Case Report: Bangladeshi man



Chromoblastomycosis

Definition

• Infection of cutaneous and subcutaneous tissues caused by dematiaceous fungi

• Common agents include:

o Fonsecaea pedrosoi

o Phialophora verrucosa

o Cladosporium carrionii

o Rhinocladiella aquaspersa

• All our saprophytic fungi found in:

o Soil

o Wood

o Vegetation

o Paper

Presentation of the disease

• Lesions form at site of inoculation and grow slow

• Asymptomatic in most cases

• If symptoms are present they include:

o Pruritis

o Pain (rare)

• Lesions usually present months to years before patients seek medical attention for diagnosis

Common Anatomical Sites

• Lower extremities (most common)

o Foot

o Ankle

o Lower leg

o May cause elephantiasis of infected limbs

• Also found on other sites such as:

o Abdomen

o Chest

o Back

o Face

o Mucous membranes (rare)

• Most lesions are localized, but may spread through scratching or lymphatic spread

• Disseminated disease has only been shown in less than 5% of patients

Lesions of Chromoblastomycosis

• Initial lesions are small nodules that eventually form irregular, verrucous plaques.

• Five types of lesions present during progression:

o Nodular- pink scaly growths; enlarge to form tumor

o Tumorous- papillomatous and lobular; resemble cauliflower

o Verrucous- (most common) wart-like appearance

o Plaque – slightly raised; scaly and pink to reddish

o Cicatrical- large and serpiginous; scar found in center of lesion

Complications

• May lead to secondary bacterial infection

• Bacterial infection symptoms:

o Fever

o Pain

o Edema

o Localized lymphadenopathy

Laboratory Aspects

Causative Agent

- Chromoblastomycosis is caused by a few of the species dematiaceous, the most common organism is Fonsecaea Pedrosoi.

- Other agents include: Fonsecaea compacta, Cladophialophora carrionii, Phialophora verrucosa, and Rhinocladiella aquaspersa

- Dematiaceous fungi causing chromoblastomycosis are slow growing and usually need to be incubated

- Most species form dark brown, green, or black velvety colonies upon incubation

Virulence Factors

- Infection occurs through minor breaks in the skin

- Most patients that are infected cannot recall the event in which they were infected

- Person to person spread of chromoblastomycosis has not as of yet been documented

- Diagnosis of chromoblastomycosis is based on results from typical skin lesions and the presence of sclerotic bodies from examination

Epidemiology and Ecology

∙ Found in soil and woody plant material in tropical and subtropical climates

∙ Occurs with traumatic implantation of fungal elements into the skin

∙ Rural areas, most commonly associated with agricultural related activities

∙ Immunocompromised

∙ Immunosuppressed

- received organ transplants

∙ Low incidence in children

- theory that the spores lie dormant in the tissue for many years

∙ Rarely in animals

- unknown if there is transfer from animals to humans

Histopathology

- The lesion shows a chronic inflammatory response. Dematiaceous (darkly pigmented) hyphae and sclerotic (hard or hardening) bodies are found in the outmost layer of the epidermis. These hardening bodies are round, thick-walled,chestnut brown, and 5-12 µm in diameter.

Treatment

∙ Early treatment

- surgical excision – necessary to take unaffected areas too and recurrence is common with this treatment

- electrodessication

- cryosurgery

- topical heat

∙ inexpensive

- anti-fungal treatment

∙ Thiabendazole

∙ 5-flurocytosine

∙ Amphotericin B

∙ Advanced cases- systemic treatment

- Itraconazole

- Terbinafine

Case Report: Bangladeshi man

∙ 70 year old Bangladeshi man

- lived in Britain for 50 years

- referred with a lesion on right forearm

∙ Lesion occurred 40 years prior

- excised and grafted in India

∙ 1993 lesion reoccurred

- no past medical history or regular medication

- examination revealed a hardened plaque with central crusting

∙ Skin scrapings taken

- microscopy was negative

∙ Skin biopsy

- pseudoepitheliomatous hyperplasia and dermal infiltrate with granuloma formation

- higher power showed Langhans giant cells with characteristic sclerotic bodies

- diagnose as chromoblastomycosis

∙ Patient lost for follow-up when he returned to India for holiday

- returned about 6 months later and started Itraconazole

- lost again for follow-up

Case Report: A clinical and mycological study of 71 cases from

Sri Lanka

- Attapattu, Mycopathologia. (1997) 137: 145–151

-Data collected by Mycology Division of the Medical Research Institute

-71 cases of patients with chromoblastoycosis were detected over a 16 year period

-67 of these had thick walled microscopic pheoid muriform cells from superficial crusts or biopsies.

-69 of the patients had positive cultures.

-2 patients were diagnosed via microscopy alone.

-Disease duration last from one month to 25 years,

- 43/71 received medical advice within 5 years, 13/71 patients after 10 years and 3/71 patients waited 20 years.

-Majority of patients came from Ratnapura and were involved in agricultural work or gem mining

- Lesions were seen mostly on lower limbs on 55 out of 77 patients.

-Foot lesions were only on 19 out of 77 patients.

-Lesions were at multiple locations in 5 out of the 77 cases.

-Treatment

-5 fluorocytosine at a dose of 1200 mg a day was distributed to patients infected by F. pedrosoi and results were seen within 3 weeks.

-One male patient, infected by P. verrucosa, was treated with 5 fluorocytosine and local dressing of miconazole nitrate solution. Complete healing occurred after three weeks and he was sent home after 4 weeks. He was lost for a follow up visit.

Case Report

Background

- 70 yr old male agriculturist

- Had a history of painless a verrucous lesion on the middle of his leg

- Experienced this lesion for 1 year after an abrasion from a coconut tree

- Had a skin biopsy and it showed that there was evidence of fungal elements

Diagnosis and Treatment

- Cladophialophora was isolated from the culture that was taken

- Because of this, chromoblastomycosis was diagnosed

- The patient was first treated with itraconazole, however there was no response

- Because there was no response complete surgical resection of the lesion was performed

- Follow-up examination was done after one year and the lesion was absent

Discussion

- Chromoblastomycosis mostly occurs in adult males ages 30-50 yrs old

- Infection is usually present in the leg and feet

- This is a slowly progressing lesion and average time of diagnosis is roughly 1-4 yrs after the injury

- Antifungal treatment is performed first, and if there is no response then surgery is performed

References

Topley and Wilson's Microbiology and Microbial Infections, 10th edition. 2005. Vol 3. Medical Mycology. Hodder, Arnold

 (accessed June 17, 2008 and June 19, 2008)

mycology.adelaide.edu.au (accessed June 17, 2008)

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