紫色毛癣菌所致老年头癣继发头面部带状疱疹1例

冉昕 汪盛 王琳 冉玉平

(四川大学华西医院皮肤性病科，成都 610041)

·病例报告·

紫色毛癣菌所致老年头癣继发头面部带状疱疹1例

冉昕 汪盛 王琳 冉玉平

(四川大学华西医院皮肤性病科，成都 610041)

患者女，62岁，头皮红斑、丘疹、鳞屑1个月，加重伴脓疱3周，结痂1周。取痂壳直接镜检发现真菌菌丝，将痂壳接种沙堡弱培养基25℃培养25 d见紫色菌落生长，周围有红色色素。提取菌落DNA做PCR扩增后测序为紫色毛癣菌，诊断为老年头癣。经牛奶送服伊曲康唑联合2%酮康唑洗剂洗头后外用萘替芬酮康唑治疗3周后患者头皮痂壳消退，但于右侧头面部出现带状分布簇集张力性水疱，诊断为带状疱疹。服用溴夫定片125 mg/d治疗9 d后水疱消退。

头癣；紫色毛癣菌；伊曲康唑；带状疱疹；溴夫定

1 临床资料

患者女，62岁。头皮红斑、丘疹、鳞屑1个月，加重伴脓疱3周，结痂1周。患者1个月前无明显诱因头皮出现红斑、丘疹、鳞屑，自觉瘙痒，未予重视。3周前患者头部出现脓疱，疱壁厚，疱液黄色浑浊，门诊治疗无效。1周前以“湿疹伴感染”在当地住院治疗。血常规、血生化、电解质未见异常。免疫学检查：IgG 19.20 g/L (8～15.5)，IgA 3 530 mg/L (836～2 900)，IgM 652 mg/L (700～2 200)，IgE 706.64 IU/mL (0.1～150)。补体：C3 0.671 g/L (0.785～1.52)，C4 0.16 g/L (0.14～0.36)。ANA 1∶320均质型核仁型，SSA+++，ENA阴性。左颞部头皮组织病理活检：表皮棘层水肿，真皮小血管周围较多淋巴细胞、组织细胞及中性粒细胞浸润及上皮样肉芽肿形成。予苯唑西林钠、莫匹罗星抗感染，氯雷他定、酮替芬抗过敏，白芍总苷、复方甘草酸苷等抗炎，1∶9聚维酮碘溶液湿敷等抗细菌治疗6 d后皮损无明显改善，遂到我科就诊。查体见头皮可见多发红斑、鳞屑、结痂 (见图1A)，皮肤镜下见糜烂、渗出及黄白色痂壳，毛发未见明显受累 (见图1B)。紫外光皮肤镜下见痂壳处有黄白色荧光 (见图1C)。头皮痂壳处标本经10%KOH涂片直接镜检见分隔真菌菌丝 (见图2A)。将头皮痂壳种植至沙堡弱培养基中，于25℃培养25 d后，有紫色菌落生长，其周围有红色色素 (见图2B)。用DNA试剂盒 (Omega Bio-tek)提取菌落DNA，以NL引物做PCR扩增后测序，做BLAST比对结果为紫色毛癣菌 (Trichophytonviolaceum)，同源性99% (GenBank登录号:KY123853)。诊断：紫色毛癣菌所致头癣。用钝刀刮去头皮痂壳，予口服伊曲康唑胶囊200 mg，2次/d (牛奶送服)；用2%酮康唑洗剂清洗皮损后外用1%萘替芬-0.25%酮康唑乳膏，联合内服头孢地尼 (100 mg/d)、泼尼松 (20 mg/d)和复方甘草酸苷2片，2次/d。治疗3周后复诊患者头皮痂壳完全消退，遗留瘢痕及新发生长 (见图1D)。复查真菌镜检和培养均阴性。但患者右侧头皮、耳前、面颊部、口唇及下颌部新出现带状分布红斑，其上有簇集性水疱及大疱，伴疼痛明显 (见图1E)。皮肤镜下见水疱为张力性 (见图1F)。根据临床表现考虑右侧头面部带状疱疹 (三叉神经下颚支受累)。因患者院外已服用盐酸伐昔洛韦胶囊150 mg，3次/d，共4 d，症状未控制，仍有新发水疱。故将抗病毒药物改为口服溴夫定片 (左代)125 mg，1次/d；普瑞巴林 (乐瑞卡)75 mg，2次/d，外用喷昔洛韦乳膏。治疗10 d后，头顶皮损明显好转，面部红斑、水疱基本消退，遗留少许痂壳及色素沉着，仍自觉右侧面部疼痛 (见图1G)。停用溴夫定片，后续继续予普瑞巴林镇痛及抗真菌治疗 (见图3)。治疗16周后头皮头癣和右头面部疱疹痊愈，遗留少量色素沉着 (见图1H)。患者皮损变化和治疗用药过程见图3。随访1 a头癣和带状疱疹未复发。

2 讨 论

此例老年女性头皮结痂，未见典型的头癣病发表现，误诊为“湿疹”延误治疗。经真菌镜检、培养及分子测序明确了感染源为紫色毛癣菌，确诊为头癣，予抗真菌治疗疗效明显；治疗头癣期间右头面部发生带状疱疹。

尚不清楚头癣和头面带状疱疹相继发生的关联性，但两种病原体均易感染免疫功能低下人群，如老人，糖尿病[1]、HIV[2]及自身免疫性疾病患者[3]等。此例老年女性，免疫学检查ANA及SSA阳性，虽然无红斑狼疮、干燥综合征等临床表现，仍提示有潜在免疫功能异常，需定期检测免疫指标及临床随访。

紫色毛癣菌 (Trichophytonviolaceum)为亲人性皮肤癣菌，一般炎症较轻，常导致发内感染引

图1患者临床及皮肤镜表现：A.头皮多发红斑、脓疱、结痂 (0 d)；B.皮肤镜下可见黄白色痂壳，表皮的糜烂、渗出，但毛发未见明显受累；C.紫外光皮肤镜见痂壳处有黄白色荧光；D.伊曲康唑等治疗3周，头皮痂壳完全消退，遗留大片红斑，新发有所生长 (21 d)；E.右耳、右面颊部、口唇及下颌部带状红斑及簇集张力性水疱，疼痛明显 (21 d)；F.皮肤镜下可见含黄色疱液的张力性水疱；G.溴夫定治疗带状疱疹9 d，头皮面部红斑、水疱基本消退 (35 d)；H.治疗16周复诊，头皮及右耳及右面部皮损好转 (112 d)图2真菌检查结果：A.10%KOH真菌直接镜检发现菌丝；B.25℃，SDA培养25 d，紫色菌落生长，周围有红色色素图3患者诊治及用药时间图

Fig.1Clinical and dermoscopic manifestation:A.Erythema,pustules and scabs on scalp (0 d);B.Dermoscopy shows yellowish scab and erosion and effusion on the epiderma without hair damage;C.Scalp scabs under UV light dermoscopy shows yellowish-white fluorescence;D.Treat with itraconazole for 3 weeks,scalp scabs are improved,remain erythema and lately grown hairs (21 d);E.Band-like erythema with clustery tension blisters appear on right ear,right cheek,lips and underjaw,and lesion area lead to severe pain (21 d);F.Dermoscopy observation of clustery tension blisters;G.Treat herpes zoster with brivudine 125 mg daily for 9 days,scalp erythema and blisters almost disappear (35 d);H.Lesion improved more (112 d) 16 weeks after treatmentFig.2Fungal examination results:A.10% KOH direct microscopic examination finds hyphae;B.Culture with 25℃ for 25 days shows purple colonies with reddish peripheryFig.3Time course of clinical manifestation and treatment起黑点癣。但本例临床表现特殊，最终经直接镜检、培养及分子测序等明确病原菌。清除头皮带菌痂壳后内服伊曲康唑联合外用1%萘替芬-0.25%酮康唑乳膏及2%酮康唑洗剂清洗皮损，疗效显著。

溴夫定 (Brivudine)是胸腺嘧啶核苷酸类似物新型抗病毒药物，在病毒胸腺嘧啶核苷酸激酶的作用下转化为活性化合物-5'三磷酸溴乙烯基，整合入病毒DNA中抑制脱氧胸腺嘧啶 (DTMP)合成，控制病毒复制[4]。与阿昔洛韦 (800 mg，5次/d)比较，溴夫定 (125 mg，1次/d)可缩短张力性水疱结痂时间，更快控制病毒复制[5]，缩短带状疱疹后遗神经痛时间[6]。溴夫定比泛昔洛韦和伐昔洛韦更好缓解疼痛[7]。本患者先后联合使用伊曲康唑胶囊和溴夫定片，未出现副作用，肝肾功未见明显异常，两病均治愈。

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AcaseoftineacapitiscausedbyTrichophytonviolaceumandsuperveneofcraniofacialherpeszosterinanelderlypatient

RAN Xin,WANG Sheng,WANG Lin,RAN Yu-ping

(DepartmentofDermatoverenology,WestChinaHospital,SichuanUniversity,Chengdu610041)

A 62-year-old female patient,whose scalp developed pruritus erythema for 1 month,exacerbated to pustules for 3 weeks,formed scabs for 1 week.KOH direct microscopic examination finds typical hyphae on scalp scales.Culture on Sabouraud Dextrose Agar (SDA),with 25℃ for 25 days,shows purple colonies with reddish periphery.The pathogen's DNA was extracted for PCR amplification and the products was sequenced and identified asTrichophytonviolaceum,which confirmed the patient's diagnose of tinea capitis.She was administrated itraconazole 200 mg twice a day taken with milk,combine with 1% naftifine-0.25% ketoconazole cream,after wash with 2% ketoconazole shampoo.Her scalp scales are improved 3 weeks later.However,band clustery tension blisters appeared on right scalp,right ear,right cheek,lips and underjaw,which was diagnosed as herpes zoster.The lesion was controlled after we prescribed brivudine 125 mg daily for 9 days.

tinea capitis;Trichophytonviolaceum;itraconazole;herpes zoster;brivudine

[Chin J Mycol，2017，12(5):291-292]

R 756.1 R 752.1+2

A

1673-3827(2017)12-0291-02

冉昕，男 (汉族)，硕士，住院医师.E-mail:ranfjk@126.com

冉玉平,E-mail:ranyuping@vip.sina.com

2017-03-06

[本文编辑] 施 慧