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Verrucous Plaques on the Arm—Diagnosis

Verrucous Plaques on the Arm—Diagnosis Diagnosis: Chromoblastomycosis. Microscopic findings and clinical course The histologic sections revealed pseudoepitheliomatous hyperplasia overlying a prominent dermal granulomatous infiltrate with multinucleated giant cells. Clusters of neutrophils, along with lymphocytes, plasma cells, and eosinophils were also present. Dark brown, thick-walled, spherical spores were identified inside multinucleated giant cells and free in the tissue. Analyses under periodic acid–Schiff and Gomori methenamine silver stains highlighted these sclerotic bodies. Fonsecaea pedrosoi was confirmed by fungal culture as the etiologic agent. The patient was diagnosed as having chromoblastomycosis. Treatment was to include oral itraconazole, but the patient was subsequently lost to follow-up. Discussion Chromoblastomycosis is a chronic infection of cutaneous and subcutaneous tissues caused by a group of dematiaceous fungi. According to Sobera and Elewski1 Pedroso made the first observation in Brazil in 1911, while the first US case report was published by Medlar and Lane in 1915. In the largest reports, F pedrosoi was responsible for 86% to 96% of cases, while Phialophora verrucosa, Fonsecaea compacta, Cladophialophora carrionii, and Rhinocladiella aquaspersa made up most of the remaining cases.2 Chromoblastomycosis most commonly affects people living in tropical and subtropical climates, with most cases described in Madagascar, Brazil, and Costa Rica.2 The disease is more prevalent in adult male patients, most of whom work as laborers in rural areas.3 Clinically, skin-colored to pink papules insidiously enlarge into nodules and/or plaques with a verrucous surface. Central atrophy, scarring, and ulceration can also develop.3 Self-inoculation through scratching and lymphatic dissemination can lead to the development of satellite lesions.4 Most morbidity is attributed to secondary lymphedema and disability of affected limbs, secondary bacterial infection, and, rarely, the development of squamous cell carcinoma.3 Since the infection is caused by traumatic inoculation, the lower limb is the most commonly affected site, often owing to lack of footwear. Differential diagnoses include other mycoses, verrucous carcinoma, leishmaniasis, verrucous tuberculosis, and leprosy.2 Diagnosis is confirmed by tissue microscopy or fungal culture. Histologically, rounded, thick-walled, brown, muriform cells with a single or double septum are pathognomonic. These sclerotic bodies are also commonly referred to as Medlar bodies or copper pennies. Chromoblastomycosis is often recalcitrant to treatment. Limited disease is best treated by complete excision, with cryotherapy and local application of heat as additional options. Advanced cases often require systemic therapy. Itraconazole (200-400 mg/d) and terbinafine (250-500 mg/d) have proven the most effective and well-tolerated treatments, with outcomes varying with medication regimen and disease severity.5 These agents, along with surgical excision, currently provide the best chance of cure.5 Second-generation triazoles, such as posaconazole, have been efficacious in a few cases, and may emerge as important treatment options in the future.5,6 Return to Quiz Case. References 1. Sobera JElewski B Chromoblastomycosis. Bolognia JJorizzo JRapini R Dermatology.2nd. London, England: Elsevier-Mosby; 2007:1150 Google Scholar 2. Hospenthal D Agents of chromoblastomycosis. Mandell GBennett JDolin R Principles and Practice of Infectious Disease.6th. Philadelphia, PA: Churchill Livingstone; 2005:29882991Google Scholar 3. Lupi OTyring SKMcGinnis MR Tropical dermatology: fungal tropical diseases. J Am Acad Dermatol 2005;53 (6) 931- 951PubMedGoogle ScholarCrossref 4. López Martínez RMéndez Tovar LJ Chromoblastomycosis. Clin Dermatol 2007;25 (2) 188- 194PubMedGoogle ScholarCrossref 5. Esterre PQueiroz-Telles F Management of Chromoblastomycosis: novel prospectives. Curr Opin Infect Dis 2006;19 (2) 148- 152PubMedGoogle ScholarCrossref 6. Negroni RTobón ABustamante B et al. Posaconazole treatment of refractory eumycetoma and chromoblastomycosis. Rev Inst Med Trop Sao Paulo 2005;47 (6) 339- 346PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Verrucous Plaques on the Arm—Diagnosis

Archives of Dermatology , Volume 145 (2) – Feb 1, 2009
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Verrucous Plaques on the Arm—Diagnosis

Abstract

Diagnosis: Chromoblastomycosis. Microscopic findings and clinical course The histologic sections revealed pseudoepitheliomatous hyperplasia overlying a prominent dermal granulomatous infiltrate with multinucleated giant cells. Clusters of neutrophils, along with lymphocytes, plasma cells, and eosinophils were also present. Dark brown, thick-walled, spherical spores were identified inside multinucleated giant cells and free in the tissue. Analyses under periodic acid–Schiff and Gomori...
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Publisher
American Medical Association
Copyright
Copyright © 2009 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archdermatol.2008.578-b
Publisher site
See Article on Publisher Site

Abstract

Diagnosis: Chromoblastomycosis. Microscopic findings and clinical course The histologic sections revealed pseudoepitheliomatous hyperplasia overlying a prominent dermal granulomatous infiltrate with multinucleated giant cells. Clusters of neutrophils, along with lymphocytes, plasma cells, and eosinophils were also present. Dark brown, thick-walled, spherical spores were identified inside multinucleated giant cells and free in the tissue. Analyses under periodic acid–Schiff and Gomori methenamine silver stains highlighted these sclerotic bodies. Fonsecaea pedrosoi was confirmed by fungal culture as the etiologic agent. The patient was diagnosed as having chromoblastomycosis. Treatment was to include oral itraconazole, but the patient was subsequently lost to follow-up. Discussion Chromoblastomycosis is a chronic infection of cutaneous and subcutaneous tissues caused by a group of dematiaceous fungi. According to Sobera and Elewski1 Pedroso made the first observation in Brazil in 1911, while the first US case report was published by Medlar and Lane in 1915. In the largest reports, F pedrosoi was responsible for 86% to 96% of cases, while Phialophora verrucosa, Fonsecaea compacta, Cladophialophora carrionii, and Rhinocladiella aquaspersa made up most of the remaining cases.2 Chromoblastomycosis most commonly affects people living in tropical and subtropical climates, with most cases described in Madagascar, Brazil, and Costa Rica.2 The disease is more prevalent in adult male patients, most of whom work as laborers in rural areas.3 Clinically, skin-colored to pink papules insidiously enlarge into nodules and/or plaques with a verrucous surface. Central atrophy, scarring, and ulceration can also develop.3 Self-inoculation through scratching and lymphatic dissemination can lead to the development of satellite lesions.4 Most morbidity is attributed to secondary lymphedema and disability of affected limbs, secondary bacterial infection, and, rarely, the development of squamous cell carcinoma.3 Since the infection is caused by traumatic inoculation, the lower limb is the most commonly affected site, often owing to lack of footwear. Differential diagnoses include other mycoses, verrucous carcinoma, leishmaniasis, verrucous tuberculosis, and leprosy.2 Diagnosis is confirmed by tissue microscopy or fungal culture. Histologically, rounded, thick-walled, brown, muriform cells with a single or double septum are pathognomonic. These sclerotic bodies are also commonly referred to as Medlar bodies or copper pennies. Chromoblastomycosis is often recalcitrant to treatment. Limited disease is best treated by complete excision, with cryotherapy and local application of heat as additional options. Advanced cases often require systemic therapy. Itraconazole (200-400 mg/d) and terbinafine (250-500 mg/d) have proven the most effective and well-tolerated treatments, with outcomes varying with medication regimen and disease severity.5 These agents, along with surgical excision, currently provide the best chance of cure.5 Second-generation triazoles, such as posaconazole, have been efficacious in a few cases, and may emerge as important treatment options in the future.5,6 Return to Quiz Case. References 1. Sobera JElewski B Chromoblastomycosis. Bolognia JJorizzo JRapini R Dermatology.2nd. London, England: Elsevier-Mosby; 2007:1150 Google Scholar 2. Hospenthal D Agents of chromoblastomycosis. Mandell GBennett JDolin R Principles and Practice of Infectious Disease.6th. Philadelphia, PA: Churchill Livingstone; 2005:29882991Google Scholar 3. Lupi OTyring SKMcGinnis MR Tropical dermatology: fungal tropical diseases. J Am Acad Dermatol 2005;53 (6) 931- 951PubMedGoogle ScholarCrossref 4. López Martínez RMéndez Tovar LJ Chromoblastomycosis. Clin Dermatol 2007;25 (2) 188- 194PubMedGoogle ScholarCrossref 5. Esterre PQueiroz-Telles F Management of Chromoblastomycosis: novel prospectives. Curr Opin Infect Dis 2006;19 (2) 148- 152PubMedGoogle ScholarCrossref 6. Negroni RTobón ABustamante B et al. Posaconazole treatment of refractory eumycetoma and chromoblastomycosis. Rev Inst Med Trop Sao Paulo 2005;47 (6) 339- 346PubMedGoogle ScholarCrossref

Journal

Archives of Dermatology – American Medical Association

Published: Feb 1, 2009

Keywords: chromoblastomycosis,arm

References

  • Chromoblastomycosis.
    Elewski B
  • Agents of chromoblastomycosis.
    Hospenthal D
  • Tropical dermatology: fungal tropical diseases.
    McGinnis MR; J Am Acad Dermatol
  • Chromoblastomycosis.
    Méndez Tovar LJ; Clin Dermatol
  • Management of Chromoblastomycosis: novel prospectives.
    Queiroz-Telles F; Curr Opin Infect Dis
  • Posaconazole treatment of refractory eumycetoma and chromoblastomycosis.
    Bustamante B; Rev Inst Med Trop Sao Paulo

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