Two Cases of Drug-Resistant Ringworm In New York City

The CDC is reporting 2 cases of tinea (ringworm) that occurred in New York City. A local dermatologist reported the 2 patients to public health officials.

The cases were published in the latest Morbidity and Mortality Weekly Report.

“Skin culture isolates from each patient were previously identified by a clinical laboratory as Trichophyton mentagrophytes and were subsequently forwarded to the Wadsworth Center, New York State Department of Health, for further review and analysis,” MMWR reported. “Sanger sequencing of the internal transcribed spacer region of the ribosomal gene, followed by phylogenetic analysis performed during March 2023, identified the isolates as T indotineae After subsequent analysis the isolates were identified as T indotineae.”

The following are descriptions of the 2 cases:

Patient A
This patient was a 28 year old woman who developed a pruritic eruption in the summer of 2021 and sought treatment through a dermatologist 6 months later. She was in the third trimester of pregnancy during this appointment. During the appointment, it was observed she had plaques on her neck, abdomen, pubic region, and buttocks.

She was diagnosed with tinea, and after she gave birth began oral terbinafine. It was later discontinued, and she was prescribed itraconazole.

After a 4-week course of itraconazole, her rash resolved. They did note the patient is being monitored for potential recurrence of infection.

The patient had no recent international travel history, which suggested a potential transmission of T indotineae in the United States.

Patient B
A 47 year old woman developed a pruritic eruption in the summer 2022 while visiting Bangladesh. While in the country she was given a topical antifungal and steroid creams.

Upon returning to the US, she have 3 subsequent emergency department visits in the fall of the same year. For each of the visits, she was prescribed various treatments including:

Visit 1: hydrocortisone 2.5% ointment and diphenhydramine
Visit 2: clotrimazole cream
Visit 3: terbinafine cream

The patient did not experience any improvement in her condition. In December of last year, she was evaluated by dermatologists who prescribed her a 4-week course of oral terbinafine.

Her symptoms did not improve, and she was prescribed a 4-week course of griseofulvin. She saw an approximately 80% improvement while on this last medication. The authors reported that itraconazole therapy is being considered, pending further evaluation given the recent confirmation of suspected T indotineae infection. The woman’s son and husband reported similar eruptions and are being evaluated.

Takeaways
CDC reports there are 2 important takeaways from these cases. “Health care providers should consider T indotineae infection in patients with widespread tinea, particularly when eruptions do not improve with first-line topical antifungal agents or oral terbinafine,” the MMWR reported. “Culture-based identification techniques used by most clinical laboratories typically misidentify T indotineae as T mentographytes or T interdigitale; correct identification requires genomic sequencing."