Microsoft Word - 4-박영민.DOC

Size: px

Start display at page:

Download "Microsoft Word - 4-박영민.DOC"

우리 시
5 years ago
Views:

1 증례보고 항암요법치료중인다발성골수종환자에서원심고리홍반으로발현한몸백선 1 예 = Abstract = 가톨릭대학교의과대학피부과학교실 김은정 김혜성 김형옥 박영민 A Case of Tinea Corporis Mimicking Erythema Annulare Centrifugum in a Patient Treated with Chemotherapy Due to Multiple Myeloma Eun Jung Kim, Hei-Sung Kim, Hyung-Ok Kim and Young-Min Park Department of Dermatology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea Tinea corporis usually presents as an erythematous annular plaque with a scaly, concentrically expanding border. However, it is often difficult to diagnose when the initial manifestation is atypical, especially in immunocompromised patients. Early accurate diagnosis on mycologic basis may be of value in controlling the disease and preventing severe infection. We herein report an atypical case of tinea corporis that presented with skin lesions resembling erythema annulare centrifugum. A 61-year-old female presented with multiple, pruritic, polycyclic plaques on the back for a few days. She had been diagnosed with multiple myeloma, and was being treated with Velcade chemotherapy. KOH examination was positive, and on histological examination, fungal hyphae were noted on Periodic acid-schiff (PAS) stain. Fungal cultures from skin scrapings showed growth of Trichophyton rubrum. [Kor J Med Mycol 2009; 14(3): ] Key Words: Atypical tinea corporis, Immunocompromised patient, Multiple myeloma, Trichophyton rubrum 서 론 몸백선은머리, 수염, 손발, 및샅고랑등을제외한피부에피부사상균이감염되어일으키는질환으로대부분표피각질층에국한되어발생하나일부모낭을침범하기도한다 1. 전형적인임상양상은건조한인설반또는소수포성병변이중심부는호전되면서주변으로번져나가는윤상형 별책요청저자 : 박영민, 서울시서초구반포동 505, 가톨릭대학교의과대학서울성모병원피부과전화 : (02) , Fax: (02) yymmpark6301@hotmail.com 병변이생기는것이지만, 이외에도원인균주의종류, 병변의위치와숙주의면역상태등에따라매우다양한임상양상을보일수있다 2~5. 비전형적인임상양상을보일경우다른피부질환과유사하여감별이어려울수있다 6~10. 특히면역이저하된환자에서비전형적인임상양상으로나타나다른염증성피부질환으로오진하게되는경우병변은치료에저항하고빠르게확산되며심재성감염으로진행할수있어초기에몸백선의의심을갖고적절한진균학적검사를시행하는것이매우중요하다 11,12. 저자들은다발성골수종을진단받고항암치료로면역이저하된환자에서홍반성의윤상형

김은정등 : 항암요법치료중인다발성골수종환자에서원심고리홍반으로발현한몸백선 1

Pruritic, multiple, erythematous, polycyclic plaques on the back; inset: close-up view 판이여러개가융합되는양상을보여원심고리홍반과유사한임상소견을보였으나진균학적검사상 Trichophyton rubrum ( 이하 T.

과거력및가족력 : 2년전다발성골수종을진단받고 VAD (Vincristine, Adriamycin, Dexamethasone) 항암요법 3회와 Bortezomib (Velcade ) 항암요법 2회시행받았으며기관지폐렴과다발성병적골절이발생하여장기간입원치료중임.

2 김은정등 : 항암요법치료중인다발성골수종환자에서원심고리홍반으로발현한몸백선 1 예 Fig. 2. Fungal hyphae (arrows) in the keratin layer (PAS, 400) Fig. 1. Pruritic, multiple, erythematous, polycyclic plaques on the back; inset: close-up view 판이여러개가융합되는양상을보여원심고리홍반과유사한임상소견을보였으나진균학적검사상 Trichophyton rubrum ( 이하 T. rubrum) 이검출된비전형적인몸백선 1예를경험하고문헌고찰과함께보고한다. 증 례 환자 : 조 O O, 61세여자환자주소 : 등에발생한환상의다발성홍반성판현병력 : 환자는다발성골수종과기관지폐렴및다발성병적골절로내과에장기입원치료중한달전부터등에다수의홍반성판이발생하여퍼지는양상을보여피부과에의뢰되었다. 과거력및가족력 : 2년전다발성골수종을진단받고 VAD (Vincristine, Adriamycin, Dexamethasone) 항암요법 3회와 Bortezomib (Velcade ) 항암요법 2회시행받았으며기관지폐렴과다발성병적골절이발생하여장기간입원치료중임. 피부소견 : 등의병변은소양감이있는환상의홍반성판으로융기된변연부는미세한인설을동반하고있었으며원심성으로확장되고중심부는경미한과색소침착을남기면서치유되는양상으로여러개의인접한병변들은서로융합하고있었다 (Fig. 1). 진균학적검사소견 : 등에서시행한 KOH 직접도말검사상격벽이있는균일한굵기를가진균사와포자가관찰되었다. 병변변연부에서채취한인설을 Sabouraud dextrose agar 배지에접종하여 25 배양기에서배양한결과중심부가약간융기된솜털모양으로자라는흰원형의균집락을관찰할수있었으며배지의뒷면은황갈색을나타내어 T. rubrum으로동정하였다. 병리조직학적검사소견 : 각질층에는과각화증과국소적인이상각화증소견이관찰되었으며, 진피에는경미한단핵구의침윤이관찰되었다. PAS 검사상각질층에서균사를확인할수있었다 (Fig. 2). 치료및경과 : 폐렴과골절에대한보조적치료를시행하던중기관지폐렴과다발성고열을동반한패혈증이발생하여사망하였다. 고찰몸백선은피부사상균증중발백선, 샅백선과

3 Table 1. The reported cases of tinea corporis caused by T. rubrum with clinical presentation mimicking other dermatologic diseases Reference No. Sex/Age Underlying Disease Host Immunity Other Dermatologic Diseases Mimicked 6 M/69 Autoimmune hypothyroidism Immunocompetent Subacute cutaneous lupus erythematosus 7 F/46 None Immunocompetent Subacute cutaneous lupus erythematosus 8 M/57 None Immunocompetent Sweet syndrome F/51 None Immunocompetent Pustular psoriasis M/28 None Immunocompetent Impetized herpes M/56 None Immunocompetent Pseudolymphoma M/64 None Immunocompetent Pseudolymphoma 9 M/44 AIDS Immunocompromised Kaposi's sarcoma 10 M/55 Renal transplantation Immunocompromised Blastomycosis infection Our case F/61 Multiple myeloma Immunocompromised Erythema annulare centrifugum 손발톱백선다음으로높은발생빈도를보이는질환이다. 인체친화성진균인 T. rubrum 에의한경우는비노출부위에호발하고, 동물친화성진균은노출부위에흔히발생한다 1. 전형적인임상양상은인설을동반한홍반성구진및소수포로약간융기되어주변으로퍼져나가면서중심부는정상피부색깔또는경미한색소침착을남기는환상형병변을보인다. 비전형적인임상형으로다수의환상형반이동심원모양을이루는와상백선 (tinea imbricata) 과환상형반이여러개융합되어발생하는다환성 (polycyclic) 병변, 심한과각화를보이는건선양 (psoriasiform) 병변등이있고, 이밖에도스테로이드제제의투여나도포에의해모양이변형된잠행백선 (tinea incognito) 이있다 1,3,13,14. 심한임상형으로육아종, 모낭염, 농양, 독창, 가성균종 (pseudomycetoma) 등의양상으로나타나기도한다 15~17. T. rubrum은몸백선을일으키는주원인균중하나로 ringworm 형태로주변으로퍼져나가는환상형반이가장흔한임상양상이지만, 비전형적인임상양상으로나타나는경우종종다른피부질환과혼동되어진균학적검사가시행되지않으면다른피부질환으로오진할수있다. 국 내외문헌에보고된 T. rubrum에의한비전형적인몸백선이다른피부질환과유사한임상양상으로나타나혼동되었던증례로는햇빛노출부위에다발성의인설을동반한윤상형반으로나타나아급성홍반성루푸스와혼동된경우 6,7, 붉은색구진과농포로나타나농포성건선과혼동된경우 8, 가성림프종이나 Sweet 증후군과유사하게나타난경우 8, 농가진양단순포진 (impetized herpes simplex) 과유사하게나타난경우 8, AIDS 환자에서 Kaposi 육종과유사한병변으로발생한경우 9, 임상양상과진균학적검사소견이분아진균증과혼동되었으나최종적으로 T. rubrum 에의한몸백선으로진단된경우 10 등이보고되었다 (Table 1). 이외에도비전형적인임상양상으로우췌양및건선양병변으로발생한경우 14, 가성막성병변으로발생한경우 18, 심재성침범을보인결절의양상으로발생한경우 11,12 등이보고되었다. 몸백선에서의다양한임상형을결정하는인자들로는원인사상균의종류, 각질층의습윤한정도, 접종진균의양과같은국소적인자및아토피피부염이나당뇨등진균감염에대한감수성이증가되어있는질환의동반유무와숙주의

4 김은정등 : 항암요법치료중인다발성골수종환자에서원심고리홍반으로발현한몸백선 1 예 면역상태등이있다 19,20. 특히백혈병, 림프종, 다발성골수종과같은기저질환을동반하거나스테로이드나면역억제제를투여받아면역이저하된환자의경우비전형적인임상양상으로발생하는경우가많아임상적으로다른염증성피부질환과의감별이어려울수있다. 또한면역이억제된환자에서표재성감염이적절히치료되지못하고만성적으로지속되는경우진피나피하의심재성감염으로진행하거나드물게는내부장기까지침범할수있어초기에 KOH 도말검사와진균배양검사등적절한진균학적검사를시행하는것이매우중요하다. 저자들은다발성골수종으로진단받고항암치료를받은환자의등에여러개의환상형판이서로융합되는다환성병변이발생하여임상적으로원심고리홍반을의심하였으나, 진균학적검사상 T. rubrum이동정된몸백선의증례를경험하고면역이저하된환자에서몸백선이다른피부질환의양상으로발현하여혼동될수있음을시사하는흥미로운증례로생각되어보고하는바이다. REFERENCES 1. Verma S, Heffernan MP. Superficial fungal infection: Dermatophytosis, onychomycosis, tinea nigra, piedra. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffel DJ. editors. Fitzpatrick's dermatology in general medicine. 7 th ed. New York:McGraw-Hill Book, 2008: Ziemer M, Seyfarth F, Elsner P, Hipler UC. Atypical manifestations of tinea corporis. Mycoses 2007; 50: Kang GS, Go WT, Suh MK, Ha GY, Lee JI. A case of tinea corporis caused by Trichophyton verrucosum showing tinea imbricata-like clinical appearance. Kor J Med Mycol 2008; 13: Sun PL, Ho HT. Concentric rings: an unusual presentation of tinea corporis caused by Microsporum gypseum. Mycoses 2006; 49: Luque AG, Biasoli MS, Sortino MA, Lupo SH, Bussy RF. Atypical tinea corporis caused by Microsporum gypseum in a subject with acquired immune deficiency syndrome. J Eur Acad Dermatol Venereol 2001; 15: Duaden E, Bartolome B, Pascual M, Fraga J, Garcia- Diez A. Autoinvolutive photoexacerbated tinea corporis mimicking a subacute cutaneous lupus erythematosus. Acta Derm Venereol 2001; 81: Modi GM, Maender JL, Coleman N, Hsu S. Tinea corporis masquerading as subacute cutaneous lupus erythematosus. Dermatol Online J 2008; 14: 8 8. Ginter G, Soyer HP. Unusual clinical manifestations caused by Trichophyton rubrum--atypical "rubrophytoses". Hautarzt 1989; 40: Kwon KS, Jang HS, Son HS, et al. Widespread and invasive Trichophyton rubrum infection mimicking Kaposi's sarcoma in a patient with AIDS. J Dermatol 2004; 31: Squeo RF, Beer R, Silvers D, Weitzman I, Grossman M. Invasive Trichophyton rubrum resembling blastomycosis infection in the immunocompromised host. J Am Acad Dermatol 1998; 38: Lowther AL, Somani AK, Camouse M, Floretino FT, Somach SC. Invasive Trichophyton rubrum infection occurring with infliximab and long-term prednisone treatment. J Cutan Med Surg 2007; 11: Novick NL, Tapia L, Bottone EJ. Invasive Trichophyton rubrum infection in an immunocompromised host. Am J Med 1987; 82: Wacker J, Durani BK, Hartschuh W. Bizarre annular lesion emerging as tinea incognito. Mycoses 2004; 47: Kim JA, Kim SW, Moon SE. A case of verrucous and psoriasiform tinea corporis by Trichophyton rubrum. Korean J Dermatol 1997; 35: Chun BN, Yu HJ, Son SJ. A clinical and mycologic study of tinea corporis. Korean J Dermatol 1989; 27:

5 16. Kim K, Chae YS, Suh KS, Kim ST. Clinical and histopathologic findings of dermatophytic granulomas. Korean J Dermatol 1992; 30: Lee KH, Myung KB, Lee SN. Pseudomycetoma due to Trichophyton schoenleinii occurring in two brothers. Ann Dermatol 1989; 1: Lu S, Xi L, Zhang J, Lu C. Pseudomembranous-like tinea of the scrotum: report of six cases. Mycoses 2009; 52: Dahl MV. Immunological resistance to dermatophyte infections. Adv Dermatol 1987; 2: Dahl MV. Suppression of immunity and inflammation by products produced by dermatophytes. J Am Acad Dermatol 1993; 28: S19-S

Microsoft Word - 5-서무규.DOC

Microsoft Word - 5-서무규.DOC 강교신등 : 와상백선의양상을보인 Trichophyton verrucosum 에의한몸백선 1 예 대한의진균학회지제 13 권제 4 호 2008 증례보고 와상백선의양상을보인 Trichophyton verrucosum 에의한몸백선 1 예 = Abstract = 동국대학교의과대학피부과학교실, 진단검사의학교실 1, 병리학교실 2 강교신 고우태 서무규 하경임 1 이종임