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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 3  |  Page : 59-61

Cutaneous chromoblastomycosis: A case report from central India


1 Department of Microbiology, Sri Aurobindo Institute of Medical Sciences, Medical College and Post Graduate Institute, Indore, Madhya Pradesh, India
2 Department of Pathology, Sri Aurobindo Institute of Medical Sciences, Medical College and Post Graduate Institute, Indore, Madhya Pradesh, India
3 Department of Pediatrics, Gagrani Hospital, Dewas, Madhya Pradesh, India

Date of Web Publication8-Oct-2015

Correspondence Address:
Trupti Bajpai
Department of Microbiology, Sri Aurobindo Institute of Medical Sciences Medical College and Post Graduate Institute, MR-10 Crossing, Indore-Ujjain Road, Indore - 453 555, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2148-7731.166861

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  Abstract 

A case of 36-year-old male patient with multiple papular lesions on the lateral aspect of the lower part of his left forelimb was confirmed mycologically and histopathologically, as a case of chromoblastomycosis. The etiological isolate was identified as Fonsecaea pedrosoi and was successfully managed.

Keywords: Chromoblastomycosis, dematiceous fungi, Fonsecaea pedrosoi


How to cite this article:
Bajpai T, Nandedkar S, Bhatambare G, Gagrani N. Cutaneous chromoblastomycosis: A case report from central India. Sifa Med J 2015;2:59-61

How to cite this URL:
Bajpai T, Nandedkar S, Bhatambare G, Gagrani N. Cutaneous chromoblastomycosis: A case report from central India. Sifa Med J [serial online] 2015 [cited 2019 Sep 18];2:59-61. Available from: http://www.imjsu.org/text.asp?2015/2/3/59/166861


  Introduction Top


Chromoblastomycosis is a chronic, noncontagious, localized fungal infection of cutaneous and subcutaneous tissues. [1] The disease is known to occur on the lower extremities of limbs and rarely on the face and other sites on the body. It is especially common among bare-footed farm workers following traumatic implantation of dematiceous fungi. [2] Clinically, it presents as nodules, indurated papules, or rarely psoriasiform plaques. [3],[4] Diagnosis is made by direct microscopic demonstration of pathognomic, brown sclerotic bodies (also called as medular bodies, muriform cells, copper-pennies) [5] in biopsy specimen and positive fungal culture for confirmation. [1] The present report deals with a unique case of cutaneous chromoblastomycosis from the central India.


  Case Report Top


A 36-year-old, otherwise healthy male visited the skin outpatient department (OPD) of our teaching tertiary care hospital. Clinically, he presented with the complaints of slowly spreading, small, papular, hyperpigmented, brown-to-skin colored, itchy, nodular, warty lesions of about 6 months duration. Dermatological examination revealed 1 × 1 cm sized, irregular, indurated, serpiginous, erythematous plaques located on the lateral aspect of the lower part of his left forelimb. He was following home remedies until he reached our hospital OPD for treatment.

His physical and systemic examination did not show any abnormality and there was no history of trauma or thorn prick. Hematological and biochemical parameters were within normal limits. Radiological examination did not reveal any bone involvement.

Laboratory Diagnosis

The patient's skin biopsy sample was subjected to histopathological and microbiological investigations. Histopathological examination showed evidence of hyperkeratosis, acanthosis, and pseudoepitheliomatous hyperplasia. The reticular dermis showed moderate microabscess and a granulomatous inflammatory cell infiltrate [Figure 1] with giant cells containing several rounded, brownish (copper-colored), thick-walled fungal spores [Figure 2]. No mycelial elements were seen. On this ground, the diagnosis of chromoblastomycosis was given with the recommendation of fungal culture. Fine-needle aspiration material from the lesion was subjected to culture on Sabauraud's dextrose agar (SDA; HiMedia, Mumbai) with chloramphenicol (50 mg/ml). Incubation at room temperature revealed small, olivaceous-black colonies that appeared after 19 days of incubation. The colonies became heaped up, folded, velvety-black upon further incubation. The reverse of the slant was jet black in color. [1] Wet preparation of the growth revealed small, rounded, thick-walled, brownish septate bodies arranged in small clusters [Figure 3]. Lactophenol cotton blue (LPCB) examination of the growth revealed septate, branching hyphae with phialophora type of sporulation [5] [Figure 4]. The individual conidia were smooth-walled, single-celled, broadly clavate structures. Isolation of Fonsecaea pedrosoi on SDA was confirmed.
Figure 1: H and E stained (×40) image showing microabscess and a granulomatous inflammatory cell infiltrate with giant cells. H and E = Hematoxylin and eosin


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Figure 2: H and E stained (×400) image showing copper pennies


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Figure 3: Dematiceous fungi (×40) in wet preparation


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Figure 4: LPCB preparation showing phialophora type of sporulation. LPCB = Lactophenol cotton blue


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Demonstration of these fungal bodies (known as sclerotic bodies) by histopathological and microbiological investigation is pathognomic of chromoblastomycosis. The patient responded well to the oral itraconazole (400 mg/day) and terbinafine (500 mg/day) combination therapy for 2 months. Pulse therapy of 200 mg itraconazole (twice daily for 1 week/month) was continued for rest of the year with an advice of regular follow-up. [2],[4],[6],[7] The patient slowly recovered from the symptoms of the disease.

The manuscript has been approved by the institutional ethical committee.


  Discussion Top


Chromoblastomycosis is commonly caused by dematiaceous fungi like Fonsecaea pedrosoi, Fonsecaea compacta, Phialophora verrucosa, and Cladophialophora carrionii, and occasionally by Exophiala spinifera and Wangiella dermatitidis.[2],[4],[5],[7] It has been reported from several tropical and subtropical areas of the world, [2],[4] including India. [3],[7] However, reports from central India are relatively sparse. [8] We have reported a case of cutaneous chromoblastomycosis caused due to a mold, Fonsecaea pedrosoi, that has been documented as the most common cause of chromoblastomycosis. [1],[3],[5]

Cutaneous chromoblastomycosis is a localized infection of skin and subcutaneous tissues (rarely involve underlying bone) that clinically appear in the form of nodules, plaque-like, verruccous, cicartricial or tumorous growth. Ours was a case of cutaneous chromoblastomycosis of about 6 months' duration, hence it exhibited only papules instead of more severe forms as shown in the long duration cases presented by few authors previously. [4],[6],[8]

Usually, the disease process remains localized to one lower extremity, [6],[8] and it was lower part of forelimb in our case; more common in middle-aged males (30-50 years) residing in rural areas [2],[3],[4],[6],[8] and our patient was a 36-year-old male residing in city. However, there are studies that have reported involvement of sites other than arms and foot, [2],[3] and have been reported rarely in females [3],[4] and in persons of extreme ages, that is, children and elderly. [4],[7]

Infection usually follows traumatic implantation of the etiological agent via minor wounds or penetration of foreign bodies such as wood splinters and is common among agricultural workers. [6],[7],[8] In our case, the patient was an industrial worker and could not provide any history of trauma or wood stick injury. The patient was well-educated and was more of a health conscious and presented to the hospital OPD with not very old history of lesions. Hence, his case could be handled appropriately by dermatologist, pathologists, and microbiologists without delay. Chromoblastomycosis must be differentiated from other conditions such as blastomycocis, leprosy, mycetoma, cutaneous tuberculosis, tertiary syphilis, malignancy, dermal leshmaniasis, sporotrichosis, paracoccidiomycosis, lobomycosis, protothecosis, phaeohyphomycosis, varrucosa cutis, and varrucosa vulgaris. In our case, since the condition was correctly diagnosed; hence, there was no chance of unnecessary prescriptions with treatment options. Since there are no serological tests available for diagnosis of chromoblastomycosis mycological; histopathological investigations are essential to confirm the diagnosis of the disease. Microscopy and culture provides highly sensitive means of diagnosis that are both simple and inexpensive. Culture is found to be positive in 72% of the cases studied, while sclerotic bodies have been observed in 84% of the cases reported by various authors from different regions. [8] In our case, both the investigations were found to be positive.

Chromoblastomycosis spreads very slowly, is rarely fatal, and usually have good prognosis; but is a therapeutic challenge. There are several treatment options including medication, cryotherapy, and surgery. In our case, medication alone that was initially prescribed for 2 months and the pulse therapy that was extended for 1 year was able to manage the patient's condition. Pulse regimen is more economical with better compliance than the conventional continuous regimen, although optimum treatment duration depends on individual cases. This may be because the case was of short duration and diagnosed immediately. [2],[3],[4],[6],[7],[8]

Our case is unique because so far almost negligible reports on chromoblastomycosis due to Fonsecaea pedrosoi have been documented from our region including central India. Secondly, our patient was an industrial worker and had no history of trauma or wood stick injury prior to onset of infection. Thirdly, a high clinical suspicion by the dermatologist and collaborative efforts by pathologists and microbiologists resulted into excellent diagnosis.

In conclusion, instead of initiating a long-term treatment with antitubercular drugs, physician should consider chromoblastomycosis in the differential diagnosis of long standing skin lesions in patients from tropical and subtropical areas. Our report emphasizes the need for awareness about this disease and excellent coordination among clinician, pathologist, and a microbiologist.


  Acknowledgement Top


The authors wish to thank the management, technical and clinical staff of Sri Aurobindo Institute of Medical Sciences, Medical College and Post Graduate Institute, Indore for their kind support.

 
  References Top

1.
Sharma MM, Mishra RN, Nageshwari RG, Jadhav SV, Gupta N. Chromoblastomycosis of the face: A rare case report from the district of western Maharashtra, India. J Clin Diagnostic Res 2012;6:899-901.  Back to cited text no. 1
    
2.
Fatemi MJ, Bateni H. Oral chromoblastomycosis: A case report. Iran J Microbiol 2012;4:40-3.  Back to cited text no. 2
    
3.
Panicker NK, Chandanwale SS, Sharma YK, Chaudhari US, Mehta GV. Chromoblastomycosis: Report of two cases on face from urban industrial area. Indian Dermatol Online J 2013;4:371-3.  Back to cited text no. 3
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4.
Khan I, Khan AR, Khan MS. Clinicopathological study of cutaneous chromoblastomycosis in Pakistan. J Pak Assoc Dermatol 2012;22:122-5.  Back to cited text no. 4
    
5.
Chander J. In: Textbook of Medical Mycology. 2 nd ed. Ch. 13. Chromoblastomycosis. New Delhi: Mehta publishers; 2002. p. 144-6.  Back to cited text no. 5
    
6.
Ramraje SN, Gokhale J, Gupta S. Cutaneous chromoblastomycosis. J Case Rep 2013.  Back to cited text no. 6
    
7.
Pradeepkumar NS, Joseph NM. Chromoblastomycosis caused by Cladophialophora carrionii in a child from India. J Infect Dev Ctries 2011;5:556-60.  Back to cited text no. 7
    
8.
Shah H, Verma K, Dhand PL, Soni R, Shakya P. Chromoblastomycosis. Natl J Integret Res Med 2011;2:57-9.  Back to cited text no. 8
    


    Figures

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



 

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