Chromoblastomycosis

SK Sayal, GK Prasad, KZ Jawed, S Sanghi, S Satyanarayana

 Department of Dermatology and Department of Pathology, Base Hospital, Delhi Cantt-10, India

Correspondence Address:
S K Sayal
Department of Dermatology, Base Hospital, Delhi Cantt-10
India

Introduction

Chromoblastomycosis is primarily a disease of tropical or subtropical regions, mainly in persons working outdoors in agricultural occupations, thus reported most commonly in men.

The characteristic lesion is the warty papule or plaque eventually leaving a fibrotic scar. The disease spreads in the adjacent skin with characteristic satellite lesions surrounding the primary source. Metastatic spread to other organs is reported but clearly represents a decided minority of cases.[2]

The treatment modalities are divided into three groups: surgery, physical modalities and systemic antifungal medications.

We report here an uncommon case of chromoblastomycosis with a favourable response to intraconazole.

Case Report

A 62-year-old man presented with multiple cauliflower-like growths over left foot and ankle of 12 years duration. He first developed a small warty growth over the instep following a thron prick injury. Subsequently, satellite lesions continued to appear gradually attaining the present size.

Clinically, there were multiple dry, polysize papillomatous plaques and tumours over left foot and ankle with clustering at most of the places. Intervening skin was oedematous with maceration and foul smelling discharge at places. Systemic examination was essentially normal.

Routine haematological and biochemical parameters and X-ray chest were normal. VDRL and ELISA for HIV 1 and 2 were negative. Direct KOH mount for fungus was negative. Histopathological sections of the skin revealed marked accanthosis, paillomatosis and parakeratosis. Dermis showed inflammatory infiltrate of neutrophils, histiocytes and foregin body gaint cells. Thick walled brownish spores, some with pseudoseptate arrangement were seen singly And in clusters of 23 [Figure - 1].

H e was diagnosed as a case of Chromoblastomycosis clinically and later confirmed histologically. He was treated with tab itraconazole 200 mg daily for six months with significant improvement and is on follow up.

Discussion

Carrion described five types of lesions in a case of chromoblastomycosis-nodules, tumours, plaques, warty lesions, and scarring lesions.[3] The primary lesion is a pink scaly papule that expands to form a superficial nodule. Coalescence of the lesions results in the formation of raised purplish irregular plaques. All these types of lesions were seen in our case.

The diagnosis is based on KOH examination, identification of organism in histological sections, culture of the organism that reveals slow growing green to black colonies, and, microscopic appearance of the conidia formation identifies species.

Till the advent of the present generation triazole antifungal agents, reliable medical therapy was not available and, radical, often mutilating surgery was considered the optimal approach. More recent experience has shown itraconazole to be an effective agent and some authors consider it the treatment of choice.[4],[5] Clinical and biologic cure has been reported in mild to moderate disease after a mean duration of therapy of 7.2 months with itraconazole alone.[6] Our patient responded well to itraconazole in six months, with discharge having dried up and a marked reduction in the size of lesions. Some authors have combined other modes of therapy, including cryosurgery[7] to treat larger lesions. However, the extent of lesions in our case may necessitate surgical intervention also at a later date.

1.	Benenson A. Control of Communicable Diseases in Man, ed 14, American Public Health Association, Washington, D.C., 1985, pp 79-80. [Google Scholar]
2.	Carrion A. Chromoblastomycosis and related infections: New concepts, differential diagnosis, and nomenclatorial implications. Int J Dermatol 1975;14:27-32. [Google Scholar]
3.	Carrion A. Chromoblastomycosis. Ann NYAcad Sci 1950;50:1255-1282. [Google Scholar]
4.	Tuffanelle I, Milihwen P. Treatment of Chromoblastomycosis. J Am Acad Dermotol 1990;23:728. [Google Scholar]
5.	Smith C, BarkerJ, Hay R. Acase of Chromoblastomycosis responding to treatment with itraconazole. Br J Dermatol 1993;128:436-439. [Google Scholar]
6.	Queiroz-Telles F, Purim KS, Fillus JN, et al. Itraconazole in the treatment of Chromoblastomycosis due to Fonsecaea pedrosoi. Int J Dermatol 1992;31:805-812. [Google Scholar]
7.	Bonifaz A, Martinez-Soto E, carrasco-Gerard E, et al. Treatment of Chromoblastomycosis with itraconazole, cryosurgery, and a combination of both. Int Dermatol 1997;36:542-547. [Google Scholar]