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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 2  |  Issue : 3  |  Page : 200-202

Chromoblastomycosis: A report of two cases from a tertiary care hospital of eastern India


Department of Microbiology, Institute of Post Graduate Medical Education and Research, 244 AJC Bose Road, Kolkata, India

Date of Web Publication25-Oct-2013

Correspondence Address:
Kalidas Rit
70B T.C. Mukherjee street, PO: Rishra, Dist: Hooghly 712 248
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.120590

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  Abstract 

Chromoblastomycosis is an uncommon chronic fungal infection of the skin and subcutaneous tissue caused by dematiaceous fungi. We present here two cases of chromoblastomycosis, one with an atypical presentation. The diagnosis was made by demonstration of sclerotic bodies on the histopathological examination of skin biopsies and isolation of Fonsecaea pedrosoi on culture in both of them. Chromoblastomycotic skin lesions particularly atypical ones may be confused with other clinical conditions involving skin and are presented here for their academic interest.

Keywords: Atypical, chromoblastomycosis, Fonsecaea pedrosoi, sclerotic bodies


How to cite this article:
Naha A, Rit K, Dey R. Chromoblastomycosis: A report of two cases from a tertiary care hospital of eastern India . Int J Health Allied Sci 2013;2:200-2

How to cite this URL:
Naha A, Rit K, Dey R. Chromoblastomycosis: A report of two cases from a tertiary care hospital of eastern India . Int J Health Allied Sci [serial online] 2013 [cited 2019 Oct 22];2:200-2. Available from: http://www.ijhas.in/text.asp?2013/2/3/200/120590


  Introduction Top


Chromoblastomycosis is an uncommon chronic localized fungal infection of the skin and subcutaneous tissue presenting with slowly progressive verrucous lesions. [1] The lower limbs and dorsum of the hand are commonly affected. The infection is caused by dematiaceous (pigmented) fungi, which produce sclerotic or muriform bodies within the tissue. The most common causative organisms are Fonsecaea pedrosoi, Phialophora verrucosa, Fonsecaea compacta, and Cladophialophora carrionii.[2] The fungi is usually found in soil, wood, and rotting vegetables and infection often results from trauma such as puncture from a splinter of wood. [3]


  Case Reports Top


Case 1

A 54-year-old male agricultural worker presented with multiple verrucous lesions with scaling of skin involving almost whole of his left leg [Figure 1]. The lesions first appeared over his left knee like small ringworm like lesions 10 years earlier. He was treated for it without much improvement. There was history of severe pruritus along with heavy scaling mostly at night for the past 4 years. There was no history of trauma and splinter injury in the affected region. On physical examination, the general physical condition was good and there were no specific findings, except for the skin lesions. Routine blood, renal function tests, liver function tests, urine examination, and chest X-ray were within normal limits. Screening for human immunodeficiency virus (HIV) test was nonreactive.
Figure 1: Verrucous nodular lesions of chromoblastomycosis involving entire lower limb

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Case 2

A 46-year-old male patient presented with an irregular nontender itchy scaly plaque [Figure 2] of 5 × 6 cm in diameter on the right forearm, which slowly increased in size over the past 3 years. There was intact sensation over the lesion and no regional lymphadenopathy was detected. Rest of the physical examination and routine investigations were within normal limit.
Figure 2: Chromoblastosis lesion of forearm

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Microscopic examination of direct potassium hydroxide (KOH) mount preparation of collected materials from skin lesions in both the patients showed plenty of sclerotic bodies [Figure 3]. Analysis of skin biopsy material in both the cases revealed clusters of small, round, thick walled, brown sclerotic bodies (muriform cells), which are diagnostic of chromoblastomycosis. Acid fast stained sections for bacilli were negative. Culture of tissue biopsy material on Sabouraud's dextrose slant medium showed slow growing, velvet like, dark-brown colonies with slightly elevated center [Figure 4]. Microscopic examination of lactophenol cotton blue preparation revealed flask or fusiform shaped brown conidiophores and ovoid conidia were located either at the end or at the side of the conidiophores [Figure 5]. The causative agent in both the cases was thus diagnosed as Fonsecaea pedrosoi.
Figure 3: PAS stained smear showing sclerotic bodies

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Figure 4: Culture of Fonsecaea pedrosoi on Sabouraud's dextrose slant agar media

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Figure 5: Lactophenol cotton blue appearance of Fonsecaea pedrosoi under microscope

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Both patients were treated with systemic itraconazole 200 mg/day. Liver function tests results before and during treatment were normal. There was great relief of symptoms in the first patient. The second patient was completely cured within 9 months of therapy and repeat biopsy showed complete absence of fungal elements.


  Discussion Top


Chromoblastomycosis is a dermal mycosis caused by a group of (black) fungi and usually characterized by the presence of the verrucous nodular lesions that are mostly located on one of the limbs, [4] like in our cases. The infection usually occurs through inoculation, with the majority of lesions occurring on the feet and legs of persons involved in outdoor activity. One of the affected person was a farmer and the other was a gardener. There are few reported cases of chromoblastomycosis in the states of Assam, Bihar, Uttar Pradesh, and Jammu-Kashmir in the Indian subcontinent. [5]

The initial lesion of chromoblastomycosis is usually solitary and unilateral, presenting as a small, pink, smooth surface papular lesion like that of our second case. This papular lesion slowly increases over time and may have a scaly surface. With time, the initial lesion may evolve into several types of skin lesions like nodular, tumor, plaque, cicatricial, and verrucous types leading to a polymorphic appearance like that of our first case. [6]

Histological, the tissue response in chromoblastomycosis is nonspecific. Usually histopathological examination shows pseudoepitheliomatous type of hyperplasia, hyperkeratosis, intraepidermal abscess containing inflammatory cells, and medlar bodies. [7] Chromoblastomycosis skin lesions must be differentiated from tubercular verrucosa cutis, leprosy, leishmaniasis, mycetoma, and tertiary syphilis. [8] The diagnosis is based on demonstration of sclerotic bodies either in KOH mounts or in tissue section followed by isolation and identification of the causative agents.

The treatment for chromoblastomycosis is cryosurgery in smaller lesions; triazole derivatives and terbinafine for larger ones; and in some cases, a combination of both. [9] Here both the patients responded well with prolonged oral itraconazole therapy.

 
  References Top

1.Hay RJ. Deep fungal infections. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, editors. Fitzpatrick's dermatology in general medicine. 7 th ed. New York: McGraw-Hill; 2008. p. 1833-4.  Back to cited text no. 1
    
2.Lopez Martinez R, Mendez Tovar LJ. Chromoblastomycosis. Clin Dermatol 2007; 25:188-94.  Back to cited text no. 2
    
3.Santos AL, Palmeira VF, Rozental S, Kneipp LF, Nimrichter L, Alviano DS, et al. Biology and pathogenesis of Fonsecaea pedrosoi, the major etiologic agent of chromoblastomycosis. FEMS Microbiol Rev 2007; 31:570-91.  Back to cited text no. 3
    
4.Pradhan SV, Talwar OP, Ghosh A, Swami RM, Shiva Raj KC, Gupta S. Chromoblastomycosis in Nepal: A study of 13 cases. Indian J Dermatol Venereol Leprol 2007;73:176-8.  Back to cited text no. 4
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5.Rajendran C, Ramesh V, Misra RS, Kandhari S, Upreti HB, Datta KK. Chromoblastomycosis in India. Int J Dermatol 1997; 36:29-33.  Back to cited text no. 5
    
6.Revankar SG. Dematiaceous fungi. Mycoses 2007; 50:91-101.  Back to cited text no. 6
    
7.Suh MK, Sung YO, Yoon KS, Ha GY, Kim JR. A case of chromoblastomycosis caused by Fonsecaea pedrosoi. Korean J Dermatol 1996;34:832-6.  Back to cited text no. 7
    
8.Carrion AL. Chromoblastomycosis and related infections: Not understood, differential diagnosis, and nomenclatorial implications. Int J Dermatol 1975;14:27-32.  Back to cited text no. 8
    
9.Ranawaka RR, Amarasinghe N, Hewage D. Chromoblastomycosis combined treatment with pulsed itraconazole therapy and liquid nitrogen cryotherapy. Int J Dermatol 2009;48:397-400.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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