A forty-six-year-old male presented to our dermatology clinic with two-year history of itching on his groin. His medical history revealed various topical corticosteroid creams without improvement of the skin lesion. Dermatological examination revealed erythematous nodules and follicular pustules on erythematous background on the inguinal area (Figure 1a). Potassium hydroxide (KOH) examination was negative. Tzanck smear revealed abundant neutrophils without bacteria, fungi, or parasite. The histopathological examination showed granuloma formation with multinuclear giant cells and Periodic acid-Schiff (PAS)-positive hyphae and spores around the hair follicles (Figure 1b, 1c). Hematoxylin-eosin (H&E)-stained slides were examined under an immunofluorescence microscope, and these hyphae and spores showed autofluorescence (Figure 1d). Based on the clinical and histopathological findings, a Majocchi’s granuloma was considered. All lesions disappeared with topical and systemic terbinafine (250 mg/day) treatment for six weeks. Pearls; Clinical: Not only bacteria, but also fungi, parasites, and viruses may cause folliculitis. Cytology should be initially done to identify the causes of infectious folliculitis. In case of negative cytology, histopathological examination and molecular methods can be used. Cytological: To cytologically identify all of the causes of folliculitis, four separate samples should be taken: (i) the first sample is stained with May-Grünwald-Giemsa for routine cytological examination; (ii) the second sample is used for KOH testing; (iii) the third sample is stained with an acid-fast stain to detect mycobacteria; and (iv) the last specimen is Gram-stained to identify whether it is Gram-positive or Gram-negative (1). Histopathological: In infectious diseases, a definitive diagnosis should be done to identify the etiologic agent. The detection of fungal elements is challenging, when histopathological examination is performed with the H&E staining. However, PAS and Gomori’s Methenamine Silver staining can facilitate the detection of fungal spores, hyphae, and arthrospores within the hairs, hair follicles, and in the dermal infiltrates. In addition, autofluorescence can be detected, when H&E stained slides are examined under a fluorescent microscope (2).
Kirk alti yasinda erkek hasta inguinal bölgede kasinti nedeniyle basvurdu. Iki yildir oldugu ögrenilen bu yakinmalarin kortikosteroidli kremler ile düzelmedigi ögrenildi. Dermatolojik muayenede inguinal bölgede eritemli zeminde püstülleri ve ve eritemli nodülleri tespit edildi (Resim 1a). Potasyum hidroksit inceleme negatif idi. Tzanck yayma inceleme yapildi ve bol nötrofil tespit edildi. Sitolojik incelemede bakteri, mantar ve parazit elemanlari tespit edilmedi. Histopatolojik incelemede kil follikülleri çevresinde PAS boyasi ile pozitif boyanan hifa ve sporlar tespit edildi (Resim 1b, 1c). Perifolliküler alanda granülom yapisi ve multinükleer dev hücreler gözlendi. Hematoksilen-eozin boyali preparatlar immünofloresan mikroskop ile degerlendirildiginde hifa ve sporlarin otofloresan verdigi gözlendi (Resim 1d). Mevcut histopatolojik bulgular ile hastada Majocchi granülomu düsünüldü. Alti hafta süreyle uygulanan topikal ve sistemik terbinafin (250 mg/gün) tedavisi ile lezyonlar tamamen düzeldi. Ipuçlari; Klinik: Bakteriler yaninda çok sayida mantar, parazit ve virüs follikülite neden olabilir. Enfeksiyöz follikülitlerin ayriminda ilk yapilmasi gereken sitolojik incelemelerdir. Sitoloji negatif ise histopatoloji ve moleküler yöntemler kullanilabilir. Sitolojik: Follikülit hastalarinda tüm etkenlerin sitolojik olarak tespiti için potasyum hidroksit inceleme yaninda Giemsa, Gram ve asit-fast boyama yapilmalidir (1). Histopatolojik: Fungal enfeksiyonlarin kesin tanisi için etkenlerin görülmesi gerekir. Majocchi granülomu ve invaziv dermatofitik enfeksiyonlarda etkenlerin rutin boyalar ile tespiti güç olabilir. Bu tür olgularda PAS ve GMS gibi bazi özel boyalar kullanilabilecegi gibi immünofloresan mikroskop ile otofloresan veren dermatofitler saptanabilir (2).
