唐教清　莊凱文　冉昕　冉玉平

(四川大學(xué)華西醫(yī)院皮膚性病科，成都 610041)

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·病例報告·

斷發(fā)毛癬菌所致嬰兒膿癬并發(fā)癬菌疹1例

唐教清莊凱文冉昕冉玉平

(四川大學(xué)華西醫(yī)院皮膚性病科，成都 610041)

患兒男，5個月，額部發(fā)際處紅斑3個月。皮膚科檢查：前額發(fā)際處大片紅斑，相互融合、邊界較清，紅斑內(nèi)頭發(fā)稀疏，個別折斷或脫失，毛囊性膿皰及皮下膿腫，經(jīng)真菌鏡檢、培養(yǎng)及提取DNA做PCR后測序鑒定，確診為斷發(fā)毛癬菌致嬰兒膿癬，予口服伊曲康唑 (33 mg/d)及外用2%酮康唑洗劑、1%萘替芬-0.25%酮康唑乳膏等治療。在治療中出現(xiàn)頭面部多發(fā)散在環(huán)狀鱗屑性丘疹及紅斑，診斷膿癬繼發(fā)癬菌疹，加用潑尼松 (5 mg/d)口服，改用1%盧立康唑乳膏?？拐婢幬矬w外藥敏試驗(yàn)證實(shí)1%盧立康唑乳膏比1%萘替芬-0.25%酮康唑乳膏抗菌活性更強(qiáng)。伊曲康唑治療9周、潑尼松治療5周后皮損完全消退，重新長出新發(fā)，無瘢痕禿發(fā)形成。停藥后隨訪1 a無復(fù)發(fā)。

斷發(fā)毛癬菌；膿癬；癬菌疹；嬰兒

[Chin J Mycol，2016，11(3):185-186]

1　臨床資料

1.1病歷資料

患兒男，5個月，體重6.25 kg。因額部發(fā)際處紅斑3個月就診。3個月前無明顯誘因于額部發(fā)際處出現(xiàn)散在紅斑，逐漸增多，融合成片 (見圖1)。在當(dāng)?shù)蒯t(yī)院予以“頭孢類抗生素”口服治療無效。發(fā)病后一般情況可，無發(fā)熱、咳嗽、腹瀉等癥狀。無貓、犬、兔等寵物接觸史，既往史、家族史無特殊。各系統(tǒng)體格檢查未發(fā)現(xiàn)明顯異常。皮膚科檢查：前額發(fā)際處大片紅斑，相互融合，紅斑不規(guī)則、邊界較清，紅斑內(nèi)頭發(fā)稀疏，個別折斷或脫失，無鱗屑、丘疹、滲液、膿皰或膿腫。

1.2實(shí)驗(yàn)室檢查

血常規(guī)、肝腎功能各項(xiàng)指標(biāo)正常。皮損鏡檢見數(shù)個真菌孢子 (見圖2a)，皮損真菌培養(yǎng) (沙堡弱培養(yǎng)基，28℃培養(yǎng)7 d)：生長出白色絨毛狀菌落 (見圖2b)，顯微鏡下見圓形、梨形或棒狀小分生孢子沿菌絲側(cè)生生長 (見圖2c)。對所得真菌的rRNA基因內(nèi)轉(zhuǎn)錄間隔區(qū) (Inter transcribed spacer，ITS)進(jìn)行了克隆測序，在GenBank中經(jīng)Blast序列比對，與斷發(fā)毛癬菌 (Trichophytontonsurans)的ITS序列同源性為98% (GenBank登錄號KU992674)。取純培養(yǎng)菌落，用“打孔法”進(jìn)行抗真菌藥物體外藥敏試驗(yàn)，結(jié)果證實(shí)1%盧立康唑乳膏比1%萘替芬-0.25%酮康唑乳膏對該菌抗菌活性更強(qiáng) (見圖3)。

1.3診斷

斷發(fā)毛癬菌致嬰兒膿癬。

1.4治療

予伊曲康唑膠囊33 mg (打開膠囊將其內(nèi)微粒分成1/3)口服，1次/d，純牛奶送服，外用2%酮康唑洗劑、1%萘替芬-0.25%酮康唑乳膏。治療過程中紅斑逐漸融合，出現(xiàn)少許毛囊性膿皰，紅斑下觸及膿腫 (見圖4a)，頭面部非原發(fā)皮損部位逐漸出現(xiàn)散在多發(fā)環(huán)狀鱗屑性丘疹及紅斑 (見圖4b)，診斷膿癬繼發(fā)癬菌疹，加用潑尼松5 mg口服，1次/d，并將1%萘替芬-0.25%酮康唑乳膏改為1%盧立康唑乳膏外用。加潑尼松治療5周后，環(huán)狀鱗屑性丘疹及紅斑、膿皰基本消退，予停用，代之復(fù)方甘草酸苷片25 mg口服，1次/d。伊曲康唑使用9周后皮疹消退，新生頭發(fā)長出，予停用?？诜?fù)方甘草酸苷片鞏固治療共8周后停藥 (見圖4c)，隨訪1 a無復(fù)發(fā)，治療期間無不良反應(yīng)，復(fù)查血常規(guī)、肝腎功能正常。

2　討　　論

頭癬多發(fā)生于3～7歲兒童[1]，罕見于嬰兒期。膿癬是頭癬特殊類型，多由親動物性或親土性皮膚癬菌引起，斷發(fā)毛癬菌在我國所有膿癬患者中占7.37%[2]，我國兒童頭癬致病菌以親動物性犬小孢子菌為主，親人性斷發(fā)毛癬菌在兒童膿癬中僅占4.31%[3]。本例2個月齡時發(fā)病，抗真菌治療過程中

圖1治療前，額部發(fā)際處紅斑，部分頭發(fā)折斷或脫失圖2真菌學(xué)檢查：a.頭皮皮損涂片顯微鏡檢見數(shù)個真菌孢子 (×400)；b.皮損真菌培養(yǎng)：白色絨毛狀菌落 (沙堡弱培養(yǎng)基，28℃培養(yǎng)7 d)；c.挑取菌落行顯微鏡檢查：圓形、梨形或棒狀小分生孢子沿菌絲側(cè)生生長 (×400)圖3抗真菌藥物體外藥敏試驗(yàn)：1%盧立康唑乳膏比1%萘替芬-0.25%酮康唑乳膏對該菌抗菌活性更強(qiáng) (A.陰性對照丙酸氯倍他索乳膏，B.1%萘替芬-0.25%酮康唑乳膏，C.1%盧立康唑乳膏)圖4a.抗真菌治療1周時，紅斑逐漸融合，出現(xiàn)毛囊性膿皰，紅斑下觸及膿腫；b.抗真菌治療2周時，頭面部散在環(huán)狀鱗屑性丘疹及紅斑；c.治療結(jié)束時 (伊曲康唑治療9周，潑尼松治療5周后序貫復(fù)方甘草酸苷治療8周)，皮損消退，新生頭發(fā)長出

Fig.1Before treatment,erythema around forehead hairline,and hair loss or broken hairFig.2Mycological examination:a.Smear microscopy showed several fungal spores (original magnification 400×);b.Culture:showed white fluffy colonies (Sabouraud's medium,28℃ for 7 days);c.Microscopic examination of picked colonies:round,lateral short rod-like or pear-shaped microconidia along the hyphae,which is a identified asTrichophytontonsurans(original magnification 400×)Fig.3Antifungal susceptibility testinvitro:1% luliconazole cream is superior to 1% naftifine-0.25% ketoconazole cream (A.negative control,clobetasol propionate cream;B.1% naftifine-0.25% ketoconazole cream;C.1% luliconazole cream)Fig.4a.After one-week antifungal treatment,erythema was confluent,and follicular pustules and skin abscesses were presented;b.After 2-week antifungal treatment,sporadic annular scaly papules and erythema over the head and face were presented;c.At the end of treatment,the lesions disappeared completely,and new hair grew back

出現(xiàn)膿皰、膿腫等癬菌疹，不同于常見親人性皮膚癬菌所致頭癬，臨床罕見，易誤診為毛囊炎、頭皮膿腫等。系統(tǒng)抗真菌治療聯(lián)合口服糖皮質(zhì)激素可減輕炎癥反應(yīng)、縮短療程及減少瘢痕性脫發(fā)風(fēng)險[4-5]，聯(lián)合應(yīng)用糖皮質(zhì)激素后皮膚炎癥及膿癬周圍不適能更快減輕，頭發(fā)生長更早[6]。續(xù)貫復(fù)方甘草酸苷使炎癥反應(yīng)持續(xù)改善，且可保護(hù)肝功能，減少藥物性肝損害發(fā)生幾率。Meta分析[7]顯示1%盧立康唑乳膏治療皮膚癬菌病安全而有效。本例中，抗真菌藥物體外藥敏試驗(yàn)確認(rèn)1%盧立康唑乳膏比1%萘替芬-0.25%酮康唑乳膏對該菌抗菌活性更強(qiáng)，符合Meta研究結(jié)論。

[1]Ginter-Hanselmayer G,Weger W,Ilkit M,et al.Epidemiology of tinea capitis in Europe:current state and changing patterns[J].Mycoses,2007,50(s2):6-13.

[2]朱敏,李莉,朱均昊,等.膿癬的發(fā)病情況和病原菌變遷:上海地區(qū)19年的回顧性研究[J].中國真菌學(xué)雜志,2013,7(5):273-276.

[3]李彩霞,劉維達(dá).我國大陸近年兒童頭癬流行情況的回顧分析[J].中國真菌學(xué)雜志,2011,6(2):77-82.

[4]Dolder SE,O'Neill BJ,O'Brien MM,et al.A new paradigm in the treatment of kerions:treat the inflammation[J].Skinmed,2012,10(1):14-16.

[5]Castriota M,Ricci F,Paradisi A,et al.Erythema nodosum induced by kerion celsi of the scalp in a child:a case report and mini-review of literature[J].Mycoses,2013,56(3):200-203.

[6]Proudfoot LE,Higgins EM,Morris-Jones R.A retrospective study of the management of pediatric kerion inTrichophytontonsuransinfection[J].Pediatr Dermatol,2011,28(6):655-657.

[7]Feng X,Xie J,Zhuang K,et al.Efficacy and tolerability of luliconazole cream 1% for dermatophytoses:A Meta‐analysis[J].J Dermatol,2014,41(9):779-782.

A case of infant kerion with dermatophytid reaction due toTrichophytontonsurans

TANG Jiao-qing,ZHUANG Kai-wen,RAN Xin,RAN Yu-ping

(Desect1mentofDermatovenereology,WestChinaHospital,SichuanUniversity,Chengdu610041,China)

A 5-month-old male infant had erythema around frontal hairline for 3 months.Physical examination showed large erythema with clear boundary,hair loss or broken hair,follicular pustules and skin abscesses.Based on the microscopic examination of the KOH preparation,culture and DNA extracted PCR-sequencing identification,infant kerion due toTrichophytontonsuranswas diagnosed.Treatment of oral itraconazole (33 mg/d),topical wash with 2% ketoconazole shampoo,then 1% naftifine-0.25% ketoconazole cream were administrated.During the therapeutic session,sporadic annular scaly papules and erythema were appeared over the head and face,which was considered as secondary dermatophytid reaction,be deal with by adding prednisone (5 mg/d) orally and changing topical drug with 1% luliconazole cream.Antifungal susceptibility testinvitroshowed that 1% luliconazole cream is superior to 1% naftifine-0.25% ketoconazole cream.After 9 weeks treatment of itraconazole and 5 weeks of prednisone,the lesions resolved,and new hair grew back without scarring or alopecia.No recurrence after treatment was observed with one-year follow-up.

Trichophytontonsurans;kerion;dermatophytid;infant

2016-03-30[本文編輯]王飛

唐教清，男 (漢族)，碩士研究生在讀.E-mail:tjiaoq@foxmail.com

冉玉平，E-mail:ranyuping@vip.sina.com

R 756.1

A

1673-3827(2016)11-0185-02