Chromoblastomycosis masquerading as implantation dermoid

BR Vani; K Geethamala; V Srinivasa Murthy; M Sudharao

doi:10.4103/2148-7731.138313

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CASE REPORT

Year : 2014 | Volume : 1 | Issue : 3 | Page : 42-44

Chromoblastomycosis masquerading as implantation dermoid

BR Vani, K Geethamala, V Srinivasa Murthy, M Sudharao
Department of Pathology, Employees State Insurance Corporation Medical College and Post Graduate Institute of Medical Science and Research, Bangalore, Karnataka, India

Date of Web Publication

7-Aug-2014

Correspondence Address:
B R Vani
Department of Pathology, Employees State Insurance Corporation Medical College and Post Graduate Institute of Medical Science and Research, Bangalore - 560 010, Karnataka
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2148-7731.138313

Abstract

Chromoblastomycosis (CBM) is a rare chronic fungal infection of skin and subcutaneous tissue caused by dematiaceous fungi. We report herein a case of chromoblastomycosis, which appeared clinically as an implantation dermoid cyst in a 68-year-old male. The study emphasizes the need for clinical suspicion, awareness of the entity, and diligent search for sclerotic bodies in histopathology. Early diagnosis and treatment can prevent untoward complications.

Keywords: Chromoblastomycosis, dematiaceous fungi, mycotic granulomas, sclerotic bodies

How to cite this article:
Vani B R, Geethamala K, Murthy V S, Sudharao M. Chromoblastomycosis masquerading as implantation dermoid. Sifa Med J 2014;1:42-4

How to cite this URL:
Vani B R, Geethamala K, Murthy V S, Sudharao M. Chromoblastomycosis masquerading as implantation dermoid. Sifa Med J [serial online] 2014 [cited 2023 Dec 1];1:42-4. Available from: https://www.imjsu.org/text.asp?2014/1/3/42/138313

Introduction

Chromoblastomycosis (CBM) is a rare chronic fungal infection of skin and subcutaneous tissue caused by dematiaceous fungi. These commonly occur in the age group of 20-40 years. ^[1],[2] Usual clinical presentation is in the form of a verrucous nodule, plaque, or as an ulcer with crusting, chiefly in the extremities. ^[3],[4] Such verrucous lesions are at times mistaken clinically for squamous cell carcinoma. ^[1],[3] We report a case of CBM clinically diagnosed as implantation dermoid cyst in an elderly male.

Case Report

A 68-year-old male, agriculturist by occupation, presented to surgical outpatient department with a swelling on the dorsum of right toe. He had a thorn prick two months ago followed by development of cystic swelling. Clinical diagnosis of implantation dermoid cyst was made. With prior pre-operative investigations, the patient was subjected to excision biopsy of the lesion and specimen sent to pathology department for histopathological examination (HPE).

Grossly, the specimen was a spherical, skin-covered, grey-white, soft tissue measuring 2 cm × 1 cm × 1 cm. Cut surface revealed a thick-walled cystic lesion with brownish rough lining. HPE revealed a cyst in the dermis. The cyst was composed of granulation tissue, with acute and chronic inflammatory cells, histiocytes, and foreign body giant cells. In addition, neutrophilic abscesses and granulomas were also seen. Hence, further deeper sections were taken wherein sparse, brown-colored, acute-angled septate hyphae and sclerotic bodies were seen. Some of which were within the mycotic granulomas and others within giant cells. A final diagnosis of chromoblastomycosis was made.

Discussion

CBM is a slowly progressive fungal infection, first described by Max Rudolf in 1914. ^[2] At least five species have been recognized to be causative agents for CBM; Cladosporium carrionii, Fonsecace compacta, F. pedrosoi, Phialophora verrucosa, and Rhinocladielle aquaspersa.^[1],[3],[5] In 1915, Medlar reported the first case of CBM from Boston and described the pathognomonic globe-shaped 5-12 u-thick-walled sclerotic bodies in tissues and exudates and called them Medlar bodies/chestnut/copper penny bodies or muriform cells. ^[6]

These dematiaceous fungi are found in soil or decaying vegetable matter; hence, the reported cases of infection are more in agriculturists. ^[2],[4],[5] Similarly, our index case was also from agricultural background. Infection occurs by trivial traumatic inoculation, which often goes unnoticed. ^[4] Various reports from different parts of India have documented similar cases. However, as per literature search this is the second case to be reported after Shanthala et al. from southern part of India. ^[4] More than 90% of the cases were seen in males, with the mean age being 41.9 years. ^[1],[2],[7] Shanthala et al., described a similar case in a 72-year-old male. ^[4] In most instances, the lower extremities were affected with either unitary or multiple lesions. ^[1],[3] Unusual cutaneous sites afflicted were the penile shaft, vulva, ala of the nose, and extracutaneous spread was seen in the pleural cavity, ileocecal region, laryngotracheal area, and tonsils. ^[8] In the present case, the patient presented with single lesion on the right toe.

Tissue reaction is similar to other fungi such as pheomycosis, blastomycosis, coccidiomycosis, paracoccidiomycosis, sporothrix with neutrophilic abscess, and granulomas described as mixed mycotic granulomas. ^{[1],[3],[5],[9]} The unique presence of sclerotic bodies and hyphae distinguishes these black yeasts from other dematiaceous fungi-like pheomycosisas in the present case. Sclerotic bodies are adaptive mechanisms which facilitate survival of organisms in host tissue, evading defense mechanisms. Sometimes fungal cells are expelled from skin through epidermal denudation. Hence, these expelled fungi are visible on the surface of the lesion as black dots. ^{[1],[3],[5],[9]} Duration of symptoms varies from 3 months to 13 years. ^[9] Scratching causes satellite lesions and secondary bacterial infections. Long standing lesions may progress to form lymphatic fibrosis and elephantiasis of legs. ^[10] Recurrent lesions are common and they have a potential for subsequent development of squamous cell carcinoma. ^[2] In the present case, the patient presented early [Figure 1], therefore no secondary lesions were seen and it was a clinically unsuspected but histopathologically diagnosed case of CBM [Figure 2].

Figure 1: Hematoxylin and Eosin photomicrograph showing dermal cystic structure lined by fi brous wall and granulomas (10×). Inset showing mycotic granuloma with neutrophilic abscess (40×)

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Figure 2: H&E photomicrograph showing mycotic granuloma with giant cells and pigmented budding and hyphal fungal forms (40×). Inset shows sclerotic body(40×)

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Treatment options available are cryosurgery, excision of solitary lesions, and itraconozole antifungal therapy. ^[2],[4],[11] However, response to the medical line of treatment is poor. Various authors have reported successful treatment with newer azoles. Hence, early intervention enables us to prevent recurrence/relapses and a favorable outcome.

High clinical suspicion, early excision, and diligent search for sclerotic bodies on histopathology are of prime importance to avoid complications. In the present case, surgery with antifungal treatment was curative and patient responded well with no recurrence or relapse since three years of follow up.

Conclusion

CBM is a rare chronic fungal infection of skin and subcutaneous tissue caused by dematiaceousfungi. If left unnoticed or untreated, it may end up with serious untoward complications. This study emphasizes the need for clinical suspicion, awareness of the entity, and diligent search for sclerotic bodies in histopathology, early diagnosis, and treatment.

References

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2.	Pradhan SV, Talwar OP, Ghosh A, Swami RM, Shivaraj KC, Gupta S. Chromoblastomycosis in Nepal: A study of 13 cases. Indian J Dermatol Venereol Leprol 2007;73:176-8. [PUBMED]
3.	Jagdish C. Chromoblastomycosis. In: Textbook of Medical Mycology. 3 ^rd ed. New Delhi: Mehta publishers; 2009. p. 175-86.
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9.	Jayalakshmi P, Looi LM, Soo-Hoo TS. Chromoblastomycosis in Malaysia Mycopathologia 1990;109:27-31.
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11.	Poirriez J, Breuillard F, Francois N, Fruit J, Sendid B, Gross S, et al. A case of chromomycosis treated by a combination of cryotherapy, shaving, oral 5-fluorocytosine and oral amphotericin. Am J Trop Med Hyg 2000;63:61-63.