully with prednisone. Cutaneous tuberculosis would have shown
caseating granulomatous changes on biopsy and is therefore an incorrect choice.
Fungal infection can also demonstrate granulomatous changes on biopsy, but of a
completely different type. Fungal organisms could be detected with the proper stain.
The complete lack of scale spoke loudly against this choice as well. Erythematous
plaques and adenopathy suggest mycosis fungoides, also known as cutaneous T-cell
lymphoma, but the biopsy results ruled this diagnosis out.
To diagnose sarcoidosis, the clinician
must consider it in the differential—but providers outside of dermatology and
pulmonology may not be familiar enough with the condition to order a biopsy. Two
aspects of this patient’s disease were key. Sarcoid is more common in African
American women than in any other group, and the annular intradermal skin lesions
were typical sarcoidal lesions. |
