Sir,

Preseptal cellulitis typically affects children and is usually secondary to infections around the face and cranium.1 We report an unusual case associated with vesicular hand lesions resulting from Trichophyton interdigitale. This has been reported in only two children2 and should be considered in adults with skin lesions.

Case report

A 43-year-old man working in a pet shop developed painful right periorbital rash, photophobia, and blurred vision since a week. Initial treatment with Daktacort ointment and Ferofenedine tablets for 1 week was ineffective.

A delineated erythematous lesion involved the right eyelids and cheek (Figure 1a). Apart from chemosis, conjunctival discharge, and reduced vision of 6/18, the ocular examination and movements were normal. No infection, immunodeficiency, or allergy was identified. A week after oral Flucloxacillin and Chloramphenicol ointment, the rash persisted with reduced corneal sensation, while the chemosis resolved. Painful vesicles with ulcerated margins appeared over the dorsum of his right hand (Figure 1b). Herpes simplex blepharoconjunctivitis was suspected and treated with Aciclovir 3% ointment but the lesions spread to his palm. Dermatologists considered animal fungus infection or fish-tank granuloma in view of his occupation. Identical lesions were found on the hand and eyelids and scrapes from his hand isolated fungal elements on a potassium hydroxide slide with cotton blue stain. Dermatophyte agar isolated Trichophyton mentagrophytes variety interdigitale (Figure 2). Having failed to respond to antibacterial and antiviral agents, the lesions dramatically resolved in 3 weeks with topical Daktarin and oral Itraconazole (200 mg twice-a-day and then once-a-day for 10 days each).

Figure 1
figure 1

(a) Preseptal cellulitis of the right eye showing chemosis and an erythematous rash of the lids (a week after initial antibiotic treatment). (b) Vesicular lesions with erythematous ulcerated margins on the dorsum of the right hand involving the middle, ring, and little finger.

Full size image
Figure 2
figure 2

Culture showing numerous microconidia, macroconidia, chlamydospores, and spiral hyphae in T. mentagrophytes var. interdigitale. (Courtesy of Mycology Online: Department of Microbiology and Immunology, Mycology Unit, Adelaide Women's and Children's Hospital, Adelaide, Australia).

Full size image

Comment

In 1937 Hubert classified preseptal cellulitis.3 The main causative organisms are Pneumococcus, Staphylococcus, Mucormycosis, and Aspergillosis.4, 5 Our case however, isolated Trichophyton which is a common dermatophyte causing tinea.4 Dermatophytes have low infectivity and virulence with anthropophilic, zoophilic,4, 6 and phytophilic transmission.7 Tinea is difficult to diagnose as seen in four children misdiagnosed with bullous impetigo.8 Skin scrapes and cultures are important for early diagnosis. Infections respond to a variety of antifungal agents including clotrimazole and miconazole.8 Triazole and itraconazole may have better efficacy with shorter treatment time.9

Dermatophyte infections can masquerade as bacterial, viral preseptal cellulites, or allergic dermatitis and should be considered in resistant cases. To our knowledge this is the first case of T. interdigitale infection causing preseptal cellulitis in an adult.