Majocchi’s Granuloma due to Trichophyton rubrum 
This is GMS stain and culture of a skin biopsy from a patient’s leg.
66M. 4 mo after heart Tx: painless leg nodules that spread distally x 5 weeks. No pain. No fever.
PE unremarkable except lesions in left leg / foot + tinea pedis
Biopsy: GMS fungal elements in dermis. Culture: Trichophyton rubrum
Histopath shows fungal elements (GMS) - not sufficient for identification. 
Important: Send specimen for culture identification!!!
Treatment: Itraconazole Rx
What is Majocchi granuloma?
 - Pathology: inflammatory / granulomatous fungal infection of the dermis / subcutaneous tissues - mainly caused by dermatophytes (>95%)
 - Occurs in immunocompetent and compromised hosts! 
 - Location: mostly lower extremities but can occur anywhere
 - Risks: Trauma such as shaving and scratching - most common - allows fungus invasion, Topical steroids and conditions with immunosuppression, Preexisting dermatophytosis, Animal contact
Majocchi granuloma pathogens:
 - Dermatophytes >95%: T. rubrum, T. mentagrophytes, T. violaceum, T. tonsurans, Microsporum, Epidermophyton 
 - Non-dermatophytes: Aspergillus, Phoma
Majocchi granuloma in transplant:
 - Indolent course: nodules, papules, plaques, pustules, abscess
 - Lower extremity most common; dissemination rare
 - Preexisting tinea common
 - T. rubrum most common pathogen
 - Systemic Rx: terbinafine, Itraconazole
Majocchi granuloma Treatment:
 - Topical Rx - does not penetrate deeper dermis! Not recommended as sole Rx.
 - Systemic Rx is recommended - Options: Terbinafine, Itraconazole, Others
Majocchi granuloma Pearls:
1. Fungal infection of dermis and subQ; most common T. rubrum and other dermatophytes
2. Competent and compromised hosts
3. Localized mostly to lower extremity; rare dissemination
4. Dx: pathology and culture
5. Rx: Oral antifungal Rx recommended

Mayo Clinic Infectious Diseases @MayoClinicINFD

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