冉昕 汪盛 王琳 冉玉平

(四川大學(xué)華西醫(yī)院皮膚性病科，成都 610041)

·病例報告·

紫色毛癬菌所致老年頭癬繼發(fā)頭面部帶狀皰疹1例

冉昕 汪盛 王琳 冉玉平

(四川大學(xué)華西醫(yī)院皮膚性病科，成都 610041)

患者女，62歲，頭皮紅斑、丘疹、鱗屑1個月，加重伴膿皰3周，結(jié)痂1周。取痂殼直接鏡檢發(fā)現(xiàn)真菌菌絲，將痂殼接種沙堡弱培養(yǎng)基25℃培養(yǎng)25 d見紫色菌落生長，周圍有紅色色素。提取菌落DNA做PCR擴增后測序為紫色毛癬菌，診斷為老年頭癬。經(jīng)牛奶送服伊曲康唑聯(lián)合2%酮康唑洗劑洗頭后外用萘替芬酮康唑治療3周后患者頭皮痂殼消退，但于右側(cè)頭面部出現(xiàn)帶狀分布簇集張力性水皰，診斷為帶狀皰疹。服用溴夫定片125 mg/d治療9 d后水皰消退。

頭癬；紫色毛癬菌；伊曲康唑；帶狀皰疹；溴夫定

1 臨床資料

患者女，62歲。頭皮紅斑、丘疹、鱗屑1個月，加重伴膿皰3周，結(jié)痂1周?；颊?個月前無明顯誘因頭皮出現(xiàn)紅斑、丘疹、鱗屑，自覺瘙癢，未予重視。3周前患者頭部出現(xiàn)膿皰，皰壁厚，皰液黃色渾濁，門診治療無效。1周前以“濕疹伴感染”在當(dāng)?shù)刈≡褐委?。血常?guī)、血生化、電解質(zhì)未見異常。免疫學(xué)檢查：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)。補體：C3 0.671 g/L (0.785～1.52)，C4 0.16 g/L (0.14～0.36)。ANA 1∶320均質(zhì)型核仁型，SSA+++，ENA陰性。左顳部頭皮組織病理活檢：表皮棘層水腫，真皮小血管周圍較多淋巴細(xì)胞、組織細(xì)胞及中性粒細(xì)胞浸潤及上皮樣肉芽腫形成。予苯唑西林鈉、莫匹羅星抗感染，氯雷他定、酮替芬抗過敏，白芍總苷、復(fù)方甘草酸苷等抗炎，1∶9聚維酮碘溶液濕敷等抗細(xì)菌治療6 d后皮損無明顯改善，遂到我科就診。查體見頭皮可見多發(fā)紅斑、鱗屑、結(jié)痂 (見圖1A)，皮膚鏡下見糜爛、滲出及黃白色痂殼，毛發(fā)未見明顯受累 (見圖1B)。紫外光皮膚鏡下見痂殼處有黃白色熒光 (見圖1C)。頭皮痂殼處標(biāo)本經(jīng)10%KOH涂片直接鏡檢見分隔真菌菌絲 (見圖2A)。將頭皮痂殼種植至沙堡弱培養(yǎng)基中，于25℃培養(yǎng)25 d后，有紫色菌落生長，其周圍有紅色色素 (見圖2B)。用DNA試劑盒 (Omega Bio-tek)提取菌落DNA，以NL引物做PCR擴增后測序，做BLAST比對結(jié)果為紫色毛癬菌 (Trichophytonviolaceum)，同源性99% (GenBank登錄號:KY123853)。診斷：紫色毛癬菌所致頭癬。用鈍刀刮去頭皮痂殼，予口服伊曲康唑膠囊200 mg，2次/d (牛奶送服)；用2%酮康唑洗劑清洗皮損后外用1%萘替芬-0.25%酮康唑乳膏，聯(lián)合內(nèi)服頭孢地尼 (100 mg/d)、潑尼松 (20 mg/d)和復(fù)方甘草酸苷2片，2次/d。治療3周后復(fù)診患者頭皮痂殼完全消退，遺留瘢痕及新發(fā)生長 (見圖1D)。復(fù)查真菌鏡檢和培養(yǎng)均陰性。但患者右側(cè)頭皮、耳前、面頰部、口唇及下頜部新出現(xiàn)帶狀分布紅斑，其上有簇集性水皰及大皰，伴疼痛明顯 (見圖1E)。皮膚鏡下見水皰為張力性 (見圖1F)。根據(jù)臨床表現(xiàn)考慮右側(cè)頭面部帶狀皰疹 (三叉神經(jīng)下顎支受累)。因患者院外已服用鹽酸伐昔洛韋膠囊150 mg，3次/d，共4 d，癥狀未控制，仍有新發(fā)水皰。故將抗病毒藥物改為口服溴夫定片 (左代)125 mg，1次/d；普瑞巴林 (樂瑞卡)75 mg，2次/d，外用噴昔洛韋乳膏。治療10 d后，頭頂皮損明顯好轉(zhuǎn)，面部紅斑、水皰基本消退，遺留少許痂殼及色素沉著，仍自覺右側(cè)面部疼痛 (見圖1G)。停用溴夫定片，后續(xù)繼續(xù)予普瑞巴林鎮(zhèn)痛及抗真菌治療 (見圖3)。治療16周后頭皮頭癬和右頭面部皰疹痊愈，遺留少量色素沉著 (見圖1H)?；颊咂p變化和治療用藥過程見圖3。隨訪1 a頭癬和帶狀皰疹未復(fù)發(fā)。

2 討 論

此例老年女性頭皮結(jié)痂，未見典型的頭癬病發(fā)表現(xiàn)，誤診為“濕疹”延誤治療。經(jīng)真菌鏡檢、培養(yǎng)及分子測序明確了感染源為紫色毛癬菌，確診為頭癬，予抗真菌治療療效明顯；治療頭癬期間右頭面部發(fā)生帶狀皰疹。

尚不清楚頭癬和頭面帶狀皰疹相繼發(fā)生的關(guān)聯(lián)性，但兩種病原體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，免疫學(xué)檢查ANA及SSA陽性，雖然無紅斑狼瘡、干燥綜合征等臨床表現(xiàn)，仍提示有潛在免疫功能異常，需定期檢測免疫指標(biāo)及臨床隨訪。

紫色毛癬菌 (Trichophytonviolaceum)為親人性皮膚癬菌，一般炎癥較輕，常導(dǎo)致發(fā)內(nèi)感染引

圖1患者臨床及皮膚鏡表現(xiàn)：A.頭皮多發(fā)紅斑、膿皰、結(jié)痂 (0 d)；B.皮膚鏡下可見黃白色痂殼，表皮的糜爛、滲出，但毛發(fā)未見明顯受累；C.紫外光皮膚鏡見痂殼處有黃白色熒光；D.伊曲康唑等治療3周，頭皮痂殼完全消退，遺留大片紅斑，新發(fā)有所生長 (21 d)；E.右耳、右面頰部、口唇及下頜部帶狀紅斑及簇集張力性水皰，疼痛明顯 (21 d)；F.皮膚鏡下可見含黃色皰液的張力性水皰；G.溴夫定治療帶狀皰疹9 d，頭皮面部紅斑、水皰基本消退 (35 d)；H.治療16周復(fù)診，頭皮及右耳及右面部皮損好轉(zhuǎn) (112 d)圖2真菌檢查結(jié)果：A.10%KOH真菌直接鏡檢發(fā)現(xiàn)菌絲；B.25℃，SDA培養(yǎng)25 d，紫色菌落生長，周圍有紅色色素圖3患者診治及用藥時間圖

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起黑點癬。但本例臨床表現(xiàn)特殊，最終經(jīng)直接鏡檢、培養(yǎng)及分子測序等明確病原菌。清除頭皮帶菌痂殼后內(nèi)服伊曲康唑聯(lián)合外用1%萘替芬-0.25%酮康唑乳膏及2%酮康唑洗劑清洗皮損，療效顯著。

溴夫定 (Brivudine)是胸腺嘧啶核苷酸類似物新型抗病毒藥物，在病毒胸腺嘧啶核苷酸激酶的作用下轉(zhuǎn)化為活性化合物-5'三磷酸溴乙烯基，整合入病毒DNA中抑制脫氧胸腺嘧啶 (DTMP)合成，控制病毒復(fù)制[4]。與阿昔洛韋 (800 mg，5次/d)比較，溴夫定 (125 mg，1次/d)可縮短張力性水皰結(jié)痂時間，更快控制病毒復(fù)制[5]，縮短帶狀皰疹后遺神經(jīng)痛時間[6]。溴夫定比泛昔洛韋和伐昔洛韋更好緩解疼痛[7]。本患者先后聯(lián)合使用伊曲康唑膠囊和溴夫定片，未出現(xiàn)副作用，肝腎功未見明顯異常，兩病均治愈。

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[2] Hambro CA,Yin NC,Yang C,et al.Trichophytonrubrumtinea capitis in an HIV-positive patient with generalized dermatophytosis[J].JAAD Case Rep,2016 24;3(1):19-21.

[3] 郭艷陽,吳卓彥,高繼鑫等.系統(tǒng)性紅斑狼瘡繼發(fā)泛發(fā)性淺部真菌病1例[J].醫(yī)學(xué)真菌學(xué),2016,10(6):368-370.

[4] Hew K,Dahlroth SL,Veerappan S,et al.Structure of the varicella zoster virus thymidylate synthase etablishes functional and structural similarities as the human enzyme and potentiates itself as a target of brivudine[J].PLoS One,2015,10(12):e0143947.

[5] Wassilew SW,Wutzler P.Oral brivudin in comparison with acyclovir for improved therapy of herpes zoster in immunocompetent patients:results of a randomized,double-blind,multicentered study[J].Antiviral Research,2003,59(1):49-56.

[6] Wassilew SW,Wutzler P.Oral brivudin in comparison with acyclovir for herpes zoster:a survey study on postherpetic neuralgia[J].Antiviral Research,2003,59(1):57-60.

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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 (漢族)，碩士，住院醫(yī)師.E-mail:ranfjk@126.com

冉玉平,E-mail:ranyuping@vip.sina.com

2017-03-06

[本文編輯] 施 慧