Chromomycosis: report of a case and management by cryosurgery, topical chemotherapy, and conventional surgery

Chromoblastomycosis

Chromoblastomycosis (CBM), also known as chromomycosis, is one of the most prevalent implantation fungal infections, being the most common of the gamut of mycoses caused by melanized or brown-pigmented fungi. CBM is mainly a tropical or subtropical disease that may affect individuals with certain risk factors around the world. The following characteristics are associated with this disease: (i) traumatic inoculation by implantation from an environmental source, leading to an initial cutaneous lesion at the inoculation site; (ii) chronic and progressive cutaneous and subcutaneous tissular involvement associated with fibrotic and granulomatous reactions associated with microabscesses and often with tissue proliferation; (iii) a nonprotective T helper type 2 (Th2) immune response with ineffective humoral involvement; and (iv) the presence of muriform (sclerotic) cells embedded in the affected tissue. CBM lesions are clinically polymorphic and are commonly misdiagnosed as various other infectious and noninfectious diseases. In its more severe clinical forms, CBM may cause an incapacity for labor due to fibrotic sequelae and also due to a series of clinical complications, and if not recognized at an early stage, this disease can be refractory to antifungal therapy.

Thermotherapy in dermatologic infections

The use of local induced hyperthermia or thermotherapy for dermatologic infections has not been fully explored in the more recent medical literature. Herein, we discuss the rationale behind the use of thermotherapy and review reported clinical experience with its use in the management of cutaneous infections.

Treating chromoblastomycosis with systemic antifungals

Chromoblastomycosis is a subcutaneous mycosis for which there is no treatment of choice but rather, several treatment options, with low cure rates and many relapses. The choice of treatment should consider several conditions, such as the causal agent (the most common one being Fonsecaea pedrosoi ), extension of the lesions, clinical topography and health status of the patient. Most oral and systemic antifungals have been used; the best results have been obtained with itraconazole and terbinafine at high doses, for a mean of 6 - 12 months. In extensive and refractory cases, chemotherapy with oral antifungals may be associated with thermotherapy (local heat and/or cryosurgery). Limited or early cases may be managed with surgical methods, always associated with oral antifungal agents. It is important to determine the in vitro sensitivity of the major causal agents to the various drugs, by estimating the minimum inhibitory concentration, as well as drug tolerability and drug interactions.

Chromoblastomycosis: clinical and mycologic experience of 51 cases

This is a study of 51 cases of chromoblastomycosis detected in a 17-year period, all of which were clinically and mycologically proven by direct examinations, cultures and biopsies. The therapeutic results of the various treatments used are reported. Most cases were males (36 of 51; 70%), the mean age was 35 years and farmers predominated (74%); the most frequent lesions were in the lower limbs (54%). Major clinical presentations were nodular (41%) and verrucous (26%). The principal aetiologic agent isolated was Fonsecaea pedrosoi (90%). Overall results of the various treatments were as follows: 31% were cured, 57% improved and 12% failed. The best results were obtained with cryosurgery for small lesions, with itraconazole for large ones, and in some cases the combination of both treatments.

Successful treatment of chromoblastomycosis due to Fonsecaea pedrosoi by the combination of itraconazole and cryotherapy

BACKGROUND

Many methods and medications had been tried for the treatment of chromoblastomycosis with unsatisfactory results. Recently, there were several reports showing a good response of chromoblastomycosis to itraconazole, but it took as long as 18-30 months for lesions to heal.

METHODS

Itraconazole, 200 to 400 mg/day alone or in combination with monthly liquid nitrogen cryotherapy, was tried on 10 cases of chromoblastomycosis, caused by Fonsecaea pedrosoi in order to increase the potency of the drug and shorten the duration of treatment.

RESULTS

The 10 cases included five newly diagnosed and five recalcitrant cases. Two patients were cured by 200 mg/day alone within 3 months. Seven patients required itraconazole, 400 mg/day, with combined cryotherapy to cure the lesions within 5 to 10 months. One case showed marked improvement but no cure. After the period of 1-year follow-up, only one case had a recurrent infection.

CONCLUSIONS

Itraconazole was highly effective and may be useful in the treatment of chromoblastomycosis. A high dose is indicated in chronic fibrotic lesions in combination with liquid nitrogen cryotherapy, with higher efficacy and quicker healing than with medication alone.

The role of surgery in the management of uncommon skin infections

BACKGROUND

Some infections do not respond readily to antibiotic therapy. In particular, fungi and mycobacteria often require prolonged treatment, which is expensive and prone to adverse effects.

OBJECTIVE

To investigate the role of surgery in the treatment of skin infections.

METHODS

Literature review.

RESULTS

Infections caused by atypical mycobacteria, certain fungi, and those involving joints often respond well to surgical treatments. In several situations excision produces a higher cure rate than antibiotic treatment.

CONCLUSION

Excision, drainage, or debridement has been shown to be superior to drug therapy in several infections and a reasonable alternative in others.

Treatment of chromoblastomycosis

Treatment of chromoblastomycosis is frequently difficult and unsatisfactory. A representative case is presented of this chronic subcutaneous fungal infection, characterized by warty, cauliflower-like lesions usually on the extremities. Chromoblastomycosis and its treatment are reviewed, with attention to itraconazole, a new triazole compound, as the possible drug of choice.

Chromoblastomycosis treated by Mohs micrographic surgery

Mohs micrographic surgery has been used to treat a variety of skin cancers with excellent results. We present a case where the application of this technique was used effectively to treat a lesion of localized cutaneous chromoblastomycosis. One year following the surgery no recurrence has occurred.

Chromoblastomycosis and phaeohyphomycosis: new concepts, diagnosis, and mycology

The nomenclature for the mycoses caused by dematiaceous fungi should represent the combined clinical, pathologic, and mycologic relationships exhibited in the diseases. Chromoblastomycosis encompasses chronic, localized infections of the cutaneous and subcutaneous tissues that contain sclerotic bodies and histologically show hyperkeratotic pseudoepitheliomatous hyperplasia with keratolytic microabscess formation in the epidermis. In contrast, phaeohyphomycosis is a collective term for a heterogeneous group of mycotic infections that contain dematiaceous yeastlike cells, pseudohyphae-like elements, hyphae, or any combination of these forms in tissue. The terms superficial, cutaneous and corneal, subcutaneous, and systemic phaeohyphomycosis are proposed for the major categories of phaeohyphomycosis. The term chromomycosis is rejected for mycoses caused by the dematiaceous fungi.