Lower Limb Nodulo-ulcerative Lesion in Kidney Transplant Recipient - An Unusual Diagnosis

Treatment-Resistant Chromoblastomycosis Successfully Managed With Surgical Excision

Chromoblastomycosis is an uncommon, chronic granulomatous fungal infection of the skin and subcutaneous tissue. Chromoblastomycosis is most commonly caused by the traumatic inoculation of dematiaceous (pigmented) fungi, most commonly Fonsecaea species, Phialophora species, and Cladophialophora species. Chromoblastomycosis usually affects agricultural workers in tropical and subtropical climates. The World Health Organization classifies chromoblastomycosis as a neglected tropical and occupational disease that commonly affects middle-aged men in poor to middle-income countries. The cutaneous lesions of chromoblastomycosis typically affect the lower extremities and present as polymorphous, hyperkeratotic, or fungating small papules, plaques, verrucous nodules, or ulcers; therefore, a high degree of clinical suspicion is necessary to consider the diagnosis of chromoblastomycosis. The diagnosis is made by visualization of the thick-walled pigmented structures referred to as sclerotic bodies (also known as Medlar bodies or muriform bodies) or pigmented septate hyphae or both on a biopsy specimen of the lesion. Treatment may consist of locally destructive techniques, prolonged systemic antifungal therapy, and/or surgical excision. In this paper, we present an immunocompetent 80-year-old Caucasian woman who developed an isolated lesion of chromoblastomycosis on the forearm while gardening in Texas, a non-endemic area for the disease. Her infection was refractory to systemic antifungal medications and cryotherapy with liquid nitrogen. Ultimately, her fungal infection was successfully treated with a wide local surgical excision of the infectious cutaneous lesion.

The Role of Excision for Treatment of Chromoblastomycosis: A Cutaneous Fungal Infection Frequently Mistaken for Squamous Cell Carcinoma

BACKGROUND

Chromoblastomycosis is an uncommon fungal infection of the skin caused by a variety of dematiaceous fungal species that is typically contracted through direct inoculation into the skin.

OBJECTIVE

To collect and examine data pertaining to the clinical presentation and management of patients with chromoblastomycosis.

METHODS

Through a retrospective study, a pathology medical record search was performed from January 2004 to December 2020 at a single institution.

RESULTS

A total of 9 patients were identified. Seven of 9 cases occurred in solid organ transplant recipients. All cases were located on the extremities. Six of 9 cases were clinically suspected to be squamous cell carcinoma. Seven of 9 cases were treated with surgical excision. Six of 9 patients were treated with oral antifungal medication. Four of 9 patients had received combination therapy. Eight of 9 patients had no recurrence of the disease after treatment.

CONCLUSION

Chromoblastomycosis presents as verrucous papules or nodules and may clinically and histopathologically mimic squamous cell carcinoma. Immunosuppression is likely a risk factor for the development of chromoblastomycosis. This study highlights the importance of clinical awareness of this disease's clinical presentation and prevalence in immunosuppressed patient populations.

Dematiaceous fungal infections in solid organ transplantation: systematic review and bayesian meta-analysis

BACKGROUND

Dematiaceous fungi cause a number of infectious syndromes referred to as phaeohyphomycosis among both immunocompetent and immunocompromised hosts. We performed a systematic review to characterize these infections in solid organ transplant recipients (SOTR).

METHODS

We searched PubMed database (last searched 1/6/2022) for English-language reports on dematiaceous fungal infections in SOTR. Included reports needed individualized demographic, treatment, and outcome data; pediatric reports were excluded. A universally applicable bias assessment was performed on reports. Models for infection type and outcome were created using the Bayesian paradigm.

RESULTS

We included 149 reports on 201 cases of dematiaceous fungal infections in SOTR. The mean age was 54 years, 72% were men, and kidney recipients accounted for 61% of cases. Skin and soft tissue infection (SSTI) was the most common infectious syndrome (73%). Death from infection occurred in 7% of cases (14/201), with disseminated (32%) cases having the highest mortality. Our model for infection type predicted the relative probability of central nervous system infection to be highest in liver recipients. Across all transplant types, higher relative probabilities of disseminated and pulmonary infections occur in the early post-transplant period, and the predicted probabilities for these infection types decreased after 100 months post-transplantation.

DISCUSSION

We identified SSTI as the most common dematiaceous fungal infections in SOTR. Disseminated infections carried the worst prognosis. The evidence in this review is limited by the heterogeneity of included cases. No funding source was used, and this review's protocol was not registered. This article is protected by copyright. All rights reserved.