Successful Treatment of Refractory Majocchi’s Granuloma with Voriconazole and Review of Published Literature

Abstract

Majocchi's granuloma (MG) is a rare deep skin dermatophyte infection that can occur either in immunocompetent or in immunocompromised individuals. Oral itraconazole or terbinafine is considered to be the first choice of treatment. We report an immunocompetent man with deep nodular form of MG, the form which is generally found in immunosuppressed individuals. Previous treatment with either oral itraconazole or terbinafine yielded no apparent improvement. After a series of examination, the man was diagnosed as having Trichophyton rubrum-induced MG mixed with bacterial infection as evidenced by growth of Klebsiella pneumoniae in tissue bacterial culture. The patient was treated with a combination of cefoselis and levofloxacin for bacterial clearance followed by voriconazole treatment. After approximately 4 months of voriconazole treatment, the lesions completely resolved. Alternative medicine (voriconazole) can be considered in case of refractory infections during MG treatment.

Majocchi’s granuloma: current perspectives

“…Although ketoconazole was frequently used previously, about half of the patients reported today are treated with terbinafine (250 mg/day). 8 , 13 , 36 , 40 , 43 , 47 , 54 , 68 – 71 Other systemic antifungal drugs are itraconazole (100–200 mg/day), 32 , 44 , 53 , 72 griseofulvin (250–500 mg/day), 10 , 35 , 63 voriconazole, 73 and posaconazole. 28 Antifungal therapy should be continued until the lesions are completely resolved.…”

“…Rallis et al 37 reported a patient who did not respond to systemic itraconazole treatment, but responded well to systemic terbinafine treatment. Liu et al 73 reported the case of a patient with a mixed infection of T . rubrum and Klebsiella pneumoniae and treated this case first with systemic antibiotics (combined cefoselis and levofloxacin for 7 days) and then voriconazole (200 mg, twice daily).…”

Pubic Majocchi's Granuloma Unresponsive to Itraconazole Successfully Treated with Oral Terbinafine

“…However, in a recently published case, an immunocompetent man with an MG refractory to itraconazole and oral terbinafine was treated successfully with voriconazole [7]. …”

Successful treatment of resistant onychomycosis with voriconazole in a liver transplant patient

“…The higher efficacy of voriconazole might be related to the broader spectrum of activity against various fungal pathogens, the rapid absorption after oral administration, the high bioavailability (90%-96%) with steady plasma concentration after oral intake, the absence of affection by gastric PH and the efficient distribution to the different human tissues. 4,10 The challenge in our case was the past history of liver transplantation; such patients are vulnerable to different type of infections due to the immunocompromised status that lead to unusual presentations and…”