Tinea corporis instigating emergency caesarean delivery

Introduction

There are different dermatoses that may affect women during pregnancy and postpartum. These can be broadly categorised into physiological changes, existing dermatoses modified in pregnancy, infections, pregnancy-specific dermatoses and tumours presenting in pregnancy. ¹ These may confer no risk to mother and baby, for example, physiological changes or confer maternofetal risks, for example, prematurity and neonatal blistering with pemphigoid gestationis. Correct diagnosis and prompt treatment is required to gain symptom control for pregnant women and to optimise the pregnancy.

Tinea corporis is a common fungal infection of the skin on the body, that can also affect other body sites, for example, tinea pedis (Athlete's foot), tinea capitis (scalp), tinea crura (groin) and onychomycosis (nail). ² Tinea corporis generally responds well to topical antifungal treatment without complications for mother and fetus. ³ However, complications may arise if dermatoses are not diagnosed and treated promptly as highlighted in this case of tinea corporis that resulted in an emergency caesarean delivery under general anaesthesia.

Case history

A 29-year-old woman in her first pregnancy underwent induction of labour at 39 weeks and 2 days of gestation due to reduced fetal movements.

She had a low-risk pregnancy prior to this admission. She has a history of mild childhood asthma and unmedicated anxiety and depression. She had no pets at home and no recent foreign travel.

The patient was commenced on an oxytocin infusion following artificial rupture of membranes. At 2 cm dilated with the oxytocin infusion rate at 4 ml/h, she requested an epidural. During the anaesthetic review, the anaesthetist noticed a rash covering her back and abdomen. The anaesthetist sought advice from a consultant colleague and the decision was made that regional anaesthesia was contraindicated due to the risk of this unknown infection seeding into the epidural space. An alternative of patient-controlled analgesia with intravenous remifentanil was commenced but this did not provide sufficient analgesia. The patient did not tolerate increasing the rate of the oxytocin infusion to increase the frequency of contractions. She withdrew her consent to proceed with the induction of labour process and requested a caesarean birth. She was counselled that this would be performed under a general anaesthetic. She delivered a live baby girl born in good condition with a weight of 3.36 kg and Apgars of 9, 8 and 10 at 1, 5 and 10 minutes respectively.

On review of her history after delivery, the itchy rash had been present since 2015, initially starting in the groin. It did not respond to topical emollients, and gradually spread over time. She did report to a skin picking habit and has previously seen psychotherapists for this. She did not seek further medical attention for her rash due to her skin picking and mental health. On examination she had a scaly annular rash with a leading edge and central sparing, affecting her back and abdomen (Figure 1(a) and (b)).

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Figure 1.

Scaly annular rash with central sparing affecting (a) back, (b) abdomen, with (c) resolution post treatment with oral fluconazole with some post-inflammatory hyperpigmentation.

Investigations

There was insufficient sample for mycology from skin scrapings. Skin punch biopsy demonstrated focal parakeratosis with psoriasiform hyperplasia and occasional neutrophils. Periodic acid Schiff stain demonstrated very scant fungal hyphae within the stratum corneum confirming the diagnosis of tinea corporis (Figure 2).

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Figure 2.

Periodic acid Schiff stain demonstrated very scant fungal hyphae within the stratum corneum (magnification 100×).

Treatment

We opted to treat the tinea corporis with oral fluconazole 50 mg once daily for 4 weeks due to the size of the rash, longstanding history and the fact that she was breastfeeding. On review 11 weeks post-partum, she had no residual rash except some post-inflammatory hyperpigmentation (Figure 1(c)).

Discussion

Tinea corporis is commonly encountered in primary care and does affect women of childbearing potential. ⁴ In this case, delayed diagnosis and treatment resulted in our patient having a caesarean delivery under general anaesthesia because she was unable to achieve satisfactory intrapartum analgesia in the absence of regional anaesthesia. Not only is caesarean delivery associated with a risk of maternal complications and longer postnatal recovery period, but there is also the resultant impact for future pregnancies and birth, including an increased risk of uterine rupture and placenta accreta spectrum. This patient's rash was visible over her abdomen and presumably would have been evident at antenatal appointments during abdominal palpation. Topical and oral terbinafine are safe antifungals for use in pregnancy. ⁵

Tinea corporis is caused by dermatophyte infections, most commonly Trichophyton rubrum. ² Other causes include Trichophyton mentagrophytes, T. tonsurans and Microsporum canis, the latter more commonly associated with animal contact. ² Fluconazole has the best safety evidence among anti-fungal medication in breastfeeding, ⁶ and is active against dermatophytes. ³ Whilst rare, fungal meningitis has been associated with epidural analgesia, although the source was unknown and the case was unrelated to tinea corporis. ⁷ There are case reports of epidurals performed after skin disinfection without complication with tinea versicolor, which is a more superficial infection with Malassezia. ⁸ However, the risk with tinea corporis is not known.

There may be multiple causes of rash in pregnancy, from pregnancy-specific dermatoses (atopic eruption of pregnancy, polymorphic eruption of pregnancy, pemphigoid gestationis, intrahepatic cholestasis of pregnancy), physiological changes in pregnancy, existing dermatoses modified by pregnancy and infections. ⁹ Tinea corporis differs from these other rashes by having a scaly erythematous ring-like (annular) edge with central clear skin and is typically an isolated area. Unlike the other dermatoses, which are often more symmetrical in nature, atopic eruption of pregnancy typically presents with an itchy erythematous rash in the flexures. Polymorphic eruption of pregnancy and pemphigoid gestationis present with itchy urticated papules and plaques, the latter with occasional blistering. These typically occur on the abdomen and thighs, with umbilical involvement in pemphigoid gestationis, and umbilical sparing in polymorphic eruption of pregnancy. Intrahepatic cholestasis of pregnancy does not have a primary rash, and instead presents with excoriations from scratching. Where there is any uncertainty in the diagnosis, we would encourage prompt primary care or dermatology review.

Our case of tinea corporis affecting the maternal obstetric management highlights the importance of prompt diagnosis and treatment of rashes in pregnancy.