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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 31  |  Issue : 3  |  Page : 201-204

A study on chromoblastomycosis in a tertiary care hospital of eastern Odisha


Department of Microbiology, SCB Medical College, Cuttack, Odisha, India

Date of Web Publication17-Aug-2017

Correspondence Address:
Gitanjali Sarangi
Department of Microbiology, SCB Medical College, Cuttack - 753 007, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_78_16

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  Abstract 


Background: Chromoblastomycosis, a chronic subcutaneous mycosis, is caused by several dematiaceous Fungi, the most common being Fonsecaea pedrosoi. A majority of cases from India have been reported from the sub-Himalayan belt and South India.
Aim: The aim was to study chromoblastomycosis in the eastern coastal parts of Odisha including demographic and clinicomycological profile.
Materials and Methods: This report is a retrospective hospital record-based analysis of all cases of chromoblastomycosis who presented to the dermatology outpatient department of our tertiary care hospital during the past 5 years.
Results: A total of 11 cases of chromoblastomycosis were diagnosed during the above period. The disease was seen predominantly in middle-aged male farmers from a rural background. The lower extremity (72.7%) was more commonly affected. Verrucous and nodular lesions are the common clinical presentation. Sclerotic bodies are demonstrated in potassium hydroxide mount and histopathological section in 81.8 and 90.9% cases, respectively. The causative fungus was isolated in 90.9% of cases with F. pedrosoi, as the most common species.
Conclusion: Chromoblastomycosis mostly affects male agriculturalists, especially from a rural background. Early etiological diagnosis helps in effective management of the condition.

Keywords: Chromoblastomycosis, Fonsecaea pedrosoi, sclerotic bodies


How to cite this article:
Sarangi G, Dash M, Paty BP, Mohapatra D, Majhi S, Chayani N. A study on chromoblastomycosis in a tertiary care hospital of eastern Odisha. J Med Soc 2017;31:201-4

How to cite this URL:
Sarangi G, Dash M, Paty BP, Mohapatra D, Majhi S, Chayani N. A study on chromoblastomycosis in a tertiary care hospital of eastern Odisha. J Med Soc [serial online] 2017 [cited 2019 Jul 23];31:201-4. Available from: http://www.jmedsoc.org/text.asp?2017/31/3/201/207677




  Introduction Top


Chromoblastomycosis is an uncommon chronic localized fungal infection of the skin and subcutaneous tissue presenting with slow progressive verrucous lesion.[1],[2] The infection is caused by dematiaceous (pigmented) Fungi which produce sclerotic or muriform bodies within the tissue. The most common causative agents are Fonsecaea pedrosoi, Phialophora verrucosa, Fonsecaea compacta, and Cladosporium carrionii.[3],[4],[5] The disease is commonly seen in the rural workers working in the tropical and subtropical climates. In India, such cases have been reported from the sub-Himalayan belt and the coastal areas due to hot humid climates in these areas.[6],[7]


  Materials and Methods Top


This study included a retrospective hospital record-based analysis of 11 cases of chromoblastomycosis who presented to the dermatology outpatient department of our tertiary care hospital during a period of 5 years from January 2011 to January 2016. A detailed history including demographic data, occupation, and history of trauma was recorded. Detailed clinical examination was performed to note the pattern of presentation. Microscopic examination of scraping from the lesions and black dots over the surface of the skin was performed using 20% potassium hydroxide (KOH). A separate skin swab was collected aseptically for fungal culture using Sabouraud dextrose agar and culture for Mycobacterium species. Biopsy was undertaken from the lesion and subjected to histopathological examination in the department of pathology. The present study has been approved by the Institutional Ethics Committee.


  Results Top


A total of 11 cases of chromoblastomycosis were diagnosed during the period of 5 years. The majority of the patients were male with a male-to-female ratio of 1.4:1. The ages ranged from 21 to 65 years. Most of the patients belonged to the age group of 21–35 years (5, 45.4%) followed by the age group of 36–60 years (3, 27.2%).

Out of the 11 cases, five were farmers, three were homemakers, two were laborers, and one was student by occupation. Majority (8), i.e., 72.7% of them do not give a history of injury. Only three of them recalled a history of trauma, i.e., penetrating injury in one case and abrasions in two cases.

The site of affection was lower extremity in the majority of cases (8, 72.7%). The lesion was limited mostly to the legs in six cases and affected the heel in two cases [Figure 1]. There was involvement of the arm in three cases (27.2%) [Figure 2] and [Table 1]. The clinical presentation was verrucous or nodular lesion in eight cases and plaques of varying sizes in three cases. Scraping from the lesions and black dots gave a positive result for sclerotic bodies in nine (81.8%) cases in KOH mount as shown in [Figure 3]. All the cases were histopathologically proven with demonstrable characteristic brown thick-walled sclerotic bodies either within or outside the giant cells in ten (90.9%) cases [Figure 4].
Figure 1: Verrucous and nodular lesions on lateral surface of the left leg

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Figure 2: Verrucous lesion on the right arm with surface scaling

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Table 1: Cases of chromoblastomycosis in a tertiary care hospital

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Figure 3: Microphotograph showing brown sclerotic bodies on potassium hydroxide mount

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Figure 4: Mixed mycotic granuloma with sclerotic bodies (arrows) on H and E stain

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Isolation of the causative fungus was possible in ten (90.9%) cases. The most common species was F. pedrosoi. The other species identified were C. carrionii and P. verrucosa.

The patients were treated with a combination of antifungal itraconazole (200–400 mg once daily) and terbinafine (500 mg once daily) in the cases for 3–6 months with periodic monitoring of liver function tests. All the cases responded to the above regimen expect in one case where intravenous amphotericin B was given.


  Discussion Top


Chromoblastomycosis is a chronic localized infection of the skin and subcutaneous tissue caused by a group of dematiaceous or black Fungi. The causative agent lives in soil, woods, and plant debris.[8],[9],[10] Chromoblastomycosis was originally reported from Brazil. In India, Thomas et al. first reported two cases of chromoblastomycosis from Assam. Since then, there have been several case reports from sub-Himalayan belt, western and eastern coasts.[11]

We studied the clinicomycological features of chromoblastomycosis in our tertiary care hospital which caters the eastern costal parts of Odisha. The infection usually occurs in the age group of 20–40 years with a male preponderance.[8] In our case series, the infection was found mostly in the age group of 21–35 years (45.4%) with a male-to-female ratio of 1.4:1. Rural males from an agricultural background were commonly affected which is the common pattern of the disease worldwide.[3],[12],[13],[14] In our study, out of the 11 cases, 5 were farmers.

Reports from India, Srilanka, Nepal, and also from Central and South America show common involvement of the lower extremity as was the case with our study.[3],[14] This may be due to frequent trauma to the lower legs during agricultural work. Chromoblastomycosis rarely involves the face but a few cases have also been reported.[15],[16]

Carrion described five morphological types of chromoblastomycosis consisting of nodular lesion, tumorous verrucous lesion, plaques, and cicatricial lesion.[17] The common clinical presentation in our study was verrucous and nodular lesions. The clinical diagnosis was accurate in ten cases. In one case, there was a coexisting squamous cell carcinoma with chromoblastomycosis. As the lesions are polymorphic, they must be differentiated from verrucous vulgaris, dermal Leishmaniasis, mycetoma, squamous cell carcinoma, and sporotrichosis.

The diagnosis of chromoblastomycosis should be confirmed by direct microscopy of the scraping from the lesions in 20% KOH when thick-walled dark brown tissue form of the fungus (sclerotic/copper penny bodies) is seen, histopathological examination of a biopsy specimen with granulomatous reaction and sclerotic bodies, or by culture of scraping or biopsy material.[17] In our series, sclerotic bodies were seen in nine cases in KOH mount and, in ten cases, the causative fungus was isolated by culture. Histopathologically, all the cases were proven with one or other features of chromoblastomycosis with the presence of sclerotic bodies. Although histopathological study is more appropriate for the diagnosis of chromoblastomycosis, KOH mount and culture method are simple, convenient, and noninvasive tests for the diagnosis of subcutaneous mycosis.[18],[19]

The treatment for chromoblastomycosis is cryosurgery for small lesions, itraconazole for larger ones, and, in some cases, a combination of both.[20] All our patients were treated either with itraconazole alone or itraconazole and terbinafine combination and responded well.


  Conclusions Top


Chromoblastomycosis evolves slowly and affects the quality of life. Therefore, a high index of suspicion and prompt laboratory diagnosis will help in the initiation of therapy at an early stage to prevent the complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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López Martínez R, Méndez Tovar LJ. Chromoblastomycosis. Clin Dermatol 2007;25:188-94.  Back to cited text no. 1
    
2.
Rubin HA, Bruce S, Rosen T, McBride ME. Evidence for percutaneous inoculation as the mode of transmission for chromoblastomycosis. J Am Acad Dermatol 1991;25:951-4.  Back to cited text no. 2
    
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Minotto R, Bernardi CD, Mallmann LF, Edelweiss MI, Scroferneker ML. Chromoblastomycosis: A review of 100 cases in the state of Rio Grande do Sul, Brazil. J Am Acad Dermatol 2001;44:585-92.  Back to cited text no. 3
    
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Hay RJ. Deep fungal infections in Wolff Klaus. In: Goldsmith LA, Katz S, Gilchrest BA, Paller AS, Leffell DJ, editors. Fitzpatrick's Dermatology in General Medicine. 7th ed. New York: McGraw Hill; 2008. p. 1831-44.  Back to cited text no. 4
    
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Venugopal PV, Venugopal TV, Abirami CP. Deep fungal infections. In: Valia RG, Valia AR, editors. IADVL Textbook of Dermatology. 3rd ed. Mumbai: Bhalani Publishing House; 2008. p. 298-330.  Back to cited text no. 5
    
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7.
Chandran V, Sadanandan SM, Sobhanakumari K. Chromoblastomycosis in Kerala, India. Indian J Dermatol Venereol Leprol 2012;78:728-33.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Longley BJ. Fungal diseases. In: Elder D, Elenitsas R, Jaworsky C, Johnson B, editors. Lever's Histopathology of the Skin. 8th ed. New York: Lippincott-Raven Publishers; 1997. p. 517-52.  Back to cited text no. 8
    
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Tang WK. Chromoblastomycosis. Hong Kong Dermatol Venereol Bull 2002;10:76-9.  Back to cited text no. 9
    
10.
Maize JC, Burgdorf WH, Hurt MA, Le Boit PE, Metcalf JS. Smith T, et al. Chromomycosis. In: Cutaneous Pathology. USA: Churchill Livingstone; 1998. p. 229-30.  Back to cited text no. 10
    
11.
Thomas E, Job CK, Hadley GG. Chromoblastomycosis. Indian J Med Sci 1957;11:570-3.  Back to cited text no. 11
    
12.
Attapattu MC. Chromoblastomycosis – A clinical and mycological study of 71 cases from Sri Lanka. Mycopathologia 1997;137:145-51.  Back to cited text no. 12
    
13.
Kombila M, Gomez de Diaz M, Richard-Lenoble D, Renders A, Walter P, Billiault X, et al. Chromoblastomycosis in Gabon. Study of 64 cases. Sante 1995;5:235-44.  Back to cited text no. 13
    
14.
Agarwalla A, Khanal B, Garg VK, Agrawal S, Jacob M, Rani S, et al. Chromoblastomycosis: Report of two cases from Nepal. J Dermatol 2002;29:315-9.  Back to cited text no. 14
    
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Pradhan SV, Talwar OP, Ghosh A, Swami RM, Shiva Raj KC, Gupta S. Chromoblastomycosis in Nepal: A study of 13 cases. Indian J Dermatol Venereol Leprol 2007;73:176-8.  Back to cited text no. 15
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16.
Bharti R, Malhotra SK, Bal MS, Sharma K. Chromoblastomycosis. Indian J Dermatol Venereol Leprol 1995;61:54-5.  Back to cited text no. 16
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Vollum DI. Chromomycosis: A review. Br J Dermatol 1977;96:454-8.  Back to cited text no. 17
    
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Goette DK, Robertson D. Transepithelial elimination in chromomycosis. Arch Dermatol 1984;120:400-1.  Back to cited text no. 18
    
19.
Zaias N, Rebell G. A simple and accurate diagnostic method in chromoblastomycosis. Arch Dermatol 1973;108:545-6.  Back to cited text no. 19
    
20.
Poirriez J, Breuillard F, Francois N, Fruit J, Sendid B, Gross S, et al. Acase of chromomycosis treated by a combination of cryotherapy, shaving, oral 5-fluorocytosine, and oral amphotericin B. Am J Trop Med Hyg 2000;63:61-3.  Back to cited text no. 20
    


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