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Severe Tinea Barbae Due to Trichophyton verrucosum Infection in Dairy


Farmers
Julia Sabota, Robert Brodell, Gregory W. Rutecki,
and William L. Hoppes

From the Northeastern Ohio Universities College of Medicine Affiliated


Hospitals at Canton and Warren, Canton, Ohio

Trichophyton verrucosum infection, which is acquired from the hide of dairy cattle, is the cause
of tinea barbae, a severe pustular eruption on the face and neck. We present the cases of five
patients, three of whom had severe pustular tinea barbae and two of whom had eruptions of the
forearms. All five patients were dairy farmers. On physical examination, all five patients were
afebrile and did not appear toxic. Peripheral leukocyte counts for the three patients with pustular
tinea barbae were normal. Gram stain and bacterial cultures of the draining pustules were negative
in all three cases. Potassium hydroxide preparation showed hyphae, and cultures yielded T. verrucosum in all three cases. Four patients received therapy with fluconazole, and one received therapy
with griseofulvin; in all cases, the lesions healed. T. verrucosum can cause pustular tinea barbae in
farmers that may be mistaken for a Staphylococcus aureus infection by clinicians, including infectious
disease experts. The answer to a simple question, "Are you a dairy farmer'!", may suggest the
diagnosis of T. verrucosum in the proper clinical setting.

Superficial tinea infections are caused by dermatophytes,


fungi that infect keratinized tissue. The clinical appearance of
these infections can vary widely from annular plaques with
erythema and scaling to extensive pustular or vesiculopustular
lesions called kerions. The kerions may be misdiagnosed as
severe staphylococcal disease, which may result in patients
being admitted to the hospital for iv antibacterial therapy [1].
We describe five cases of superficial tinea infections acquired
by dairy farmers who were in close contact with infected cattle.
Case Reports
Five male dairy farmers from northeastern Ohio presented
with dermatologic complaints. Two of the patients exhibited
mildly pruritic, erythematous, scaling, annular eruptions of the
forearms. The lesions had been present for ~2 weeks and had
not responded to topical antifungal creams.
Three of the patients described a 5- to 7-day history of
pruritus, tenderness, and erythema of the beard area with a
gradual increase in the extent of involvement as well as in the
severity of the lesions. The physical examination demonstrated
severe unilateral facial and neck edema, erythema, scaling,
crusting, and large exudative pustules (figures 1, 2 and 3);
however, signs of systemic toxicity were absent. Involved hairs
were broken, loose, and easily removed. The patients were
afebrile and did not have regional lymphadenopathy. These

Received IS March 1996; revised 25 June 1996.


This paper was presented in part at the 33rd annual meeting of the Infectious
Diseases Society of America held in September 1995 in San Francisco, California.
Reprints or correspondence: Dr. William L. Hoppes, Timken Mercy Medical
Center, 1330 Timken Mercy Drive, N.W., Canton, Ohio 44708.
Clinical Infections Diseases 1996;23:1308-10
1996 by The University of Chicago. All rights reserved.
1058-4838/96/2306-0035$02.00

three patients were hospitalized, and iv therapy with antistaphylococcal antibiotics (2 g of nafcillin iv every 4 hours) was
started.
Leukocyte counts and differentials were normal for all three
patients. All gram stains and bacterial cultures were negative.
KOB preparation revealed septate hyphae, and fungal cultures
yielded Trichophyton verrucosum.
Multiple cows in one herd were examined and found to have
annular lesions that also revealed hyphae on KOB preparation.
The infected cows did not respond to single-dose griseofulvin,
but they were cured by fluconazole (200 mg po qd for 3 weeks).
Four of the patients received treatment with fluconazole (200
mg po qd) for 6-12 weeks [2]. One patient received griseofulvin (500 mg po b.i.d.) for 8 weeks. All of the patients responded
to treatment, and the infections completely resolved.

Discussion
Superficial tinea infections are caused by dermatophytes, a
group of fungi with the ability to infect and survive on the
keratin in nails, hair, and epidermis. The dermatophytes represent 39 closely related species in three genera: Microsporum,
Trichophyton, and Epidermophyton [3]. Transmission occurs
through fomites, animals, or soil.
Dermatophytoses vary in presentation and may easily be
confused with other diseases. Lesions span a spectrum from
classic annular plaques with an active border of erythema and
scaling to red, tender, edematous, exudative pustules called
kerions [1]. The inflammation associated with superficial dermatoses is the result of an allergic response to fungal antigens
present in the stratum corneum. The differential diagnosis of
dermatophytosis includes Staphylococcus aureus folliculitis,
furuncle, carbuncle, acne vulgaris, rosacea, pseudofolliculitis,
herpes simplex virus infection (recurrent or eczema herpeticum), and contact dermatitis [1, 4-7].

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em 1996;23 (December)

Tinea Barbae in Dairy Farmers

Figure 1. Severe unilateral erythema and pustules on the "beard"


area of the face of a dairy farmer with severe tinea barbae due to
Trichophyton verrucosum.

Tinea barbae is a dermatophytic trichomycosis involving the


beard and mustache areas that closely resembles tinea capitis
with invasion of the hair shaft. The infection is usually contracted by exposure to animals carrying zoophilic species of
dermatophytes, most commonly cattle and dogs [3]. The infection is classically seen in a rural setting and affects dairy farmers or cattle ranchers. In our cases the tinea barbae was always
unilateral and, on the basis of the histories obtained from these
patients, involved the side of the face or neck that the farmers
habitually turned toward and rubbed against the flank of the
cow during milking procedures.

Figure 3. Appearance of Trichophyton verrucosum infection in a


dairy farmer; the clinical manifestations of this illness can be confused
with facial cellulitis.

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Figure 2. Vesiculopustular lesions (kerions) on the neck of a dairy


farmer with severe tinea barbae due to Trichophyton verrucosum.

A KOB preparation to identify hyphae is diagnostic of


T. verrucosum infection. Scrapings of the active border of
the lesion or involved hairs should be examined. This technique has 88% sensitivity and 95% specificity [8, 9]. Wood's
light examination will confirm only the infrequent case of
microsporum infection in which the fungal organism fluoresces [6].
In summary, T. verrucosum caused ringworm in dairy cattle
and pustular tinea barbae in farmers so severe that it was mistaken for a S. aureus infection. A simple question, "Are you
a dairy farmer?", suggests the diagnosis of T. verrucosum
infection; this diagnosis can then be confirmed by a bedside

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1310

Sabota et al.

diagnostic test, the KOB preparation, sparing the patient and


system a costly admission to the hospital for iv antistaphylococcal treatment.

4.
5.
6.

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