Cromoblastomicosis: abordaje con terapia combinada / Chromoblastomycosis: a combination therapy approach

La cromoblastomicosis es una micosis de implantación crónica y progresiva causada por diversos hongos de la familia Dematiaceae. En Latinoamérica, las especies en-contradas con más frecuencia son Fonsecaea pedrosoi y Cladophialophora carrionii. El tratamiento de esta micosis puede ser un desafío por la falta de respuesta y la recidiva, en especial en individuos con lesiones crónicas y extensas.Se presenta un individuo con recaída de cromoblastomico-sis (causada por Fonsecaea pedrosoi) en miembro inferior derecho que había realizado tratamiento incompleto con terbinafina e itraconazol. El paciente respondió de mane-ra favorable al retratamiento con itraconazol y terbinafina combinado con resección quirúrgica parcial de la lesión e injerto de piel en sitio quirúrgico

Chromoblastomycosis is a chronic and subcutaneous mycosis caused by various dematiaceous fungi, In Latin America, the most frequently found species are Fonsecaea pedrosoi and Cladophialophora carrionii.Treatment is a challenge because of the lack of response and recurrence in in some cases, especially in patients with extensive and chronic lesions.We report an individual with relapse of chromoblastomycosis (by Fonsecaea pedrosoi) in the right lower limb, who had undergone incomplete treatment with terbinafine and itraconazole. The patient responded favorably to retreatment with itraconazole and terbinafine combined with partial surgical resection of the lesion and skin grafting at the surgical site.

Cromoblastomicosis verrugosa-cicatricial multifocal: una entidad desatendida en Colombia / Multifocal verrucous-cicatricial chromoblastomycosis: a neglected disease in Colombia

La cromoblastomicosis es una micosis subcutánea crónica de presentación clínica heterogénea que afecta principalmente a poblaciones de escasos recursos, lo que sumado al acceso limitado a los servicios de salud condiciona el retraso en el diagnóstico y tratamiento, ocasionando secuelas físicas graves. Se describe el caso de un hombre de 50 años con lesiones cutáneas verrugosas y cicatriciales de 30 años de evolución en la extremidad inferior y mano izquierda, además en cara en los últimos cinco años. Se realizó el diagnóstico de cromoblastomicosis de presentación multifocal y clínica mixta, con examen directo e histopatología compatibles, y cultivo para hongos positivo para Fonsecaea pedrosoi. Se indicó tratamiento oral con itraconazol y seguimiento clínico. Reconocer esta entidad es crucial para un diagnóstico y tratamiento oportunos, con el fin de evitar secuelas físicas y estigmatización secundaria. Se debe fortalecer en la atención primaria el reconocimiento de patologías desatendidas y de incidencia subestimada en Colombia, con una presentación multifocal mixta atípica y de un tiempo de evolución prolongado. El examen directo KOH es un herramienta accesible y económica en los primeros niveles de atención que puede contribuir al enfoque diagnóstico.

Chromoblastomycosis is a chronic subcutaneous mycosis with heterogeneous clinical presentation. It mainly affects low-income populations, which added to limited access to health services delays diagnosis and treatment, causing serious physical sequelae. We describe the case of a 50-year-old man with warty and cicatricial skin lesions of 30 years of evolution, at the level of left lower limb and left hand, with face involvement in the last five years. A diagnosis of chromoblastomycosis with multifocal and mixed clinical presentation was made, based on compatible direct examination and histopathology, and positive fungal culture for Fonsecaea pedrosoi. Oral treatment with itraconazole and clinical followup were stablished. Recognizing this entity is crucial for timely diagnosis and treatment, to avoid physical sequelae and secondary stigmatization. Primary health care should be strengthened for the recognition of neglected diseases whose incidence is underestimated in Colombia, with an atypical mixed multifocal presentation and a long evolution time. The KOH direct examination is an accessible and economical tool in the first levels of care that can contribute to the diagnostic approach.

Esporotricosis y cromoblastomicosis en San Ramón de Costa Rica / Sporotrichosis and chromoblastomycosis in San Ramón of Costa Rica

Objetivo: Reportar las características que mostraron la esporotricosis y cromoblastomicosis en el cantón de San Ramón (Costa Rica) para su análisis epidemiológico. Métodos: Se describe una serie de casos basada en la revisión de expedientes clínicos de pacientes diagnosticados con esporotricosis y cromoblastomicosis desde el año 1997 al 2020 en el servicio de Dermatología del Hospital Carlos Luis Valverde Vega del cantón de San Ramón. Resultados: 4 esporotricosis y 6 cromoblastomicosis predominaron en agricultores de edad avanzada. Se identificó en igual número la variante fija y la linfangítica de esporotricosis; en la cromoblastomicosis predominó la variante verrugosa de la enfermedad. Conclusión: La presente serie de casos es el primer informe realizado en torno a estas patologías en el cantón de San Ramón, por lo que no se cuenta con datos estadísticos previos. Los cambios demográficos, económicos y socioculturales de las últimas décadas podrían influir en los patrones epidemiológicos de estas entidades en la región.

Aim: To report the characteristics that sporotrichosis and chromoblastomycosis showed in San Ramón canton (Costa Rica) for its epidemiological analysis. Methods: A series of cases is described based on the review of clinical records of patients diagnosed with sporotrichosis and chromoblastomycosis in the Dermatology service of the Carlos Luis Valverde Vega Hospital located in San Ramón canton from 1997 to 2020. Results: 4 sporotrichosis and 7 chromoblastomycosis predominated in elderly farmers. The fixed and lymphangitic variants of sporotrichosis were identified in equal numbers, in chromoblastomycosis the warty variant of the disease predominated. Conclusion: This series of cases is the first report on these pathologies in the canton of San Ramón. Therefore, no previous statistical data is available. The demographic, economic and sociocultural changes of the last decades could influence on the epidemiological patterns of these entities in the region.

Cromoblastomicosis: primer caso alóctono tratado en Chile / Chromoblastomycosis: first allochthonous case treated in Chile

Resumen La cromoblastomicosis es una infección fúngica de la piel y del tejido subcutáneo, de evolución crónica, causada por hongos dematiáceos que se caracterizan por presentar melanina en su pared celular. La enfermedad se presenta en todo el mundo, principalmente en regiones tropicales y subtropicales. En Chile, solo hay un reporte de caso humano hace más de 30 años. Se presenta el caso de un varón de 46 años, haitiano, residente en Chile, con placas verrucosas en la zona tibial anterior de un año de evolución. El diagnóstico de cromoblastomicosis se confirmó al observar células muriformes en la histopatología y colonias dematiáceas en el cultivo micológico; además, en la miscroscopía directa se observaron conidias compatibles con Fonsecaea spp. Luego de seis meses de tratamiento con antimicóticos sistémicos y crioterapia, se logró la remisión completa de las lesiones.

Abstract Chromoblastomycosis is a fungal infection of the skin and subcutaneous tissue, of chronic evolution, caused by dematiaceous fungi. The disease occurs worldwide, mainly in tropical and subtropical regions, but in regions like Chile there is only one report of a human case more than 30 years ago. We present the case of a 46-year-old Haitian man, resident in Chile, with verrucous plaques in the right anterior tibial area of one year of evolution. The diagnosis of chromoblastomycosis was confirmed when muriform cells and dematiaceous colonies were observed in the histopathological analysis and the direct microscopy, respectively. After six months of treatment with systemic antimycotics and cryotherapy, complete remission of the lesions was achieved.

Diagnosis of chromoblastomycosis: an historical review

Chromoblastomycosis is a skin infection caused by dematiaceous fungi, characterized by a verrucous plaque on the limbs. It mainly affects rural workers in tropical countries. The purpose of this review is to identify how the diagnostic methods used in the propaedeutic of chromoblastomycosis emerged and were developed. The MeSH terms "chromoblastomycosis" or "chromomycosis" or "verrucous dermatitis" and "diagnosis" were used to search articles indexed in MEDLINE and LILACS databases. The description of a first-time-used method in diagnosing chromoblastomycosis or modifications and innovations in an existing technique was the criteria used to deem the article eligible. The first methods described in diagnosing chromoblastomycosis were histopathological examination and culture, which characterizes and defines the disease in the early 20th century. Subsequently, they were described as direct microscopic examination, fine needle aspiration for cytology, electron microscopy, serology, molecular tests, scintigraphy, nuclear magnetic resonance and dermoscopy. Tests based on the direct identification of the fungus through biopsy, culture, or direct microscopy are the oldest and more employed methods for diagnosing chromoblastomycosis. The polymerase chain reaction was introduced in the last few decades and is a promising technique. Dermoscopy of chromoblastomycosis shows blackish red dots and white and pink areas along with scaling. Other techniques, such as serology and skin testing for delayed-type hypersensitivity, have not been incorporated into clinical practice

Presence of hyphae in chromoblastomycosis examinations: an enigma to be solved

Abstract The detection of muriform cells in direct mycological or anatomopathological examination is considered pathognomonic for chromoblastomycosis. The morphological aspect that these fungal structures acquire were called "Borelli spiders", when associated with hyphae. Reports of this association have been described for decades, initially related to more pathogenic agents of this mycosis. More recent studies have shown aspects related to the host's immunity that participate in this process, as well as an association with a worse disease prognosis. The present study discloses the findings of complementary examinations with the presence of "Borelli's spiders" in a patient diagnosed with chromoblastomycosis.

Diagnóstico microbiológico en un paciente con cromomicosis / Microbiological diagnosis in a patient with chromomycosis

RESUMEN La cromomicosis es una micosis subcutánea; uno de los pilares para su diagnóstico certero son los resultados de los estudios microbiológicos. Se presenta el caso de un hombre campesino, que tenía, desde hacía ocho años, lesiones papulares que evolucionaron a placas verrugosas y escamosas en el antebrazo izquierdo. El examen directo micológico de las escamas, así como su cultivo, apoyaron el diagnóstico de una cromomicosis. En la microscopía de su forma de esporulación se identificó al agente etiológico: fonsecaea pedrosoi. Este hallazgo resultó novedoso pues hacía más de una década que no se diagnosticaba ni se informaba un caso de cromomicosis en el laboratorio. La promoción y prevención de salud es un pilar fundamental en el sistema de salud, ya que mediante la educación del campesinado cubano se puede prevenir esta enfermedad, disminuir los costos médicos, curar oportunamente, y mejorar la calidad de vida de los campesinos.

ABSTRACT Chromomycosis is a subcutaneous mycosis; the results of microbiological studies are one of the pillars for its accurate diagnosis. A male farmer who had, for eight years, papular lesions that evolved to warty and scaly plaques on the left forearm is presented. The direct mycological examination of the scales, as well as their culture, supported the diagnosis of a chromomycosis. The etiological agent Fonsecaea pedrosoi was identified in the microscopy of its sporulation form. This finding was novel since a case of chromomycosis had not been diagnosed or reported in the laboratory for more than a decade. Health prevention and promotion is a fundamental pillar in the health system, since through the education of the Cuban farmers this disease can be prevented, medical costs can be reduced, timely cures and the quality of life of the farmers can be improved.

Case for diagnosis. Pruritic erythematosquamous lesion in the auricle

Abstract Chromoblastomycosis is a subcutaneous mycosis with chronic evolution that mainly affects the lower limbs and, less frequently, the auricles. Clinically, it presents with papillary verrucous, nodular, and/or tumoral lesions, whether isolated or infiltrated, forming plaques and, sometimes, atrophic in some areas. Histopathologically, it is characterized by a dermal granulomatous inflammatory infiltrate, and the diagnosis can be confirmed by the presence of fumagoid bodies in anatomopathological or direct mycological exams. The treatment to be indicated will depend on the extent and location of the lesions, using systemic antifungals, surgical removal, cryotherapy, thermotherapy, and immunoadjuvants. The present study reports an atypical presentation of chromoblastomycosis on the auricle.

Chromoblastomycosis caused by Rhinocladiella aquaspersa: first case report in Guatemala

Abstract The authors report a case of 40-year-old male patient with a five-year history of chromoblastomycosis on his right leg. Diagnosis was performed by direct 40% KOH exam of skin scales, culture with micro- and macromorphologic analysis, and genotypic characterization (sequencing of a fragment of the ITS region and phylogenetic analysis) of the isolated fungus. Rhinocladiella aquaspersa was identified as the etiological agent. Initially, the treatment was with oral itraconazole 200 mg/day for one year. However, the presence of "sclerotic cells" with filaments ("Borelli spiders") resulted in a change of medical treatment: a higher dose of itraconazole (400 mg/day) and surgery, achieving clinical and mycological cure in one year. This is the first report of chromoblastomycosis caused by R. aquaspersa in Guatemala.

Study of tissue inflammatory response in different mice strains infected by dematiaceous fungi Fonsecaea pedrosoi

Abstract: Background: Diseases caused by melanized fungi include mycetoma, chromoblastomycosis and phaeohyphomycosis. This broad clinical spectrum depends on the dynamic interactions between etiologic agent and host. The immune status of the host influences on the development of the disease, as, an exemple. phaeohyphomicosis is more frequently observed in immunocompromised patients. Objectives: Examine the histological inflammatory response induced by Fonsecaea pedrosoi in several different strains of mice (BALB/c, C57BL/6, Nude and SCID, and reconstituted Nude). Methods: Fonsecaea pedrosoi was cultivated on agar gel and a fragment of this gel was implanted subcutaneously in the abdominal region of female adult mice. After infection has been obtained, tissue fragment was studied histopathologically. Results: There were significant changes across the strains, with the nodular lesion more persistent in Nude and SCID mice, whereas in immunocompetent mice the lesion progressed to ulceration and healing. The histopathological analysis showed a significant acute inflammatory reaction which consisted mainly of neutrophils in the initial phase that was subsequently followed by a tuberculoid type granuloma in immunocompetent mice. Study limitations: There is no a suitable animal model for chromoblastomycosis. Conclusions: The neutrophilic infiltration had an important role in the containment of infection to prevent fungal spreading, including in immunodeficient mice. The fungal elimination was dependent on T lymphocytes. The re-exposure of C57BL/6 mice to Fonsecaea pedrosoi caused a delay in resolving the infection, and appearance of muriform cells, which may indicate that re-exposure to fungi, might lead to chronicity of infection.

Long-pulsed 1064 nm Nd: YAG laser combined with terbinafine against chromoblastomycosis caused by and the effect of laser therapy in a Wistar rat model / 南方医科大学学报

We report a case of chromoblastomycosis caused by , which was successfully treated by long-pulsed 1064 nm Nd: YAG laser combined with terbinafine. A 60-year-old man was admitted for the presence of a 30 mm×40 mm erythematous plaque on the dorsum of his right hand for about 10 months without any subjective symptoms. Both microscopic examination and tissue biopsy of the lesion showed characteristic sclerotic bodies of chromoblastomycosis. Lesion tissue culture on SDA at 26 ℃ for 2 weeks resulted in a black colony, and slide culture identified the isolate as Fonsecaea species. ITS sequence analysis of the isolate showed a 99% homology with strain KX078407. The susceptibility of the isolate to 9 antifungal agents was determined using the microdilution method according to the guidelines of CLSI M38-A2 protocol, and terbinafine showed the lowest MIC (0.125 μg/ml). We subsequently established a Wistar rat model of chromoblastomycosis using the clinical isolate and treated the rats with long-pulsed 1064 nm Nd: YAG laser (pulse width of 3.0 ms, fluence of 24 J/cm, spot size of 3 mm, frequency of 4 Hz, repeated 3 times at an interval of 30 s) twice a week for a total of 8 sessions. Although the laser treatment alone was not able to eliminate the fungi, histopathological examination showed the aggregation of numerous lymphocytes in the local affected tissue, indicating an immune response that consequently facilitate the regression of the lesion. The patient was successfully treated by long-pulsed 1064 nm Nd: YAG laser once a week combined with terbinafine (0.25 /bid) for 8 weeks, and follow-up for 20 months did not reveal any signs of recurrence.

Chromoblastomycosis in the amazon region, BRazil, caused by fonsecaea pedrosoi, fonsecaea nubica, and Rhinocladiella similis: clinicopathology, susceptibility, and molecular identification

Chromoblastomycosis is a chronic subcutaneous disease caused by human contact with melanized fungioccurring mainly in tropical and subtropical zones worldwide. This study assessed 12 patients with chro-moblastomycosis from Rondˆonia, Brazil, Amazon region. In sum, 83.3% were men, 41.6% were from MonteNegro city, median age was 52.9 years, and median time to disease progression was 12.2 years. Lesions werelocated on the lower limbs (75%), and verruciform was prevalent form (66.6%). After 3 years of treatmentwith itraconazole, two patients were considered cured. The etiological agents were identified by the molec-ular sequence of the ribosomal internal transcribed spacer ITS1, 5.8S, and ITS2 region andß-tubulin genes.Eight strains were identified asFonsecaea pedrosoi, two wereF. nubica,and two wereRhinocladiella similis.The antifungal activity of five drugs was evaluated, and the most active drug was terbinafine (range minimalinhibitory concentration [MIC] 0.015­0.12µg/ml), itraconazole (range MIC 0.03­0.5µg/ml) and voriconazole(range MIC 0.06­0.5µg/ml). The highest MIC was 5-fluorocytosine (range MIC 2­32µg/ml), and ampho-tericin B (range MIC 0.25­2µg/ml). In conclusion, the present study expanded the epidemiological diseasedatabase and described for the first timeF. nubicaandR. similisas chromoblastomycosis agents in theBrazilian Amazon region. Our results confirmed the importance of using molecular methods to identify themelanized fungi and stimulate the recognition of the disease in other places where no cases have beenreported.

Chromoblastomycosis: an etiological, epidemiological, clinical, diagnostic, and treatment update

Abstract: Chromoblastomycosis is a chronic, granulomatous, suppurative mycosis of the skin and subcutaneous tissue caused by traumatic inoculation of dematiaceous fungi of the family Herpotrichiellaceae. The species Fonsecaea pedrosoi and Cladophialophora carrionii are prevalent in regions where the disease is endemic. Chromoblastomycosis lesions are polymorphous: verrucous, nodular, tumoral, plaque-like, and atrophic. It is an occupational disease that predominates in tropical and subtropical regions, but there have been several reports of cases in temperate regions. The disease mainly affects current or former farm workers, mostly males, and often leaving disabling sequelae. This mycosis is still a therapeutic challenge due to frequent recurrence of lesions. Patients with extensive lesions require a combination of pharmacological and physical therapies. The article provides an update of epidemiological, clinical, diagnostic, and therapeutic features.

Chromoblastomycosis, overlooked and undiagnosed: The disease as a mimic of other neglected tropical diseases

@#Chromoblastomycosis is an endemic mycoses which has been misdiagnosed or underdiagnosed in the past. This may be due to the clinicopathologic characteristics that it shares with other neglected tropical diseases such as leprosy and cutaneous tuberculosis. Correlating clinical findings with histopathologic cues will lead clinicians to correct diagnosis and subsequent treatment success.

PLECT: enfermedades tropicales de manifestación verrucosa / PLECT: tropical manifestation diseases verrucosa

Cada día es más habitual ver en nuestra consulta médica enfermedades dermatológicas endémicas de zonas tropicales, gracias a los flujos migratorios recientes y aumento del turismo hacia el extranjero. Presentamos un acrónimo muy utilizado en Brasil, PLECT, que reúne a enfermedades infecciosas que deben tenerse en mente en el diferencial de lesiones verrucosas, a saber, Paracoccidiodomicosis, Leishmaniasis Tegumentar, Esporotricosis, Cromomicosis y Tuberculosis Cutánea.

Increasingly, it is more common to see dermatological diseases that are endemic in tropical areas in our medical practice, thanks to recent migratory flows and increased tourism abroad. We present an acronym widely used in Brazil, PLECT, which brings together infectious diseases that should be borne in mind in the differential of verrucous lesions, namely, Paracoccidiodomicosis, Cutaneous Leishmaniasis, Sporotrichosis, Chromomycosis and Cutaneous Tuberculosis.

Chromoblastomycosis: tissue modifications during itraconazole treatment

Abstract: Background: Histological and mycological changes during itraconazole use have not been totally established in chromoblastomycosis. Objectives: To evaluate tissue modifications in chromoblastomycosis carriers under itraconazole treatment. Methods: A histological retrospective study of 20 cases of chromoblastomycosis seen at the university hospital at the south of Brazil, during itraconazole 400 mg daily treatment. Patients were classified into two groups: plaque or tumor lesions, and underwent periodic evaluations every four months during three years. Hematoxylin-eosin stain was used to analyze epidermal modifications, inflammatory infiltrate and fibrosis, and Fontana-Masson stain for parasite evaluation. Results: Fontana-Masson stain was superior to hematoxylin-eosin stain in fungal count in the epidermis (mean difference=0.14; p<0.05). The most distinct mycosis tissue responses were registered in the dermis. Epidermal thinning, granulomatous infiltrate decrease or disappearance, fibrosis increase and quantitative/morphological changes occurred during treatment. Study limitations: Patients could not be located to have their current skin condition examined. Conclusion: Parasitic and tissue changes verified in this study can reflect the parasite-host dynamics under itraconazole action.