Chromoblastomycosis: study of 27 cases and review of medical literature

Chromoblastomycosis: A Case Series and Literature Review

Chromoblastomycosis is a subcutaneous mycosis caused by a variety of dematiaceous fungi. Fonsecaea (F.) pedrosoi is the most common causative agent. Majority of cases have been reported from tropical and subtropical regions with rural and agricultural background. It is a chronic disease with low incidence of complications but is very refractory to therapies. This is a case series of 22 cases of chromoblastomycosis from two health-care facilities in India. Information regarding the history, clinical presentations, diagnostic methods, therapy, and outcome of treatment were retrieved. Preponderance was seen among the males and in the age group of 41-60 years. Manual and agricultural laborers were commonly affected. Lower extremities were the most common sites affected. Morphological patterns like verrucous plaque, psoriasiform plaque, and verrucous nodules were seen. Direct microscopy with potassium hydroxide (KOH) mount was positive in all the cases. Histopathology in all cases displayed suppurative granulomatous inflammation with pigmented fungal cells. Fungal culture was positive in 10 cases with F. pedrosoi being the commonest agent. Antifungal treatment alone was instituted in 10 cases, cryotherapy along with antifungal therapy was given in 9 cases, and surgical excision was done in 3 cases. Complete clinical cure was achieved in seven cases. Chromoblastomycosis is characterized by chronicity, diverse clinical presentations, and therapeutic recalcitrance. Direct KOH mount of the black dots forms an important bedside tool in the diagnosis. Long-term antifungal therapy along with adjuvant cryotherapy may be the best option for the management.

Molecular epidemiology and clinical-laboratory aspects of chromoblastomycosis in Mato Grosso, Brazil

INTRODUCTION

Chromoblastomycosis is a disease caused by melanized fungi, primarily belonging to the genera Fonsecaea and Cladophialophora, mainly affecting individuals who are occupationally exposed to soil and plant products. This research aimed to determine the clinical, epidemiological and laboratory characteristics of chromoblastomycosis in the state of Mato Grosso, Brazil.

MATERIALS AND METHODS

Patients diagnosed with chromoblastomycosis treated at the Júlio Müller University Hospital, Cuiabá, Brazil, from January 2015 to December 2020, whose isolates were preserved in the Research Laboratory of the Faculty of Medicine of the Federal University of Mato Grosso. Isolates were identified by partly sequencing the Internal Transcribed Spacer (ITS) and β-tubulin (BT2) loci. AFLP fingerprinting was used to explore the genetic diversity. Susceptibility to itraconazole, voriconazole, 5-fluorocytosine, terbinafine and amphotericin B was determined by the broth microdilution technique.

RESULTS

Ten patients were included, nine were male (mean age = 64.1 years). Mean disease duration was 8.6 years. Lesions were mainly observed in the lower limbs. Predominant clinical forms were verrucous and scarring. Systemic arterial hypertension and type II diabetes mellitus were the predominant comorbidities. Leprosy was the main concomitant infectious disease. Fonsecaea pedrosoi was the unique aetiological agent identified with moderate genetic diversity (H = 0.3934-0.4527; PIC = 0.3160-0.3502). Antifungal agents with the highest activity were terbinafine, voriconazole and itraconazole.

CONCLUSION

Chromoblastomycosis is affecting the poor population in rural and urban areas, mainly related to agricultural activities, with F. pedrosoi being the dominant aetiologic agent. All isolates had low MICs for itraconazole, voriconazole and terbinafine, confirming their importance as therapeutic alternatives for chromoblastomycosis.

New possibilities for chromoblastomycosis and phaeohyphomycosis treatment: identification of two compounds from the MMV Pathogen Box® that present synergism with itraconazole

BACKGROUND

Black fungi of the Herpotrichiellaceae family are agents of chromoblastomycosis and phaeohyphomycosis. There are few therapeutic options for these infections and it is common to associate antifungal drugs in their treatment.

OBJECTIVES

To investigate the Medicines for Malaria Venture (MMV) Pathogen Box^® for possible compounds presenting synergism with antifungal drugs used to treat black fungal infections.

METHODS

An initial screening of the Pathogen Box^® compounds was performed in combination with itraconazole or terbinafine at sub-inhibitory concentrations against Fonsecaea pedrosoi. Hits were further tested against eight Herpotrichiellaceae using the checkerboard method.

FINDINGS

No synergism was observed with terbinafine. MMV687273 (SQ109) and MMV688415 showed synergism with itraconazole against F. pedrosoi. Synergism of these compounds was confirmed with some black fungi by the checkerboard method. SQ109 and itraconazole presented synergism for Exophiala dermatitidis, F. pedrosoi, F. monophora and F. nubica, with fungicidal activity for F. pedrosoi and F. monophora. MMV688415 presented synergism with itraconazole only for F. pedrosoi, with fungicidal activity. The synergic compounds had high selectivity index values when combined with itraconazole.

MAIN CONCLUSIONS

These compounds in combination, particularly SQ109, are promising candidates to treat Fonsecaea spp. and E. dermatitidis infections, which account for most cases of chromoblastomycosis and phaeohyphomycosis.

Chromoblastomycosis in Latin America and the Caribbean: epidemiology over the past 50 years

Chromoblastomycosis is a chronic disease caused by melanized fungi that mainly affect individuals performing soil-related labour. The objective of this study was to analyse the epidemiological and clinical characteristics of chromoblastomycosis in Latin America and the Caribbean by an extensive literature review. An integrative review was performed of English, French, Portuguese, and Spanish publications in LILACS, SciELO, PubMed, SCOPUS and Web of Science databases covering the period 1969-2019. A total of 1,211 articles were identified, of which 132 were included in the review, covering 2,081 patients, 80.3% were male, the mean age was 56.1 years. The mean duration of the disease was 10.8 years. The lesions were mainly described in the lower limbs (60%). The most frequent clinical forms were verrucous (46.4%) and tumorous (21.7%). Major disease symptoms and signs consisted of itching and pain. Bacterial infection and functional limitation were important complications. Immunosuppression post-kidney transplantation was the most frequent comorbidity while leprosy was the main concomitant infectious disease. Fonsecaea pedrosoi and Cladophialophora carrionii were the predominant etiological agents. Majority of the cured cases were treated with itraconazole as monotherapy or in combination with other antifungals, surgery or cryosurgery. Chromoblastomycosis affects hundreds of rural workers in Latin America and the Caribbean, causing disability and personal, family and economic losses. It is important to prioritize epidemiological surveillance and early diagnosis of this disease in order to reveal its real prevalence and direct resources to preventive actions, diagnosis and early treatment.

LAY SUMMARY

Chromoblastomycosis is a slowly progressing chronic disease caused by melanized fungi. We collected data from South America and the Caribbean covering 1969-2019, the 132 articles included 2 081 patients, mean disease duration was 10.8 years. Fonsecaea pedrosoi and Cladophialophora carrionii predominated.

The global burden of chromoblastomycosis

BACKGROUND

Chromoblastomycosis (CBM), represents one of the primary implantation mycoses caused by melanized fungi widely found in nature. It is characterized as a Neglected Tropical Disease (NTD) and mainly affects populations living in poverty with significant morbidity, including stigma and discrimination.

METHODS AND FINDINGS

In order to estimate the global burden of CBM, we retrospectively reviewed the published literature from 1914 to 2020. Over the 106-year period, a total of 7,740 patients with CBM were identified on all continents except Antarctica. Most of the cases were reported from South America (2,619 cases), followed by Africa (1,875 cases), Central America and Mexico (1,628 cases), Asia (1,390 cases), Oceania (168 cases), Europe (35 cases), and USA and Canada (25 cases). We described 4,022 (81.7%) male and 896 (18.3%) female patients, with the median age of 52.5 years. The average time between the onset of the first lesion and CBM diagnosis was 9.2 years (range between 1 month to 50 years). The main sites involved were the lower limbs (56.7%), followed by the upper limbs (19.9%), head and neck (2.9%), and trunk (2.4%). Itching and pain were reported by 21.5% and 11%, respectively. Malignant transformation was described in 22 cases. A total of 3,817 fungal isolates were cultured, being 3,089 (80.9%) Fonsecaea spp., 552 (14.5%) Cladophialophora spp., and 56 Phialophora spp. (1.5%).

CONCLUSIONS AND SIGNIFICANCE

This review represents our current knowledge on the burden of CBM world-wide. The global incidence remains unclear and local epidemiological studies are required to improve these data, especially in Africa, Asia, and Latin America. The recognition of CBM as NTD emphasizes the need for public health efforts to promote support for all local governments interested in developing specific policies and actions for preventing, diagnosing and assisting patients.

Fonsecaeapedrosoi Conidia and Hyphae Activate Neutrophils Distinctly: Requirement of TLR-2 and TLR-4 in Neutrophil Effector Functions

Chromoblastomycosis is a chronic and progressive subcutaneous mycosis caused mainly by the fungus Fonsecaea pedrosoi. The infection is characterized by erythematous papules and histological sections demonstrating an external layer of fibrous tissue and an internal layer of thick granulomatous inflammatory tissue containing mainly macrophages and neutrophils. Several groups are studying the roles of the innate and adaptive immune systems in F. pedrosoi infection; however, few studies have focused on the role of neutrophils in this infection. In the current study, we verify the importance of murine neutrophils in the killing of F. pedrosoi conidia and hyphae. We demonstrate that phagocytosis and reactive oxygen species during infection with conidia are TLR-2- and TLR-4-dependent and are essential for conidial killing. Meanwhile, hyphal killing occurs by NET formation in a TLR-2-, TLR-4-, and ROS-independent manner. In vivo experiments show that TLR-2 and TLR-4 are also important in chromoblastomycosis infection. TLR-2KO and TLR-4KO animals had lower levels of CCL3 and CXCL1 chemokines and impaired neutrophil migration to the infected site. These animals also had higher fungal loads during infection with F. pedrosoi conidia, confirming that TLR-2 and TLR-4 are essential receptors for F. pedrosoi recognition and immune system activation. Therefore, this study demonstrates for the first time that neutrophil activation during F. pedrosoi is conidial or hyphal-specific with TLR-2 and TLR-4 being essential during conidial infection but unnecessary for hyphal killing by neutrophils.

Chromoblastomycosis in an Endemic Area of Brazil: A Clinical-Epidemiological Analysis and a Worldwide Haplotype Network

Chromoblastomycosis (CBM) is a neglected implantation mycosis prevalent in tropical climate zones, considered an occupational disease that affects impoverished rural populations. This retrospective study described clinical aspects of CBM in a hyperendemic area in Brazil and constructed a worldwide haplotype network of Fonsecaea spp. strains. The variables were collected from medical records using a standard report form, reporting 191 patients with CBM from Maranhão, Brazil. The mean age was 56.1 years, 168 (88%) patients were male and predominantly farmers (85.8%). The mean time of evolution of the disease until diagnosis was 9.4 years. Lower limbs (81.2%) and upper limbs (14.2%) were the main sites affected. Most patients exhibited verrucous (55%) and infiltrative plaque (48.2%). Fonsecaea spp. were identified in 136 cases and a haplotype network constructed with ITS sequences of 185 global strains revealed a total of 59 haplotypes exhibiting high haplotypic and low nucleotide diversities. No correlation was observed between the different haplotypes of Fonsecaea species and dermatological patterns, severity of disease or geographic distribution inside Maranhão. Data from this area contributed to better understanding the epidemiology of CBM. For the first time, a robust haplotype network with Fonsecaea strains reveals an evolutionary history with a recent population expansion.

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 fungi occurring mainly in tropical and subtropical zones worldwide. This study assessed 12 patients with chromoblastomycosis from Rondônia, Brazil, Amazon region. In sum, 83.3% were men, 41.6% were from Monte Negro city, median age was 52.9 years, and median time to disease progression was 12.2 years. Lesions were located on the lower limbs (75%), and verruciform was prevalent form (66.6%). After 3 years of treatment with itraconazole, two patients were considered cured. The etiological agents were identified by the molecular sequence of the ribosomal internal transcribed spacer ITS1, 5.8S, and ITS2 region and β-tubulin genes. Eight strains were identified as Fonsecaea pedrosoi, two were F. nubica, and two were Rhinocladiella similis. The antifungal activity of five drugs was evaluated, and the most active drug was terbinafine (range minimal inhibitory concentration [MIC] 0.015-0.12 μg/ml), itraconazole (range MIC 0.03-0.5 μg/ml) and voriconazole (range MIC 0.06-0.5 μg/ml). The highest MIC was 5-fluorocytosine (range MIC 2-32 μg/ml), and amphotericin B (range MIC 0.25-2 μg/ml). In conclusion, the present study expanded the epidemiological disease database and described for the first time F. nubica and R. similis as chromoblastomycosis agents in the Brazilian Amazon region. Our results confirmed the importance of using molecular methods to identify the melanized fungi and stimulate the recognition of the disease in other places where no cases have been reported.

Chromoblastomycosis Caused by Fonsecaea nubica: First Report in Northern China and Literature Review

Chromoblastomycosis is found worldwide with higher incidence in tropical and subtropical regions. Fonsecaea spp. is one of the major causative agents of this disease. First case of chromoblastomycosis due to Fonsecaea nubica in Northern China is reported in a 75-year-old Chinese male. We firstly summarized molecular identification methods of Fonsecaea spp. and all the strains of F. nubica reported in the literature. Sequencing of internal transcribed spacer alone and/or combined with actin (ACT1), partial cell division cycle (CDC42) and partial beta-tubulin (BT2) were most commonly used to identify species, while lactase (Lac), homogentisate (HmgA) and polyketide synthase (PKS1) were also used in some cases. Most strains were isolated from South America and Eastern China. Five clinical cases of chromoblastomycosis due to F. nubica from Asia and Europe were also reviewed. All the five patients were male, over 30 years old, and their lesions occurred after trauma.

Chromoblastomycosis Caused by Phialophora verrucosa in a Costa Rican Child with Skin Sequelae due to Snake Bite

Chromoblastomycosis is an implantation mycosis occurring among adults working in farms or with soil in tropical and subtropical areas worldwide. Fonsecaea pedrosoi is the most important agent in the tropical areas, while Phialophora verrucosa, although not a predominant agent, is found in the lowlands under the same conditions as the Fonsecae species.

We present the case of a 10-year-old aboriginal boy, belonging to a soil worker family, with a history of extensive leg lesions and lymphedema secondary to a snake bite five years earlier. He was admitted to the National Children's Hospital (part of the Caja Costarricense del Seguro Social: the social security system in Costa Rica) with multiple verrucous confluent lesions on the ankle, some with dark coloration, and no other symptoms. Clinical suspicion of chromoblastomycosis was made and later confirmed by culture. Itraconazole was started showing clinical improvement.

Chromomycosis, especially in the population with skin lesions or chronic tissue compromise, associated with the location and macroscopic findings, must be a part of our differential diagnosis. The story of an exposed pediatric patient to soil work and the history of an important leg swelling and skin disruption as sequelae of snake bite envenomation made this case unique. To our knowledge, there are no pediatric reports of Chromoblastomycosis in Latin America.

Molecular identification of chromoblastomycosis clinical isolates in Guangdong

Chromoblastomycosis is a chronic fungal infection of the skin and subcutaneous tissue. The most common etiologic agent encountered in Southern China is from the genus Fonsecaea. Fonsecaea species are often misidentified due to indistinct morphology features; furthermore, recent taxonomy revision was done on the fungi genus. Herein, a comprehensive evaluation with molecular sequencing data based on internal transcribed spacer (ITS) ribosomal DNA regions as molecular targets were implemented to 37 clinical isolates from chromoblastomycosis patients. Twenty strains that were formerly identified as Fonsecaea pedrosoi through morphological characteristic were verified to be either Fonsecaea nubica or Fonsecaea monophora, while 17 strains were appropriately identified as F. monophora. A phylogenetic method was further performed to establish the species delimitation. Our investigations validate that the clinical isolates from Guangdong consist of F. monophora and the recently found new species, F. nubica. In this study, F. pedrosoi has not been isolated from chromoblastomycosis patients in Guangdong, Southern China. Reevaluation of previous reports regarding F. pedrosoi as chromoblastomycosis etiologic agent in China is necessary for a comprehensive assessment of geographic distribution pattern of Fonsecaea species. This study is the first reported study presenting large samples of F. nubica domestic or abroad.

Case Report: A Case of Chromoblastomycosis Caused by Fonsecaea pedrosoi in Vietnam

BACKGROUND

Chromoblastomycosis is a chronic fungal infection of the skin and subcutaneous tissues caused by different melanized fungi. The disease occurs worldwide, particularly in tropical and subtropical regions but not reported in Vietnam. A 47-year-old women was admitted to hospital 103, Hanoi, Vietnam, with a 10-year lasting lesion on backside of her right shank. Diagnosis of chromoblastomycosis was made after discovery of a muriform cell in histopathological examination. A black, slow-growth fungus was isolated and identified as Fonsecaea pedrosoi after molecular analysis. After 1-month treatment with itraconazole, the lesion has significant improvement.

CONCLUSION

This is the first case of chromoblastomycosis caused by Fonsecaea pedrosoi reported in Vietnam.

Melanin particles isolated from the fungus Fonsecaea pedrosoi activates the human complement system

BACKGROUND

Melanin production has been associated with virulence in various pathogenic fungi, including Fonsecaea pedrosoi, the major etiological agent for chromoblastomycosis, a subcutaneous fungal disease that occurs in South America.

OBJECTIVE

The aim of this study was to evaluate the effects of acid-basic extracted F. pedrosoi melanin particles and fungal cell ghosts obtained by Novozym 234 treatment on their ability to activate the human complement system.

METHODS

The ability of melanin particles and fungal cell ghosts to activate the human complement system was evaluated by complement consumption, immunofluorescence, and enzyme-linked immunosorbent assay (ELISA).

FINDINGS

Unsensitised melanin particles and melanin ghosts presented complement consumption of 82.67 ± 2.08% and 96.04 ± 1.13%, respectively. Immunofluorescence assays revealed intense deposition of the C3 and C4 fragments on the surface of melanin particles and ghosts extracted from F. pedrosoi. Deposition of the C3, C4, and C5 fragments onto melanin samples and zymosan was confirmed by ELISA. Deposition of small amounts of C1q and C9 onto melanin samples and zymosan was detected by ELISA.

CONCLUSION

Fonsecaea pedrosoi melanin particles and fungal cell ghosts activated the complement system mainly through an alternative pathway.

Differential distribution patterns of Fonsecaea agents of chromoblastomycosis, exemplified by the first case due to F. monophora from Argentina

Chromoblastomycosis is a mutilating infection of the skin and subcutaneous tissues caused by melanized fungi belonging to the order Chaetothyriales. Proven cases of the main agent, Fonsecaea pedrosoi are mainly limited to (sub)tropical, humid climates of Latin and Central America and the Caribbean. Fonsecaea monophora has a global distribution along the equator. Cases outside the (sub)tropics have thus far mostly been considered to have been imported, but here we report the first endemic case by F. monophora from Argentina. Patient was a 82-year-old rural female worker from Corrientes, a province with a dry continental climate.

Chromoblastomycosis: tissue modifications during itraconazole treatment

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.

Chromoblastomycosis in India: Review of 169 cases

Chromoblastomycosis (CBM) is a chronic, progressive, cutaneous and subcutaneous fungal infection following the traumatic implantation of certain dematiaceous fungi. The disease has worldwide prevalence with predominant cases reported from humid tropical and subtropical regions of America, Asia, and Africa. Diagnosis is often delayed or misdirected either due to poor degree of clinical suspicions or clinical simulation of dermatological conditions. The infection is not uncommon in India and several case reports from the sub-Himalayan belt and western and eastern coasts of India have been published; however, very few have reviewed the cases. We reviewed 169 cases published in English literature from India during 1957 through May 2016, including 2 recent cases from our institute. A tremendous increase in the number of reported cases was noticed since 2012, since which, more than 50% of the cases had been published. A majority of the patients (74.1%) were involved in various agricultural activities directly or indirectly. The mean age at presentation was 43.3 years ± 16.0, with male to female ratio of 4.2:1. The duration of disease at the time of presentation varied from 20 days to 35 years. Any history of trauma was recalled only in 33.8% of the studied cases. The lower extremity was the most common site afflicted, followed by the upper extremity. The culture was positive in 80.3% of the cases with Fonsecaea pedrosoi, isolated as the most common fungal pathogen, followed by Cladophialophora carrionii. Although all the commercially available antifungals were prescribed in these cases, itraconazole and terbinafine were the most commonly used, either alone or in combination with other drugs/physical methods, with variable degrees of outcome. Combinations of different treatment modalities (chemotherapy and physical methods) yielded a cure rate of 86.3%. CBM is refractory to treatment and no single antifungal agent or regimen has demonstrated satisfactory results. Increased awareness with early clinical suspicion of the disease and adequate therapy are necessary to improve the outcome. However, depending upon the causative agent, disease severity, and the choice of antifungals, variable outcomes can be observed.

[Chromomycosis acquired in a non-tropical area: A case report]

BACKGROUND

Chromomycosis, or chromoblastomycosis, is caused by cutaneous inoculation of dematiaceous fungi of telluric or plant origin. It is generally seen in tropical or subtropical zones. Treatment of the condition is known to be complex. Herein we report a case of chromomycosis contracted in a temperate region of Eastern Europe/Central Asia that was effectively treated with oral itraconazole and terbinafine in combination with cryotherapy.

PATIENTS AND METHODS

A 44-year-old immunocompetent male subject consulted for a lesion on the buttocks that he had sustained 16 years earlier, and which, although never previously treated, had only become troublesome within the last few months. The examination revealed a large erythemato-squamous plaque containing a heterogeneous infiltrate. The diagnosis was based upon biopsy, with histological examination revealing sooty mould ; culture of a second sample showed the causative agent to be Fonsecaea pedrosoi. After 30 months of treatment combining oral terbinafine at a very high dose (1000mg/day), topical terbinafine and adjuvant cryotherapy, considerable, though incomplete, improvement was obtained. Finally, combined use of terbinafine (500mg/day) and itraconazole (200mg/day) led to clinical and histological cure.

DISCUSSION

The possibility of acquiring chromomycosis other than in a tropical zone is slight but has nevertheless been described, particularly in Eastern Europe. In our patient, the exact source of contamination is unknown, although it may have been acquired through frequent horse-riding or use of saunas. This case confirms the efficacy of combined itraconazole and terbinafine against this condition, which is usually difficult to treat.

Tumoral chromoblastomycosis: a rare manifestation with typical complementary exams

Chromoblastomycosis is a chronic subcutaneous fungal infection caused by traumatic implantation of dematiaceous fungi in the skin. The clinical presentation is usually a verrucous plaque lesion and the diagnosis is confirmed by the visualization of muriform bodies at direct examination or at the histologic study. This report describes a rare case of tumoral chromoblastomycosis confirmed by histologic study and whose agent was identified by culture and micromorphology.

Subcutaneous mycoses in coastal Karnataka in south India

BACKGROUND

Subcutaneous mycoses are chronic, localized infections of the skin and subcutaneous tissue which occur following traumatic implantation of the etiological agent. The causative organisms are soil saprophytes of regional epidemiology with varying ability to adapt to the tissue environment and elicit disease.

OBJECTIVES

This study was conducted to evaluate the various types of subcutaneous mycoses, including actinomycotic mycetomas, in south coastal Karnataka, India.

METHODS

Between January 2005 and January 2013, a total of 25 patients were diagnosed with subcutaneous mycoses based on a detailed clinical history and presentation, histopathology, and culture of organisms.

RESULTS

Chromoblastomycosis was the infection most commonly seen (n = 16 patients, 64%), followed by mycetoma (n = 4, 16%), sporotrichosis (n = 4, 16%), and rhinoentomophthoromycosis (n = 1, 4%). The extremities were the most common site of involvement, with the lower limb being most affected (64%). Males were more commonly afflicted (64%) than females (36%). Most patients were agricultural workers, although preceding trauma was noted in only three patients. The majority of patients responded well to therapy and were disease-free on follow-up.

CONCLUSIONS

Subcutaneous mycoses are a rare group of disorders. Chromoblastomycosis is the most frequent subcutaneous fungal infection in south India. Morphologically, chromomoblastomycoses present as verrucous, ulcerative, nodular, or eczematous lesions. Clinical diagnosis is important as culture is often negative. The incidence of infection is higher among rubber tappers. It is important to clinically differentiate chromoblastomycosis from tuberculosis verrucosa cutis. Most of the subcutaneous mycoses respond well to treatment, with the exception of rhinoentomophthoromycosis, which is a rare form of deep mycosis with associated mutilation. Eumycetomas are not observed in this part of India.

Clinical and demographic profile of chromoblastomycosis in a referral service in the midwest of São Paulo state (Brazil)

Chromoblastomycosis is one of the most frequent deep mycoses found in rural populations. This cross-sectional, retrospective and descriptive study was conducted with cases of chromoblastomycosis diagnosed throughout 20 years. A higher prevalence was observed among White male rural workers, with an average age of 59.69 years. Median time between onset of symptoms and diagnosis was 156 months. Lesions were predominantly located on the lower limbs; 34% of cases reported previous trauma. The most common associated symptoms were itching, pain and burning sensation. Mycological examination was positive in 91% of cases and Fonsecaea pedrosoi was the most prevalent etiologic agent.

Workloads and occupational accidents in a rural environment

This study's objective was to identify the types of workload accruing from agricultural work that are recognized by farmworkers and to verify occupational accidents in two rural environments. This quantitative, exploratory and descriptive study was conducted with 259 farmworkers in the state of Rio Grande do Sul, Brazil using a semi-structured questionnaire. Descriptive analysis, Person's Chi-Square test, and coefficient of contingency were used. The workloads most frequently reported by farmers were heat, fungi, chemicals, dust, repetitive movements, heavy load-lifting, and inappropriate postures. Most accidents occurred with farm implements followed by falls. Significant associations were found among different isntruments and accidents. The results suggest the need for investment in health actions in rural environments to prevent or minimize work-related accidents and diseases so that nurses can contribute in a broad and efficient manner.

Chromoblastomycosis in a Diabetic Patient Without a History of Trauma

Chromoblastomycosis (CBM) is a slowly progressive cutaneous and subcutaneous mycosis mostly seen in tropical and subtropical areas and Fonsecaea pedrosoi is the most common cause. The authors describe the case of a diabetic Haitian woman, presenting with a chronic verrucous plaque without any history of trauma. Her histopathologic results showed epidermal hyperplasia and sclerotic bodies, which are diagnostic for CBM. Her therapy began with itraconazole 200 mg tablets twice a day. The unique feature of this patient is the coincidence of diabetes and CBM. However, to the best of our knowledge, this is the first documented case of human CBM in Miami, FL, which develops the awareness regarding this diagnosis among doctors in this area. There should be a close communication between dermatologists and pathologists to make an early diagnosis of CBM and also adequate therapy, which both are fundamental to improve patient's quality of life.

In situ immune response in human chromoblastomycosis--a possible role for regulatory and Th17 T cells

BACKGROUND

Chromoblastomycosis is a chronic fungal infection that affects skin and subcutaneous tissue. Lesions can be classified in tumorous, verrucous, cicatricial and plaque type. The cellular immune response in the severe form of the disease seems to correlate with a Th2 pattern of cytokines. The humoral immune response also seems to play a role. We intended to explore the populations of regulatory T cells and the Th17 pattern.

METHODOLOGY

Twenty-three biopsies of verrucous form were obtained from patients with clinical, culture and histopathological diagnostic of chromoblastomycosis, without treatment. It was performed an immunohistochemistry method to detect Foxp3, CD25, TGF-β, IL-6, IL-17 and IL-23.

PRINCIPAL FINDINGS

IL-17 was the only cytokine with high expression in CBM when compared to normal skin. The expression of Treg cells, TGF- β, IL-6 and IL-23 were similar to normal skin.

CONCLUSIONS/SIGNIFICANCE

The constitution of a local immune response with high expression of IL-17 and low expression of other cytokines could be at least in part, an attempt to help the immune system against fungal infection. On the other hand, high levels of local immune response mediated by Th17 profile could overcome the role of Treg cells. The inefficient immunomodulation as a consequence of the unbalance by Treg/Th17 cells seems to corroborate with the less effective immune response against fungi.

Chromoblastomycosis: an exuberant case

Chromoblastomycosis is a chronic subcutaneous mycotic infection caused by dematiaceous saprophytic moulds. The most frequently isolated agent is Fonsecae pedrosoi. This article reports a case of a man from the Amazon region in Northern Brazil who presented with a lesion of 12 months' duration, which gradually increased in size until covering the majority of his right leg. A successful treatment with itraconazole was performed.

Plasmacytoid dendritic cells in cutaneous lesions of patients with chromoblastomycosis, lacaziosis, and paracoccidioidomycosis: a comparative analysis

Plasmacytoid dendritic cells (pDCs) are characterized by expression of CD123 and BDCA-2 (Blood Dendritic Cell Antigen 2) (CD303) molecules, which are important in innate and adaptive immunity. Chromoblastomycosis (CBM), lacaziosis or Jorge Lobo's disease (JLD), and paracoccidioidomycosis (PCM), are noteworthy in Latin America due to the large number of reported cases. The severity of lesions is mainly determined by the host's immune status and in situ responses. The dendritic cells studied in these fungal diseases are of myeloid origin, such as Langerhans cells and dermal dendrocytes; to our knowledge, there are no data for pDCs. Forty-three biopsies from patients with CBM, 42 from those with JLD and 46 diagnosed with PCM, were evaluated by immunohistochemistry. Plasmacytoid cells immunostained with anti-CD123 and anti-CD303 were detected in 16 cases of CBM; in those stained with anti-CD123, 24 specimens were obtained from PCM. We did not detect the presence of pDCs in any specimen using either antibody in JLD. We believe that, albeit a secondary immune response in PCM and CBM, pDCs could act as a secondary source of important cytokines. The BDCA-2 (CD303) is a c-type lectin receptor involved in cell adhesion, capture, and processing of antigens. Through the expression of the c-lectin receptor, there could be an interaction with fungi, similar to other receptors of this type, namely, CD207 in PCM and CD205 and CD209 in other fungal infections. In JLD, the absence of expression of CD123 and CD303 seems to indicate that pDCs are not involved in the immune response.

A case of extensive chromoblastomycosis from North India

A case of extensive chromoblastomycosis of the right leg and thigh with verruciform to nodular lesions evolving rapidly over five years duration is reported. The diagnosis was confirmed by visualizing pathognomonic pigmented muriform bodies with unique septate hyphae and mycological culture yielding Fonsecaea pedrosoi.

Topical application of imiquimod as a treatment for chromoblastomycosis

Chromoblastomycosis is a subcutaneous mycosis that remains a therapeutic challenge, with no standard treatment and high rates of relapse. On the basis of our recent discoveries in mouse models, we tested the efficacy of topical applications of imiquimod to treat patients afflicted with this chronic fungal infection. We report results of treatment for the first 4 recipients of topical imiquimod, all of whom displayed a marked improvement of their lesions, both with and without concurrent oral antifungal therapy.

Case of chromoblastomycosis with pulmonary involvement

Chromoblastomycosis is a slowly growing chronic cutaneous mycosis associated with a variety of cutaneous lesions. Extra-dermal involvement is rare. A 58-year-old man was admitted to the hospital with nausea, vomiting, weakness and a history of weight loss. On inspection, he had a large verrucous mass in the sacral region, and two large subcutaneous nodules in the anterior thoracic wall. He claimed the lesions were several years old. Biopsy and histological studies were positive for chromoblastomycosis. Routine chest radiography showed hilar enlargement, and a chest computed tomography was ordered. Pulmonary nodules were evident, and endoscopically acquired samples were also positive for chromoblastomycosis. Extra-dermal and systemic involvement in chromoblastomycosis is exceedingly rare and often associated with immunosuppression. There is only one other case of pulmonary chromoblastomycosis reported in the published work.

Subcutaneous fungal infections

Subcutaneous mycoses are common in tropical and subtropical regions of the world. These infections have multiple features in common, including similar epidemiology, mode of transmission, indolent chronic presentation with low potential for dissemination in immunocompetent hosts, and pyogranulomatous lesions on histopathology. Herein, we provide up-to-date epidemiologic, clinical, diagnostic, and therapeutic data for three important subcutaneous mycoses: chromoblastomycosis, mycetoma, and sporotrichosis.