Remember kerion celsi.

To cite: Brissos J, Gouveia C, Neves C, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2013-200594 DESCRIPTION A healthy 3-year-old boy presented to our emergency department with a 2-week history of inflammatory scalp lesions. Physical examination revealed diffuse erythematous lesions, with focal areas of alopecia and several pustular patches with extensive suppurative discharge (figures 1 and 2). Cervical lymphadenopathy and fever were also noted. Tinea capitis with secondary bacterial infection was diagnosed and fluconazol, intravenous flucloxacillin and clindamycin were given. Surgical drainage was performed due to multiple scalp abscesses. Trichophyton mentagrophytes was isolated from scalp brushings. A 5-month course of fluconazol was necessary for clinical cure. His mother had the same fungal infection (forearm skin lesion) and family reported guinea pig exposure for the past months. Tinea capitis is the most frequent fungal infection in children. Zoophilic dermatophytes are responsible for severe inflammatory reactions probably due to their poor adaptation to the human host. Kerion celsi is an acute purulent inflammatory process of scalp, probably due to a T-cell-mediated hypersensitivity reaction to the dermatophyte. Griseofulvin is the first therapeutic choice since late 1950s, but is not available in certain European countries. Newer antifungal agents (terbinafine, itraconazole and fluconazole) seem to have similar efficacy rates. Treatment duration should be individualised according to severity and clinical response. Adjunctive treatment is controversial but data does not support antibiotics nor surgery for routine use. Tinea capitis and particularly kerion celsi, have a high potential for misdiagnosis. Several cases are incorrectly diagnosed as bacterial infection. Delay in treatment led to more extensive, severe inflammation and consequently to scarring and alopecia in our case.