Clinical Challenge: Scalp Lesions With Drainage and Lymphadenopathy

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A 2-year-old boy presents after a recent emergency department visit for evaluation of persistent scalp lesions. The scalp lesions have visible drainage with honey-colored crusting, hair loss, and lymphadenopathy of the posterior occipital, postauricular, and cervical lymph nodes. His mother reports that he has been experiencing weeping and pain from the lesions for 3 weeks. The lesions develop as white-colored pustules before breaking open; there is a larger scaly confluent patch on the left parietal scalp. The patient is also experiencing fevers and a decrease in appetite. Complete blood cell count is notable for elevated white blood cell count (15,600/µL); platelets (488 ×103/μL); neutrophils (absolute, 9500/μL); monocytes (absolute, 1500/μL); and eosinophils (absolute, 500/μL). 

Tinea capitis is a dermatophyte fungal infection of the scalp. Most tinea capitis infections in the United States are caused by Trichophyton tonsaurans, Microsporum audouinii, and Microsporum canis.1 Tinea capitis is more commonly identified in children, although the reason for...

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Tinea capitis is a dermatophyte fungal infection of the scalp. Most tinea capitis infections in the United States are caused by Trichophyton tonsaurans, Microsporum audouinii, and Microsporum canis.1 Tinea capitis is more commonly identified in children, although the reason for this is not clear.1 While tinea capitis can present in a variety of ways, the most common presentation is scaled patches with associated alopecia.1

Clinical presentation may include singular or multiple lesions on the scalp. The alopecia occurs because of damage to the hair shaft that is invaded by the dermatophytes. Dermatophyte infections can manifest on the scalp in 2 distinguishable ways: endothrix and ectothrix. Endothrix infections occur when the fungal spores invade the shaft of the hair, which is visible under microscopic examination. Ectothrix infections involve the external portion surrounding the hair shaft.

When an individual has severe infection, as displayed in this case, the evaluating provider can identify inflammatory kerion, which occurs from significant scalp involvement that leads the host to mount an immune response.1 In this patient’s case, the immune response is evident by the significant lymphadenopathy seen in the posterior cervical, postauricular, and occipital lymph nodes. Kerion can be identified on visual examination with clinical findings of painful inflammatory plaques, pustules, crusting, suppurative drainage, and a boggy appearance.1,2 It may also lead to abscess development with purulent drainage.1 If left untreated, kerion can cause permanent scarring which ultimately prevents regrowth of hair.

To contract a tinea infection, the individual must come in direct contact with the fungus. This can occur via human contact, animal contact, or contact with a contaminated object; transmission may also occur through contact with asymptomatic carriers.1 As with other transmittable diseases, like pediculosis, children should be taught and encouraged to avoid sharing items like hats and hairbrushes. Identification of the source where the patient contracted the dermatophyte infection is essential to help prevent further spread or reinfection.1

Close follow-up to ensure compliance with the medication regimen can help promote successful treatment and healing; without it, the patient may experience treatment failure, worsening, and long-term consequences of scarring and recurrent infections. Treatment failure can also lead to psychosocial complications from shame and embarrassment related to scarring and hair loss.1

The differential diagnosis for this patient includes folliculitis, pediculosis capitis, impetigo, cellulitis, atopic dermatitis, and seborrheic dermatitis.

The patient was initially treated in the ED for folliculitis using cephalexin. Because the patient’s mother felt that the lesions had worsened since the ED visit, the patient was started on amoxicillin-clavulanate (45mg/kg/day) twice-daily dosing for bacterial skin infection. The patient was also started on ketoconazole (2% shampoo) to apply daily to the scalp for 1 week and leave in place for 5 minutes before rinsing. During this visit, the patient’s primary care provider observed the infection so that he could monitor for improvements over time.

The consulting dermatologist reviewed the patient case and images with concern that it may be tinea capitis with kerion and impetiginization. The dermatologist recommended obtaining a fungal culture. The patient’s mother was unable to bring him back to the clinic for collection of the fungal scraping, so treatment was started without it to help initiate healing. The physician agreed with use of amoxicillin-clavulanate and ketoconazole 2% shampoo 3 nights in a row and then once a week or more during treatment. The patient was started on griseofulvin microsize (20mg/kg) divided into twice-daily dosing for 8 weeks.2 The patient followed up in person with dermatology for evaluation and the griseofulvin microsize was increased to 25mg/kg divided into twice-daily dosing.

The patient did well with griseofulvin treatment. At 1-month follow-up, the patient had improvement in overall appearance of the scalp. The patient also had improvement in lymphadenopathy. A scraping of the scalp was completed and sent for analysis at the time of the dermatology visit, which showed no fungal involvement at that time. The patient will continue to follow up with his primary care provider regularly, and dermatology on an as-needed basis.

Amalia Gedney-Lose, DNP, ARNP, FNP-C, is a clinical assistant professor and Family NP at the University of Iowa College of Nursing and University of Iowa Hospitals and Clinics in Iowa City, Iowa.

References

1. Al Aboud AM, Crase JS.  Tinea capitis. In: StatPearls. StatPearls Publishing; 2022 Jan. Accessed March 31, 2022. https://www.ncbi.nlm.nih.gov/books/NBK536909/

2. Burgin S, Burkhart CN, Morrell D, Goldsmith LA.  Tinea capitis in child. In: Goldsmith LA, ed. VisualDX. VisualDX; 2019. Accessed March 31, 2022. https://www.visualdx.com/visualdx/diagnosis/tinea+capitis?diagnosisId=52394&moduleId=102