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

Reviewing the Etiologic Agents, Microbe-Host Relationship, Immune Response, Diagnosis, and Treatment in Chromoblastomycosis

Chromoblastomycosis (CBM) is a neglected human disease, caused by different species of pigmented dematiaceous fungi that cause subcutaneous infections. This disease has been considered an occupational disease, occurring among people working in the field of agriculture, particularly in low-income countries. In 1914, the first case of CBM was described in Brazil, and although efforts have been made, few scientific and technological advances have been made in this area. In the field of fungi and host cell relationship, a very reduced number of antigens were characterized, but available data suggest that ectoantigens bind to the cell membrane of host cells and modulate the phagocytic, immunological, and microbicidal responses of immune cells. Furthermore, antigens cleave extracellular proteins in tissues, allowing fungi to spread. On the contrary, if phagocytic cells are able to present antigens in MHC molecules to T lymphocytes in the presence of costimulation and IL-12, a Th1 immune response will develop and a relative control of the disease will be observed. Despite knowledge of the resistance and susceptibility in CBM, up to now, no effective vaccines have been developed. In the field of chemotherapy, most patients are treated with conventional antifungal drugs, such as itraconazole and terbinafine, but these drugs exhibit limitations, considering that not all patients heal cutaneous lesions. Few advances in treatment have been made so far, but one of the most promising ones is based on the use of immunomodulators, such as imiquimod. Data about a standard treatment are missing in the medical literature; part of it is caused by the existence of a diversity of etiologic agents and clinical forms. The present review summarizes the advances made in the field of CBM related to the diversity of pathogenic species, fungi and host cell relationship, antigens, innate and acquired immunity, clinical forms of CBM, chemotherapy, and diagnosis.

A Rare Case of Chromoblastomycosis Resembling Keloid in an Indonesian Child

Chromoblastomycosis (CBM) is a rare chronic fungal infection caused by various dematiaceous fungi. This mycosis is mostly found in middle-aged males in tropical and subtropical countries. Only few cases of CBM in children have been reported. The diagnosis of CBM is often delayed due to the similarities with other dermatological diseases, such as cutaneous tuberculosis, mycetoma, leprosy, viral warts, psoriasis vulgaris, or malignancies. We report a case of an 11-year-old healthy boy having CBM. On his left knee, there were large erythematous plaques and tumors with scaly surfaces, some lesions appeared to be cauliflower-like. The patient denied pain and pruritus. The preliminary diagnosis was keloid; however, histopathological findings led to the final diagnosis, which was established as CBM. The patient was treated with oral itraconazole 100 mg daily. His lesions partially resolved within one month of treatment. Although uncommon in children, the differential diagnosis of CBM must be considered in any suspicious lesion(s). Itraconazole 100 mg daily gave a good response in children with CBM. Accurate diagnosis and early treatment are needed to achieve successful management of CBM in children.

Chronic health effects and cost of snakebite

The burden of disability among survivors and the socio-economic impact of snakebite have not been adequately researched. We reviewed original research articles, case reports and small case series relating to chronic physical, mental and psycho-social disability and economic burden of snakebite. Both physical and psychological health problems seem common in snakebite survivors and can lead to disability and loss of productivity. Chronic physical health effects, musculoskeletal disability being the commonest, can be largely attributed to limited and delayed access to optimal treatment of acute envenoming. The economic burden is considerable, and includes health system costs, out-of-pocket expenditure and opportunity costs, with regional variations. Health systems should be more responsive to needs and circumstances of bite victims, and a more holistic approach should be developed in the treatment of snakebite which incorporates the management of chronic health effects.

•

Limited attention has been paid to chronic disability and the socio-economic impact of snakebite.

•

Physical and psychological health problems occur in snakebite survivors leading to disability and loss of productivity.

•

Chronic health effects can be largely attributed to limited and delayed access to optimal treatment of acute envenoming.

•

Economic burden includes health system costs, out-of-pocket expenditure and opportunity costs.

•

Health systems should be responsive to needs and circumstances of bite victims including care of chronic health effects.

Aspartic peptidase of Phialophora verrucosa as target of HIV peptidase inhibitors: blockage of its enzymatic activity and interference with fungal growth and macrophage interaction

Phialophora verrucosa causes several fungal human diseases, mainly chromoblastomycosis, which is extremely difficult to treat. Several studies have shown that human immunodeficiency virus peptidase inhibitors (HIV-PIs) are attractive candidates for antifungal therapies. This work focused on studying the action of HIV-PIs on peptidase activity secreted by P. verrucosa and their effects on fungal proliferation and macrophage interaction. We detected a peptidase activity from P. verrucosa able to cleave albumin, sensitive to pepstatin A and HIV-PIs, especially lopinavir, ritonavir and amprenavir, showing for the first time that this fungus secretes aspartic-type peptidase. Furthermore, lopinavir, ritonavir and nelfinavir reduced the fungal growth, causing remarkable ultrastructural alterations. Lopinavir and ritonavir also affected the conidia-macrophage adhesion and macrophage killing. Interestingly, P. verrucosa had its growth inhibited by ritonavir combined with either itraconazole or ketoconazole. Collectively, our results support the antifungal action of HIV-PIs and their relevance as a possible alternative therapy for fungal infections.