Treatment of chromoblastomycosis

Polymeric microneedle‐mediated sustained release systems: Design strategies and promising applications for drug delivery

Parenteral sustained release drug formulations, acting as preferable platforms for long-term exposure therapy, have been wildly used in clinical practice. However, most of these delivery systems must be given by hypodermic injection. Therefore, issues including needle-phobic, needle-stick injuries and inappropriate reuse of needles would hamper the further applications of these delivery platforms. Microneedles (MNs) as a potential alternative system for hypodermic needles can benefit from minimally invasive and self-administration. Recently, polymeric microneedle-mediated sustained release systems (MN@SRS) have opened up a new way for treatment of many diseases. Here, we reviewed the recent researches in MN@SRS for transdermal delivery, and summed up its typical design strategies and applications in various diseases therapy, particularly focusing on the applications in contraception, infection, cancer, diabetes, and subcutaneous disease. An overview of the present clinical translation difficulties and future outlook of MN@SRS was also provided.

Recalcitrant primary subcutaneous phaeohyphomycosis due to Phialophora verrucosa

Phialophora verrucosa has rarely been reported for causing phaeohyphomycosis, which tends to occur in immunocompromised individuals. The case of primary subcutaneous phaeohyphomycosis due to P. verrucosa in an otherwise healthy Chinese female is presented. The girl presented with asymptomatic skin lesions when she was only 16 year old. Histological examinations revealed multiple dematiceous hyphael elements in the dermis and subcutaneous tissues. Fungal cultures were identified as P. verrucosa repeatedly based on the morphological features and confirmed by the internal transcribed spacer region nucleotide sequencing. The infection was so extremely recalcitrant that prolonged systemic antifungal regimens for 12 years revealed limited effect. The skin lesions slowly progressed and caused marked disfigurement despite the encouraging results of in vitro susceptibility. However, no relevant side effects have been reported in the course, and the patient gave birth to a healthy baby while under the maintenance treatment of itraconazole and terbinafine. This case is special in terms of the early onset, the rare clinical aspect of the pathogen, the discrepancy between in vitro and in vivo antifungal activities and especially the prolonged and recalcitrant course in such an otherwise healthy host.

Infection and panniculitis

Infection-induced panniculitis may result from a number of microbes including bacteria, fungi, and parasites. Viruses have also been implicated as a cause. This type of panniculitis can occur as a primary infection by direct inoculation of infectious microorganisms into the subcutaneous tissue, or secondarily via microbial hematogenous dissemination with subsequent infection of the subcutaneous tissue. Panniculitis is rarely viewed solely in terms of infectious causes. Also, subcutaneous infections are infrequently viewed in terms of infection-induced panniculitis but rather as cutaneous infections with subcutaneous involvement. Little information exists specifically on the subject of infection-induced panniculitis outside of the realm of case reports and case series. In this review, the present authors address panniculitis from the vantage point of infectious causes, focusing on those microorganisms with infection-induced panniculitis reports in the literature. Diagnosis and treatment are also discussed.

A case of chromoblastomycosis with an unusual clinical manifestation caused by Phialophora verrucosa on an unexposed area: treatment with a combination of amphotericin B and 5-flucytosine

Chromoblastomycosis is a cutaneous and subcutaneous mycotic disease caused by the dematiaceous (black) fungi. Five species of fungi are known generally to be the cause: Fonsecaea pedrosoi, Phialophora verrucosa, Cladosporium carrionii, F. compacta and Rhinocladiella cerphilum. In infected tissue they can appear as pigmented sclerotic bodies, commonly called 'copper pennies', which are pathognomonic of chromoblastomycosis. The infection usually occurs through traumatic skin inoculation, with the majority of lesions occurring on the feet and legs of outdoor workers. We report a patient in whom the lesions had begun on the right breast, which is an unexposed area, without a history of trauma. A uniform, reliable treatment does not exist but our patient was mycologically cured with the use of amphotericin B and the subsequent combination of 5-flucytosine and itraconazole.

Subcutaneous mycoses

Subcutaneous mycoses include a heterogeneous group of fungal infections that develop at the site of transcutaneous trauma. Infection slowly evolves as the etiologic agent survives and adapts to the adverse host tissue environment. Diagnosis rests on clinical presentation, histopathology, and culture of the etiologic agents. This article considers sporotrichosis, chromoblastomycosis, and mycetoma.

In vitro susceptibility of chromoblastomycosis and phaeohyphomycosis agents to antifungal drugs

The in vitro susceptibility of chromoblastomycosis and phaeohyphomycosis agents to antifungal drugs was appraised using the reference macrodilution method proposed by the National Committee for Clinical Laboratory Standards (NCCLS) for yeasts modified for filamentous fungi. The antifungal drugs amphotericin B, 5-fluorocytosine, itraconazole and fluconazole were tested against one environmental and 18 clinical isolates. This work amended the macrodilution methods proposed by NCCLS and suggests that a conidial suspension free of hyphae leads to a more reliable assay and provides for better reproducibility. The macrodilution method was performed with 10(4) conidia ml-1. The MIC values ranged from 1.0 to 16.0 micrograms ml-1 for amphotericin B and 3.12 to 25.0 micrograms ml-1 for 5-fluorocytosine. A MIC range of 0.06 to 1.95 micrograms ml-1 was determined for itraconazole while 2.0 to 64.0 micrograms ml-1 was detected for fluconazole.

Deep fungal and higher bacterial skin infections in Thailand: clinical manifestations and treatment regimens

BACKGROUND

Deep fungal and higher bacterial skin infections occur fairly frequently in Thailand.

METHODS

Cases with a provisional diagnosis of deep fungal and higher bacterial infections were prospectively collected from 1994 to 1997 in the Granuloma Clinic, Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand. Demographic data, clinical manifestations, causative organisms, histologic features, treatment, and outcome were investigated.

RESULTS

The total cases in a 4-year period numbered 27. The male to female ratio was approximately 1:1. Mycetoma was most common, followed by chromoblastomycosis. Actinomycetoma was similar in incidence to eumycetoma. The only causative organism that could be identified among the mycetoma cases was Cladosporium carrionii, which caused mycetoma of the buttock of an aplastic anemia patient at the site of bone marrow aspiration. Surgical treatment was recommended for eumycetoma. Chromoblastomycosis was caused by C. carrionii and F. compactum and responded well with itraconazole orally. Mycotic abscesses were found in four cases, basidiobolomycosis in two cases, and cutaneous nocardiosis in one case. Cotrimoxazole was recommended in the treatment of actinomycetoma, cutaneous nocardiosis, and basidiobolomycosis.

CONCLUSIONS

Localized, chronic, slow, progressive, and usually asymptomatic were the main cutaneous manifestations of deep fungal and higher bacterial skin infections. A skin biopsy for histologic study and culture identification should be performed in every suspected case. The causative organisms were found in the histologic sections of every case, but only about one-third were found by culture.

[Therapy of infections caused by dematiaceous fungi]

Since dematiaceous fungi belong to the group of rare infectious agents causing mycoses, therapeutic recommendations are mainly deduced from observations of single cases. In cases of eumycetoma or focal phaeohyphomycoses of the central nervous system (e.g. caused by Cladophialophora bantiana or Exophiala dermatitidis) and in certain cases of chromoblastomycoses, the resection in toto is the therapy of choice, which may be accompanied by antimycotic medication. As antimycotic therapy ex juvantibus in case of phaeohy-phomycoses, a simultaneous application of itraconazole and 5-fluorocytosine is presently most promising. The success depends on an adequate duration of therapy.

[Chromoblastomycosis in Rio Grande do Sul: a report of 12 cases]

Twelve cases of chromoblastomycosis diagnosed in Rio Grande do sul during 1988-1995 are reported. The clinical aspects are analyzed and compared with the literature. Fonsecaea pedrosoi was the only microorganism isolated.

Chromoblastomycosis murine model and in vitro test to evaluate the sensitivity of Fonsecaea pedrosoi to ketoconazole, itraconazole and saperconazole

An experimental model of murine chromoblastomycosis and in vitro tests with Fonsecaea pedrosoi were used to test the sensitivity of this fungus to three different antimycotics. The experimental model was standardized in BALB/c mice inoculated intraperitoneally with a 10(6) CFU/ml suspension of a F. pedrosoi isolate. Clinical infection was evident after 5 days of inoculation. Three groups of 27 mice each were used in the experiment. One group was treated with ketoconazole (KTZ), another with itraconazole (ITZ) and the other with saperconazole (SPZ). Antimycotic therapy was continued for 21 days. The control group consisted of 40 mice which were inoculated, but not treated. Infection was documented by macroscopic and microscopic examination of affected tissue in addition to culture of tissue macerates. Minimal inhibitory concentrations (MIC) and minimal fungicidal concentrations (MFC) for the F. pedrosoi strain used were done. The in vitro results showed that SPZ was the most active with MIC 0.01 microgram/ml and MFC 0.1 microgram/ml, followed by ITZ. SPZ was also the most effective in vivo since 63% of the treated animals (p = 0.01) showed a curative effect after the observation period. We concluded that SPZ had the best in vitro and in vivo activity against F. pedrosoi.

A case of chromomycosis with tumor-like growth

A 66-year-old woman who lived on Tokunoshima Island, a small and remote southern island of the Japanese archipelago, had suffered from chromomycosis for more than 30 years and presented with a tumor-like growth on the posterior crural region of his right leg. Fonsecaea pedrosoi was identified as the pathogen from its growth pattern and micromorphological characteristics. The patient was successfully treated with 5-fluorocytosine, itoraconazole, and topical thermotherapy.

Treatment of chromomycosis with terbinafine: preliminary results of an open pilot study

In an open trial, long courses (6-12 months) of terbinafine at a dosage of 500 mg/day were administered orally to 43 patients with a diagnosis of chromomycosis. Sixteen patients (37.2%) had previously relapsed after one or two courses of thiabendazole. A spectacular improvement in the lesions, including disappearance of bacterial superinfections and of associated oedema and elephantiasis, was observed as soon as 2-4 months after the beginning of treatment. The mean number of fungal cells in skin scrapings fell by about 70% in 4 months. Mycological cure, as judged by skin scrapings, was observed in 41.4, 74.1 and 82.5% of patients infected with Fonsecaea pedrosoi after 4, 8 and 12 months of therapy, respectively. For the first time with this disease, total cure was observed even in imidazole-refractory patients or chronic cases (47.2% with a lesion present for longer than 10 years). The efficacy of terbinafine in Cladosporium carrionii-infected patients seemed higher, as indicated by the examination at 4 months.

Chromoblastomycosis

Chromoblastomycosis is a chronic cutaneous infection due to several varieties of pigmented fungi. Diagnosis is straightforward and based on clinical and microscopic findings. Despite the protracted course of the disease, dissemination of the infection is rare. New insights into the pathophysiology may permit a closer appreciation of the clinical course. Treatment in advanced cases is difficult and frequently requires extensive surgery or lengthy therapy with physical or medical approaches.

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.

Successful treatment of chromoblastomycosis with itraconazole

An unusual severe case of chromoblastomycosis due to Cladosporium carrionii unresponsive to 5-FC and some azoles is reported. With oral itraconazole at a dosage of 100 mg d(-1) for 15 months (total dose 45.5 g) the patient had a complete clinical and mycological recovery without any side-effects.

Treatment of tropical mycoses

Several subcutaneous and deep-seated mycoses are either observed more frequently in the tropical areas or are restricted to certain regions within the tropics. These mycoses include sporotichosis, chromoblastomycosis, entomophthoromycosis, eumycetoma, lobomycosis, and paracoccidioidomycosis. In sporotrichosis and paracoccidioidomycosis, therapy often results in either complete resolution or marked improvement. For decades sporotrichosis has been treated successfully with potassium iodide, but recently the triazole compounds, especially itraconazole, have proved effective and free of major side effects. The usual therapy for paracoccidioidomycosis is sulfonamides or amphotericin B; the former requires prolonged treatment, whereas the latter causes a significant degree of toxicity. Various azole derivatives (ketoconazole, fluconazole, saperconazole, and itraconazole) allow shorter treatment courses, can be given orally, and are more effective. Presently, itraconazole is the drug of choice. Chromoblastomycosis is a difficult condition to treat, especially if it is caused by Fonsecaea pedrosoi. Several therapeutic approaches have been used, including heat, surgery, cryotherapy, thiabendazole, amphotericin B combined with flucytosine, and azole derivatives, but their success has been modest. A 65% response rate has been obtained with itraconazole given for periods of 6 to 19 months; in limited trials, saperconazole appears to be more effective and requires shorter treatment courses. Only a few patients with eumycetoma respond to therapy; 70% of patients with Madurella mycetomatis respond to prolonged treatment with ketoconazole. Griseofulvin has been tried in nonresponders with partial success. Limited data in patients with Fusarium species eumycetoma indicate good responses to itraconazole. Eumycetoma caused by Pseudallescheria boydii or Acremonium species has been refractory to therapy. Therapy of entomophthoromycosis is also difficult because the diagnosis is usually established late and not all patients respond to therapy; this situation applies to infection caused by either Basidiobolus haptosporus or Conidiobolus coronatus. Although there is no consensus, African physicians prefer to use potassium iodide or trimethoprim-sulfamethoxazole. Isolated reports indicate that the azole derivatives, including the triazoles, may be effective. As for lobomycosis, all attempts at medical treatment have failed. Surgery is successful only when the lesion is small and can be fully resected; repeated cryotherapy appears to be more successful.

A case of chromoblastomycosis responding to treatment with itraconazole

Chromoblastomycosis is a rare, chronic, cutaneous infection caused by a group of dematiacaeous fungi. We report a case which, in addition to characteristic clinical and histopathological features of chromoblastomycosis, displayed atypical, deep dermal/subcutaneous involvement, and showed a good response to itraconazole.

Four non-endemic New Zealand cases of chromoblastomycosis

The majority of cases of chromoblastomycosis are reported from tropical to subtropical countries; only one previous case being reported from New Zealand. Four non-endemic cases in Pacific Island patients are described. All of the New Zealand cases were caused by Fonsecaea pedrosoi. In the present report, one patient was successfully treated by excision of the lesion followed by skin grafting. Another was treated with 200 mg ketoconazole daily for 10 weeks with no obvious improvement. No follow-up on the treatment of this case nor of the remaining two patients is available. This disease must be included in the differential diagnosis in patients who present with chronic lesions affecting the skin and subcutaneous tissues.