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14 CASES OF INFANTILE TINEA INFECTION AT A CHILDREN’S HOSPITAL
EB Eason and SJ Jue
Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, LA.
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14 CASES OF INFANTILE TINEA INFECTION AT A CHILDREN’S HOSPITAL
EB Eason and SJ Jue
Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, LA.
ABSTRACT
Purpose of study. Dermatophytic infections have been infrequently reported in young infants. When a
case of neonatal tinea capitis was diagnosed at our hospital, a retrospective chart and microbiology record
review was performed to determine its prevalence. Methods. Medical records were searched from 1/1/97
- 8/1/99 for infants < 6 months of age with dermatophytic infection. Demographic and clinical information
including birth weight, age at presentation, source and identification of isolate, exposure to affected family
members with dermatophyte infection or pets, method of treatment, and clinical outcome were obtained.
Results. We identified 14 infants (9 males, 5 females) ranging in age from 17-120 days (avg. age 68 days)
with tinea capitis due to Trichophyton tonsurans (12) and Microsporum canis (2). (Tables 1,2) Six (43%) of
the infants were less than 30 days of age (range 17-25 days). All 12 of the infants with Trichophyton
tonsurans isolated were black and the 2 infants with Microsporum canis were white. Scalp lesions in 9
infants were described as round and erythematous with scaling and central clearing. One infant had
multiple pustular lesions on the scalp and face. None of the patients’ households were reported to have
pets. Family members of 3 infants had a history of tinea corporis. Five infants were treated with oral
griseofulvin (avg. 24.2 days), 7 with antifungal cream, 8 with antifungal shampoo, and one infant was not
treated. Upon follow-up 1 infant initially treated with topical antifungal therapy without resolution was
retreated with griseofulvin with unknown outcome, 6 (43%) cases resolved, and 7 (50%) infants were lost
to follow-up. (Table 3) Of the 6 infants with resolution of infection, 2 were treated with griseofulvin, 3
received topical antifungal therapy only and 1 infant who was not treated was asymptomatic upon followup and may have been treated outside our institution. Conclusion. Tinea capitis in the neonatal period is
more common than previously thought and at least in the few neonates described in this report, did not
appear to be more extensive or severe than in older children.
INTRODUCTION
Tinea capitis is a dermatophytic infection that most commonly occurs in children 3-9 years of age.
Trichophyton tonsurans (T. tonsurans) is currently the leading cause of tinea capitis in more than 90% of
cases in North and Central America and appears to be more common in black children. Although tinea
capitis has been reported previously in young infants, cases in neonates have been rare and primarily
consist of isolated case reports.1-8 When a case of tinea capitis was diagnosed in a 17 day old neonate at
our hospital, we performed a retrospective chart and microbiology record review in order to determine the
incidence of neonatal tinea capitis in our patient population.
DISCUSSION
5
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The organisms isolated in newborns with tinea capitis have included Microsporum canis (M. canis), Microsporum
audouinni, Trichophyton tonsurans, Trichophyton rubrum, Trichophyton mentagrophyte, and Trichophyton violaceum. To
our knowledge the youngest newborn with M. canis causing tinea faciei was 6 days old 1 and the first report of T.
tonsurans causing tinea capitis and corporis in a newborn was 9 days of age.2 Over a period of 31 months, we identified
14 infants less than 4 months of age with tinea capitis, 6/14 (43%) of whom were neonates ranging in age from 17-25
days. The majority of infants were black and had T. tonsurans isolated from their scalp lesions. The only 2 white infants
identified had M. canis isolated from their lesions. Tinea capitis can be transmitted indirectly via fallen hair and
desquamated hair cells, as well as by direct contact. T. tonsurans has been isolated from combs, hairbrushes, bedding,
and clothing. Asymptomatic carriage has been demonstrated among adults and children living with an index case of
tinea capitis and this has led to a growing awareness of asymptomatic carriage as a major reservoir of infection. Of the
infants identified in our study, 3 infants had exposure to family members with dermatophyte infection who were likely the
initial source of infection. Humans may become infected with M. canis by direct contact with family pets, especially cats
and dogs which are the major carriers of this organism. None of the family members had direct contact with family pets.
The clinical presentation of these infants was similar to that of older children and consisted primarily of the seborrheic
type with circumscribed, erythematous lesions with diffuse scaling, patchy hair loss and a few demonstrated a more
inflammatory response with pustular formation. Treatment with oral griseofulvin (10-20 mg/kg/day x 4 weeks) for tinea
infection in newborns has been previously reported 3-5 and was tolerated well as it was in the few infants in our study
who were treated systemically. The two infants with M. canis infection resolved with topical therapy, one with
clotrimazole and one with terbinafine.
CONCLUSION
Tinea capitis in the neonatal period is more common than previously thought and at least in the few neonates described
in this report did not appear to be more extensive or severe than in older children. Contact with affected family members
or asymptomatic dermatophyte carriers may likely be sources of infection for these infants.
REFERENCES
1. Jacobs AH, Jacobs PH, Moore N. Tinea faciei due to Microsporum canis in a 6-day-old infant. JAMA 1972;219:1476.
METHODS
Medical records and microbiology records were reviewed from January 1, 1997 thru August 1, 1999 for
infants less than six months of age with positive cultures for dermatophytes. Demographic information
including the infant’s age, birth weight, gestational age, sex, race, mode of delivery, and environmental
factors such as affected family members and household pets were compared. Clinical information studied
included the site of the lesion, description of the lesions, organisms isolated by culture, and treatment. The
category of treatment was divided into systemic therapy, topical therapy, combined systemic and topical
therapy, or no treatment. Outcome was divided into patients with lesions that resolved with therapy,
patients who required retreatment, or patients who were lost to follow up.
Swabs or scrapings from the scalp lesions of affected children were placed on Dermatophyte Test Media
with phenol red indicator and then incubated at 30°C. The media was visually inspected for fungal growth
or color change twice a week. Fungi isolated were then identified by colonial and microscopic morphology
and stained with lactophenol cotton blue.(figures 1,2) If necessary, the isolate was then subcultured onto
Sabouraud’s Dextrose Agar for physiologic testing and further identification.
2. Manglini PR, Raman C, Durairaj P, et al. Trichophyton tonsurans infection in a 9-day-old infant. Inter J of Dermatol
1988;27:128.
3. Weston WL, Morelli JG. Neonatal tinea capitis. Pediatr Infect Dis J 1998;17(3):257-258.
4.Ungar SL, Laude TA. Tinea capitis in a newborn caused by two organisms. Pediatr Dermatol 1997;14(3):229-230.
5. Weston WL, Thorne EG. Two cases of tinea in the neonate treated successfully with griseofulvin. Clin Pediatr
1997;16(7):601-602.
6. Ghorpade A, Ramanan C, Durairaj P. Trichophyton mentagrophytes infection in a two-day-old infant. Inter J
Dermatol 1991;30:209-210.
7. Gondim-Gonzales HM, Maprunga AC, Melo-Montiero C, Lima AAB. Tinea capitis caused by Microsporum canis in a
newborn. Inter J Dermatol 1992;31:368.
8. Alden ER, Chenila SA. Ringworm in an infant. Pediatrics 1969;44 (2):261-262.
14 CASES OF INFANTILE TINEA INFECTION AT A CHILDREN’S HOSPITAL
EB Eason and SJ Jue
Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, LA.
6
Tables, graphs, illustrations and photographs can
RESULTS
be placed
on
white
rectangles
to
match
the
text
ABSTRACT
blocks. Be sure to include figure legends. Line up
Table 1. Demographics of 14 Infants with Tinea capitis
text blocks and figures whenever possible, and
try to maintain an even spacing between blocks.
Purpose of study. Dermatophytic infections have been infrequently reported in young infants. When a
case of neonatal tinea capitis was diagnosed at our hospital, a retrospective chart and microbiology record
review was performed to determine its prevalence. Methods. Medical records were searched from 1/1/97
- 8/1/99 for infants < 6 months of age with dermatophytic infection. Demographic and clinical information
including birth weight, age at presentation, source and identification of isolate, exposure to affected family
members with dermatophyte infection or pets, method of treatment, and clinical outcome were obtained.
Results. We identified 14 infants (9 males, 5 females) ranging in age from 17-120 days (avg. age 68 days)
with tinea capitis due to Trichophyton tonsurans (12) and Microsporum canis (2). (Tables 1,2) Six (43%) of
the infants were less than 30 days of age (range 17-25 days). All 12 of the infants with Trichophyton
tonsurans isolated were black and the 2 infants with Microsporum canis were white. Scalp lesions in 9
infants were described as round and erythematous with scaling and central clearing. One infant had
multiple pustular lesions on the scalp and face. None of the patients’ households were reported to have
pets. Family members of 3 infants had a history of tinea corporis. Five infants were treated with oral
griseofulvin (avg. 24.2 days), 7 with antifungal cream, 8 with antifungal shampoo, and one infant was not
treated. Upon follow-up 1 infant initially treated with topical antifungal therapy without resolution was
retreated with griseofulvin with unknown outcome, 6 (43%) cases resolved, and 7 (50%) infants were lost
to follow-up. (Table 3) Of the 6 infants with resolution of infection, 2 were treated with griseofulvin, 3
received topical antifungal therapy only and 1 infant who was not treated was asymptomatic upon followup and may have been treated outside our institution. Conclusion. Tinea capitis in the neonatal period is
more common than previously thought and at least in the few neonates described in this report, did not
appear to be more extensive or severe than in older children.
INTRODUCTION
Tinea capitis is a dermatophytic infection that most commonly occurs in children 3-9 years of age.
Trichophyton tonsurans (T. tonsurans) is currently the leading cause of tinea capitis in more than 90% of
cases in North and Central America and appears to be more common in black children. Although tinea
capitis has been reported previously in young infants, cases in neonates have been rare and primarily
consist of isolated case reports.1-8 When a case of tinea capitis was diagnosed in a 17 day old neonate at
our hospital, we performed a retrospective chart and microbiology record review in order to determine the
incidence of neonatal tinea capitis in our patient population.
Case no.
Age (days)
Sex
Race
Preterm/full term
B. wt. (grams) Fungal isolate
Therapy
Outcome
1
89
M
B
term
3955
T. tonsurans
griseofulvin + topical antifungal
unknown
2
20
F
W
term
2870
M. canis
topical antifungal
resolved
3
17
M
W
term
2495
M. canis
topical antifungal
resolved
4
80
M
B
unknown
unknown
T. tonsurans
None
resolved
5
20
F
B
term
3005
T. tonsurans
topical antifungal failure;
unknown
Medical records and microbiology records were reviewed from January 1, 1997 thru August 1, 1999 for
infants less than six months of age with positive cultures for dermatophytes. Demographic information
including the infant’s age, birth weight, gestational age, sex, race, mode of delivery, and environmental
factors such as affected family members and household pets were compared. Clinical information studied
included the site of the lesion, description of the lesions, organisms isolated by culture, and treatment. The
category of treatment was divided into systemic therapy, topical therapy, combined systemic and topical
therapy, or no treatment. Outcome was divided into patients with lesions that resolved with therapy,
patients who required retreatment, or patients who were lost to follow up.
Swabs or scrapings from the scalp lesions of affected children were placed on Dermatophyte Test Media
with phenol red indicator and then incubated at 30°C. The media was visually inspected for fungal growth
or color change twice a week. Fungi isolated were then identified by colonial and microscopic morphology
and stained with lactophenol cotton blue.(figures 1,2) If necessary, the isolate was then subcultured onto
Sabouraud’s Dextrose Agar for physiologic testing and further identification.
Figure 1 T. tonsurans (microconidia)
retreated with griseofulvin
6
120
F
B
term
2755
T. tonsurans
topical antifungal
unknown
7
120
F
B
term
3855
T. tonsurans
griseofulvin + topical antifungal
unknown
8
120
M
B
preterm
2595
T. tonsurans
griseofulvin
resolved
9
17
M
B
term
2775
T. tonsurans
topical antifungal
resolved
10
90
F
B
term
3640
T. tonsurans
topical antifungal
unknown
11
120
M
B
term
2920
T. tonsurans
griseofulvin + topical antifungal
resolved
12
25
M
B
term
2850
T. tonsurans
topical antifungal
unknown
13
90
M
B
preterm
2270
T. tonsurans
topical antifungal
unknown
14
24
M
B
preterm
2977
T. tonsurans
topical antifungal
unknown
Table 2. Characteristics of 14 Infants with
Tinea capitis at LSUHSC
Birth weight (kilograms)
68 (average)
2.98 (average)
The organisms isolated in newborns with tinea capitis have included Microsporum canis (M. canis), Microsporum
audouinni, Trichophyton tonsurans, Trichophyton rubrum, Trichophyton mentagrophyte, and Trichophyton violaceum. To
our knowledge the youngest newborn with M. canis causing tinea faciei was 6 days old 1 and the first report of T.
tonsurans causing tinea capitis and corporis in a newborn was 9 days of age.2 Over a period of 31 months, we identified
14 infants less than 4 months of age with tinea capitis, 6/14 (43%) of whom were neonates ranging in age from 17-25
days. The majority of infants were black and had T. tonsurans isolated from their scalp lesions. The only 2 white infants
identified had M. canis isolated from their lesions. Tinea capitis can be transmitted indirectly via fallen hair and
desquamated hair cells, as well as by direct contact. T. tonsurans has been isolated from combs, hairbrushes, bedding,
and clothing. Asymptomatic carriage has been demonstrated among adults and children living with an index case of
tinea capitis and this has led to a growing awareness of asymptomatic carriage as a major reservoir of infection. Of the
infants identified in our study, 3 infants had exposure to family members with dermatophyte infection who were likely the
initial source of infection. Humans may become infected with M. canis by direct contact with family pets, especially cats
and dogs which are the major carriers of this organism. None of the family members had direct contact with family pets.
The clinical presentation of these infants was similar to that of older children and consisted primarily of the seborrheic
type with circumscribed, erythematous lesions with diffuse scaling, patchy hair loss and a few demonstrated a more
inflammatory response with pustular formation. Treatment with oral griseofulvin (10-20 mg/kg/day x 4 weeks) for tinea
infection in newborns has been previously reported 3-5 and was tolerated well as it was in the few infants in our study
who were treated systemically. The two infants with M. canis infection resolved with topical therapy, one with
clotrimazole and one with terbinafine.
CONCLUSION
Figure 2 M. canis (macroconidia)
Age (days)
METHODS
DISCUSSION
Tinea capitis in the neonatal period is more common than previously thought and at least in the few neonates described
in this report did not appear to be more extensive or severe than in older children. Contact with affected family members
or asymptomatic dermatophyte carriers may likely be sources of infection for these infants.
Table 3. Treatment and Outcome According to Fungal Isolate
Griseofulvin (1)
Resolved (1)
Resolved (1)
17-120 (range)
Trichophyton
tonsurans (12)
2.2-3.8 (range)
Topical antifungal (7)
Failure (1)
REFERENCES
1. Jacobs AH, Jacobs PH, Moore N. Tinea faciei due to Microsporum canis in a 6-day-old infant. JAMA 1972;219:1476.
2. Manglini PR, Raman C, Durairaj P, et al. Trichophyton tonsurans infection in a 9-day-old infant. Inter J of Dermatol
1988;27:128.
3. Weston WL, Morelli JG. Neonatal tinea capitis. Pediatr Infect Dis J 1998;17(3):257-258.
Sex
Race
Gestational age*
males
9 (64%)
blacks
12 (86%)
Preterm < 37 wks
3 (23%)
* Gestational age and birth weight for case 4 are unknown.
females
5 (36%)
whites
2 (14%)
Unknown (5)
4.Ungar SL, Laude TA. Tinea capitis in a newborn caused by two organisms. Pediatr Dermatol 1997;14(3):229-230.
Infants with
Tinea capitis (14)
No treatment (1)
Griseofulvin +
Topical antifungal (3)
Term > 37 wks
Resolved (1)
Resolved (1)
5. Weston WL, Thorne EG. Two cases of tinea in the neonate treated successfully with griseofulvin. Clin Pediatr
1997;16(7):601-602.
6. Ghorpade A, Ramanan C, Durairaj P. Trichophyton mentagrophytes infection in a two-day-old infant. Inter J
Dermatol 1991;30:209-210.
Unknown (2)
10 (77%)
Microsporum
canis (2)
7. Gondim-Gonzales HM, Maprunga AC, Melo-Montiero C, Lima AAB. Tinea capitis caused by Microsporum canis in a
newborn. Inter J Dermatol 1992;31:368.
Topical antifungal (2)
Resolved (2)
8. Alden ER, Chenila SA. Ringworm in an infant. Pediatrics 1969;44 (2):261-262.