Majocchi granuloma mimicking skin lesion of systemic lupus erythematosus

Abstract

The cutaneous manifestations of systemic lupus erythematosus (SLE) are divided into chronic cutaneous lupus erythematosus, subacute cutaneous lupus erythematosus, and acute cutaneous lupus erythematosus. Each form presents with a range of characteristics that differentiate one from the others. Diagnosis is made through clinical evaluation, skin biopsy, and laboratory tests to detect autoantibodies such as anti-DNA, anti-RO/SSA, anti-LA/SSB, anti-Sm, among others. CASE REPORT Female, 35 years old, with SLE since 9 years of age, in remission of the disease for 12 months, already undergoing pulse therapy with cyclophosphamide and belimumab for treatment of lupus nephritis. She is currently taking mycophenolate 2 g/day and belimumab, without the need for corticosteroid therapy, with Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) = 0. Three months ago, she began to experience a single skin lesion on her left leg, 5 cm in diameter, initially interpreted as a bacterial skin infection and treatment with antibiotics was performed, but without improvement of the condition. In consultation with a dermatologist, the hypothesis of erythema nodosum or lupus skin lesion was proposed, and topical corticosteroids, prednisone, and dapsone were started, with partial improvement of the condition. As the improvement of the lesion was only partial and the patient was in remission of the systemic disease, a skin biopsy was considered for better diagnostic elucidation. The biopsy result showed findings described in Majocchi’s granuloma (deep fungal infection that affects hair follicles and adjacent thermal tissues), possibly due to immunosuppression. Using oral itraconazole and topical clotrimazole, the skin lesion improved. CONCLUSION The investigation of differential diagnoses for patients with SLE with cutaneous manifestations is extremely important to avoid the misuse of immunosuppressive drugs in patients with the disease already in remission. There are several differential diagnoses to be considered that can mimic the symptoms of cutaneous lupus, such as dermatitis, psoriasis, eczema, and fungal infections. Collaboration between different medical specialties is essential for effective and individualized management of these patients.