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Treatment of chromoblastomycosis is frequently difficult and unsatisfactory. A representative case is presented of this chronic subcutaneous fungal infection, characterized by warty, cauliflower-like lesions usually on the extremities. Chromoblastomycosis and its treatment are reviewed, with attention to itraconazole, a new triazole compound, as the possible drug of choice.
Exophiala spinifera is reported as a newly recognized agent of chromoblastomycosis. This case demonstrates that infections caused by dematiaceous fungi may be variable and that a single fungus may cause more than one type of infection. Chromoblastomycosis and phaeohyphomycosis represent extremes of a continuum of infections.
BACKGROUND: Chromoblastomycosis is reported for the first time from the states of Jammu-Kashmir and Bihar along with two additional cases from the states of Assam and Uttar Pradesh. The work carried cut on this disease in the Indian subcontinent is reviewed. METHODS: Relevant mycologic investigations, including direct microscopy, histopathology, and culture, were carried out to study the four cases. Treatment was given to two patients. RESULTS: The duration of the lesions varied from 5 to 32 years. In one case the lesion was a large erythematous plaque on the buttocks extending to the backs of the thighs, and in the others they were hypertrophic lesions on the extremities. Histopathologic study of specimens carried out in three patients revealed the causative organisms. On culture, Cladosporium carrionii was isolated in one and Fonsecaea species in the other three. The lesions in one patient were surgically excised and another patient responded well to a combined regimen of amphotericin B and 5-fluorocytosine. CONCLUSIONS: Although chromoblastomycosis is widely distributed in India, many patients remain undiagnosed due to a lack of proper facilities. Treatment is difficult and most patients are not able to afford the drugs prescribed for this condition.
BACKGROUND: Chromoblastomycosis is a subcutaneous mycosis, seen frequently in tropical areas, and caused by dematiaceous fungi. It produces nodulo-verrucous lesions in the arms and legs. There is no treatment of choice for this disease and sometimes a combination of chemotherapy and physical therapy is necessary. METHODS: The study included 12 patients diagnosed with chromoblastomycosis by means of fungal and histopathologic tests. The patients were assigned to three treatment groups: patients with small lesions, not greater than 15 cm2 in area, were assigned to Group 1, in which the treatment consisted of itraconazole 300 mg/day, or to Group 2, in which the treatment consisted of one or more sessions of open-spray cryosurgery. Patients with large lesions were assigned to Group 3 and started treatment with itraconazole 300 mg/day, until a maximal reduction of lesions occurred, and then underwent one or several cryosurgery sessions. Clinical, fungal, and laboratory tests were performed in each group before, during, and at the completion of treatment. RESULTS: Positive cultures of Fonsecaea pedrosoi were obtained in 11 out of 12 patients. Two out of four patients in Groups 1 and 3 had a clinical and fungal cure and the remaining patients experienced significant improvement. All four patients included in Group 2 achieved a cure. No important side-effects were seen among the patients included in any of the two itraconazole groups, and only two out of eight patients reported gastric discomfort. The cryosurgery group reported only normal complications of the process, such as edema and pain; two out of eight patients had a superimposed infection. CONCLUSIONS: The results of itraconazole and cryosurgery were good in cases with small lesions; antifungal therapy being more appropriate for flexion areas. The combination of itraconazole, to reduce the size of the lesions, with subsequent treatment of the remaining lesions with cryosurgery, represents a new alternative in the treatment of patients with large lesions. Both types of therapy are considered safe, with few side-effects.
Chromoblastomycosis, a localized chronic cutaneous and subcutaneous infection of the skin caused by pigmented fungi, is most common in the world's tropical and subtropical zones. The condition rarely occurs in Australia. We present 6 cases of chromoblastomycosis seen at the Royal Darwin Hospital, Northern Territory, from 1989 to 1994 and affecting predominantly male Caucasians ranging from 38 to 71 yrs of age. Clinically the lesions were verrucous or nodular. They mimicked basal or squamous cell carcinoma, nevi or solar keratoses. Histopathologic findings were nonspecific. The only pathognomonic finding was the presence of brown spores or sclerotic bodies within granulomata or within microabscesses in the skin.
A case of neoplastic transformation of lesions of chromoblastomycosis is reported in a 67-year-old farmer from French Guyana. An interesting aspect of this case was the appearance of new cutaneous lesions of chromoblastomycosis, in a different site from the original lesion, and the presence of an infected synovial cyst. The potential therapeutic role of itraconazole is discussed.
Ajoene and 5-fluorouracil (5-FU) are compounds that have shown in-vitro activity against Cladophialophora carrionii, an important etiologic agent of chromoblastomycosis. An open comparative trial was conducted to assess safety and effectiveness of topical ajoene and 5-FU in the treatment of localized chromoblastomycosis. Thirty-seven patients with a clinically and mycologically confirmed diagnosis were randomly distributed into two groups allocated to ajoene (0.5% gel; n = 19) or 5-FU (1% cream; n = 18). Topical treatment was applied to localized lesions (< or = 2.5-cm diameter) once a day, with occlusion, for 12-16 weeks. Complete clinical and mycological remission was achieved in 14/19 patients (74%) treated with ajoene and 14/18 patients (78%) treated with 5-FU. All 5-FU-treated patients developed a post-treatment scar at the site of the lesion, while ajoene-treated patients showed only a slight depigmentation of the skin. The differences observed in cure rate between ajoene and 5-FU are not statistically significant. Follow-up of all patients for 4 years revealed no relapses in the ajoene-treated group, while one patient in the 5-FU-treated group had a relapse 6 months after the end of therapy. This trial represents the first clinical use of ajoene in the control of a deep mycosis.
PURPOSE OF REVIEW: Significant advances in knowledge of chromoblastomycosis and its etiologic agents have been made in the past 5 years. New explanations and approaches that could resolve persisting medical challenges for this orphan disease are reviewed here. RECENT FINDINGS: In recent years advances have been made regarding the taxonomy and ecoepidemiology of the etiologic agents, basic knowledge of the pathogenesis of the lesions, especially the fibrotic process, and the immunologic response to chromoblastomycosis. Conversely there have been no recent significant advances in knowledge of the genetic polymorphism of the wild isolates or in development of experimental models, impairing the possibility of in-depth clinicopathologic investigations. As a result medical management is dependent on the development of diagnostic and therapeutic tools developed for other fungal diseases. SUMMARY: Recent findings are applicable in laboratory and medical practice. Benefits can accrue to basic knowledge from data collected on other cutaneous diseases of parasitic or bacterial origin.
Chromoblastomycosis is a rare, chronic, cutaneous infection caused by a group of dematiacaeous fungi. We report a case which, in addition to characteristic clinical and histopathological features of chromoblastomycosis, displayed atypical, deep dermal/subcutaneous involvement, and showed a good response to itraconazole.
Chromoblastomycosis is a cutaneous and subcutaneous mycotic disease caused by the dematiaceous (black) fungi. Five species of fungi are known generally to be the cause: Fonsecaea pedrosoi, Phialophora verrucosa, Cladosporium carrionii, F. compacta and Rhinocladiella cerphilum. In infected tissue they can appear as pigmented sclerotic bodies, commonly called 'copper pennies', which are pathognomonic of chromoblastomycosis. The infection usually occurs through traumatic skin inoculation, with the majority of lesions occurring on the feet and legs of outdoor workers. We report a patient in whom the lesions had begun on the right breast, which is an unexposed area, without a history of trauma. A uniform, reliable treatment does not exist but our patient was mycologically cured with the use of amphotericin B and the subsequent combination of 5-flucytosine and itraconazole.
Chromoblastomycosis is characterized by the slow development of polymorphic skin lesions (nodules, verrucas, tumores, plaques and scar tissue). Inside the host, infectious propagules adhere to epithelial cells and differentiate into sclerotic forms, which effectively resist destruction by host effector cells and allow onset of chronic disease. A cellular immune response against fungi is essential to control infection. Amongst the cells of the immune system, macrophages play the most important role in controlling fungal growth. In this study, we show that the fungicidal characteristic of macrophages is dependent on the fungal species that causes chromoblastomycosis. We began by observing that the phagocytic index was higher for Fonsecaea pedrosoi and Rhinocladiella aquaspersa compared with that of other fungi. Complement-mediated phagocytosis was more important for Phialophora verrucosa and R. aquaspersa and was inhibited by mannan when F. pedrosoi and R. aquaspersa conidia were phagocytosed by macrophages. We showed that macrophages killed significantly only R. aquaspersa. We also found that the phagocytosis of fungi has functional consequences for macrophages as phagocytosis resulted in down-modulation of MHC-II and CD80 expression as well as in the inhibition of the basal liberation of NO. However, the inhibition of the basal liberation of NO nor the down-modulation of MHC and co-stimulatory molecules were observed in the presence of R. aquaspersa.
Previous studies carried out in an endemic semiarid region northwest of Venezuela at Falcon State have shown a prevalence of 15.4/1000 of chromoblastomycosis following traumatisms with xenophile vegetation infected with Cladophialophora carrionii. We performed high-resolution DNA typing of human leukocyte antigen (HLA)-A, -B and -C and major histocompatibility complex class I chain related gene A (MICA) alleles and segregation analysis in 49 members of one extended family with 12 affected individuals, who have lived for approximately 70 years in this endemic zone. None of the alleles, haplotypes or genotypes is shared by all the patients. No deviation from the expected HLA haplotype distribution or association of chromoblastomycosis with HLA-A, -B and -C haplotypes was observed. Further, a haplotype-sharing transmission/disequilibria testing of 11 nuclear families did not give enough evidence to claim linkage (P = 0.398), suggesting that genes located in the short arm of chromosome 6 may not be relevant in the immune response toward infection with C. carrionii in this Venezuelan endemic zone. Deleted MICA alleles on HLA-B*4802 haplotypes were present among several members of the extended family, but only two of them were affected.
Chromoblastomycosis is a rare, deep mycosis seen mostly in tropical and subtropical regions. We have encountered a kidney transplant recipient with this subcutaneous mycosis developing as an asymptomatic mass in the right forearm. The lesion recurred after an initial local excision, but it is now apparently cured 10 months after wide surgical excision. The patient had previously been a shepherd. A 29-year-old kidney transplant recipient developed a rare deep chromoblastomycosis infection and was cured by aggressive diagnosis and surgical treatment.
It is presented a case of auricular chromoblastomycosis mimicking an eczematous lesions. The authors refer the rarity of this localization. All reported cases of auricular chromoblastomycosis have been caused by Fonsecaea pedrosoi but in the present case the etiologic agent was Phialophora verrucosa.
Antigenic preparations (saline, methylic, metabolic and exoantigens) of four agents of chromoblastomycosis, Fonsecaea pedrosoi, Phialophora verrucosa, Cladophialophora (Cladosporium) carrionii and Rhinocladiella aquaspersa were obtained. Partial chemical characterization of these antigenic preparations was obtained by determination of the levels of total lipids, protein, and carbohydrates, and identification of the main sterols and carbohydrates. Methylic antigens presented the highest lipid contents, whereas metabolic antigens showed the highest carbohydrate content. Total lipid, protein, and carbohydrate levels were in the range of 2.33 to 2.00 mg/ml, 0.04 to 0.02 mg/ml and 0.10 to 0.02 mg/ml, respectively, in the methylic antigens and in the range of 0. 53 to 0.18 mg/ml, 0.44 to 0.26 mg/ml, and 1.82 to 1.02 mg/ml, respectively, in saline antigens. Total lipid, protein, and carbohydrate contents were in the range of 0.55 to 0.20 mg/ml, 0.69 to 0.57 mg/ml and 10.73 to 5.93 mg/ml, respectively, in the metabolic antigens, and in the range of 0.55 to 0.15 mg/ml, 0.62 to 0.20 mg/ml and 3.55 to 0.42 mg/ml, respectively, in the exoantigens. Phospholipids were not detected in the preparations. Saline and metabolic antigens and exoantigens presented hexose and the methylic antigen revealed additional pentose units in their composition. The UV light absorption spectra of the sterols revealed squalene and an ergosterol fraction in the antigens. The characterization of these antigenic preparations may be useful for serological evaluation of patients of chromoblastomycosis.
Cerebral phaeohyphomycosis ("chromoblastomycosis") is a rare intracranial lesion. We report the first human culture-proven case of brain abscesses due to Fonsecaea pedrosoi in Brazil. The patient, a 28 year-old immunocompetent white male, had ocular manifestations and a hypertensive intracranial syndrome. Magnetic resonance imaging (MRI) of the brain revealed a main tumoral mass involving the right temporo-occipital area and another smaller apparently healed lesion at the left occipital lobe. A cerebral biopsy was performed and the pathological report was cerebral chromoblastomycosis. The main lesion was enucleated surgically and culture of the necrotic and suppurative mass grew a fungus identified as Fonsecaea pedrosoi. The patient had received a knife wound sixteen years prior to his hospitalization and, more recently, manifested a pulmonary granulomatous lesion in the right lung with a single non-pigmented form of a fungus present. It was speculated that the fungus might have gained entrance to the host through the skin lesion, although a primary respiratory lesion was not excluded. The patient was discharged from the hospital still with ocular manifestations and on antimycotic therapy and was followed for eight months without disease recurrence. Few months after he had complications of the previous neuro-surgery and died. A complete autopsy was performed and no residual fungal disease was found.
Thirty cases of chromoblastomycosis were diagnosed at Hospital dos Servidores do Estado do Maranhão, from November, 1988 to March, 1993. The authors report 2 (6.6%) cases, that presented an association with leprosy. The first patient developed both diseases together, showing palpable bilateral cubital nerves, perforanting ulcer of the right foot, infiltration and lesions in verrucoid plaques in left leg, with positive biopsy for dimorphic leprosy. The second case, a patient with history of lepromatous leprosy for 30 years without treatment, with vegetant lesions with a warty aspect in right elbow for 12 months, histopathologic and positive culture for chromoblastomycosis. The possible factors for development of this disease in these patients are discussed.
During a survey of 30 patients with chromoblastomycosis followed at the Hospital dos Servidores do Estado do Maranhão, the authors observed in 2 (6.6%) patients with lesions on the buttock. This is an uncommon site for the initial lesions of chromoblastomycosis. There is often a history of microtraumatism during the farming job hence the more frequent development of lesions in the lower limbs. Both patients had 10 years disease, with the presence of nodules and vegetant warty lesions in coalescent plaques on the right buttock. Etiologic diagnosis made through histopatologic and culture exams, with Fonsecaea pedrosoi isolated. The epidemiological exposure of the patients, was suggested by the fact that both worked as babaçu coconut cutters a common activity in Maranhão State. The relation between this kind of professional activity and the development of infection merits for the investigation.