Chromoblastomycosis (Chromomycosis)


Article Author:
George Kurien
Kavin Sugumar


Article Editor:
Veena Chandran


Editors In Chief:
Ahmad Al Aboud
Jayakar Thomas
Pramod Nigam


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
6/11/2019 9:50:15 AM

Introduction

Chromoblastomycosis is a chronic granulomatous infection of the skin and subcutaneous tissue caused by several different dematiaceous fungi (brown pigment producing) resulting in the formation of slow-growing, warty plaques, cauliflower-like lesions which may ulcerate. The fungi produce thick-walled, single or multicelled clusters ( sclerotic or muriform bodies). The fungi are introduced into the body usually by trauma, and hence, the lesions are mostly found in exposed parts of the body. The disease runs a chronic course and most cases can be treated to the point of cure.[1]

Etiology

The disease can be caused by a large number of fungi. They are dematiaceous, i.e., producing brown pigment. The most common fungi are Cladosporium carrionii, Phialophora verrucosa, and Fonsecaea pedrosoi. Less common pathogens are Fonsacea compactum, Exophiala spinifera, Rhinocladiella aquaspersa, Exophiala jeanselmei, and Wangiella dermatitidis. The fungi have been isolated from wood and soil and enter the body following trauma. The condition is usually found in rural communities.[1]

Epidemiology

The disease is found throughout the world including Central, South and North America, Cuba, Jamaica, Martinique, India, South Africa, Madagascar, Australia, and northern Europe. It is much more common in the tropics and subtropics. It is more common in agricultural workers. Adult male agricultural workers are most often affected, but the condition also has been reported in children.[2]

Pathophysiology

The fungi enter the skin following trauma, evoking a granulomatous response. The epidermis shows pseudoepitheliomatous hyperplasia. In the dermis, a granuloma composed of epithelioid cells and Langhans giant cells are seen. The fungal elements can be seen as sclerotic bodies which are brown septate cells. The sclerotic bodies (medlar bodies/ muriform bodies/copper pennies) are extruded transepidermally, and they are seen as black dots on the surface of the lesion. This is characteristic of chromoblastomycosis.[3]

Histopathology

The histology is that of a foreign-body granuloma with isolated areas of microabscess formation. In the organized granuloma, mainly within giant cells, groups of fungal cells may be seen. They are chestnut or golden brown, and therefore can be easily distinguished in the infiltrate. The cells are characteristically divided into several planes of division by thick septa and are termed muriform or sclerotic cells. There is marked pseudoepitheliomatous hyperplasia of the epidermis, and in some areas, apparent transepidermal elimination of fungal cells, which can be found in the stratum corneum The tissue between the granulomatous nodules shows chronic fibrosis. When ulceration has occurred, there is usually a secondary bacterial infection.[3]

Toxicokinetics

Usually, the disease will remain localized with slow peripheral extension. There can be central scarring. The early lesion can occasionally be an ulcer.  After months or many years, large hyperkeratotic masses are formed. They can be as large as 3 cm thick. Secondary ulceration can occur, however, the lesion is usually painless. Satellite lesions are produced by scratching. In some cases, there can be lymphatic spread resulting in the sporotrichoid pattern. Hematogenous dissemination is very rare, but brain abscesses have been described[4]. The secondary infection eventually may lead to lymphatic stasis and production of elephantiasis. Some forms may develop psoriasiform lesions. Squamous cell carcinoma may develop in chronic cases.[5]

History and Physical

Usually, following trauma, a small warty papule appears. It enlarges very slowly to form a thick, hypertrophic, verrucous plaque. The lesion is, by and large, asymptomatic, though some patients may complain of occasional itching. Black dots (sclerotic bodies) will be seen on the surface of the plaque. These are fungal bodies eliminated transepidermally. They are usually solitary, but a few small lesions may also be seen in the periphery. These peripheral lesions are more common when there is itching. In some lesions, the plaque is flat and expands slowly with central scarring. The lesion is usually painless but can be painful in the presence of secondary infection. There can be lymphatic spread to adjacent areas.[5]

Evaluation

Scraping from the surface of the lesion will show sclerotic bodies. They are brownish septate cells seen singly or in clusters. The surface is scraped and 10% potassium hydroxide (KOH) is added to the scrapings which are then viewed under the microscope.

Histopathology will show pseudoepitheliomatous hyperplasia of the epidermis. The dermis shows granuloma composed of epithelioid cells and Langhans giant cells. There can be collections of eosinophils, lymphocytes, and plasma cells. Within the giant cells and also free in the tissue, dark brown thick walled ovoid or spheric spores (sclerotic bodies/medlar bodies/copper pennies) can be seen. In culture, the colonies of all species are dark grey-green to black and velvety or downy with a black reverse. Three forms of conidial production are observed, acropetal budding, production of phialides, and sympodial conidiation.[3]

Treatment / Management

Single small lesions can be excised followed by antifungal therapy. If surgery is not feasible, oral antifungals alone can be given. The antifungal drugs of choice are, itraconazole 200-400 mg/day or terbinafine, 250-500 mg/day given for a period varying from 6 months to a year or more. Flucytosine alone or combined with amphotericin also may be effective. Oral supersaturated potassium iodide solution is another choice. Other approaches to treatment are cryotherapy or local application of heat.[3]

Differential Diagnosis

In the differential diagnoses, other verrucous lesions like tuberculosis verrucosa cutis, verruca vulgaris, blastomycosis, leishmaniasis, syphilis, yaws verrucous hemangioma, hypertrophic lichen planus, and lupus vularis may be considered. In the sporotrichoid type in which linear lesions occur, sporotrichosis is a very close differential diagnosis. Presence of black dots on the surface which are due to the transepidermal elimination of fungal elements is the most important differentiating feature from other conditions. The black dots can be scraped preferentially from the surface and viewed under the microscope after adding 10% KOH.[6]

Prognosis

The disease can be treated to the point of cure. Early intervention will yield better results with little morbidity. Long-standing cases which are over joints and with lymphatic involvement have relatively high morbidity. Disseminated disease with involvement of the central nervous system has the worst prognosis. Prolonged treatment with hepatotoxic drugs is another factor which has to be considered. Best results are seen in small lesions which are amenable to surgery and followed up with antifungal therapy.

Pearls and Other Issues

Surgical treatment, though highly effective, may not be feasible due to lesions being present over joints. The duration of antifungal therapy is highly variable, and patient compliance can become a deciding factor.

Enhancing Healthcare Team Outcomes

Chromoblastomycosis is a rare fungal infection and is best managed by a multidisciplinary team that includes an infectious disease consultant, surgeon, emergency department physician, wound care nurse and an internist.Chromoblastomycosis is a chronic granulomatous infection of the skin and subcutaneous tissue caused by several different dematiaceous fungi (brown pigment producing) resulting in the formation of slow-growing, warty plaques, cauliflower-like lesions which may ulcerate. [7][8][9]

The diagnosis does require clinical suspicion. The prognosis depends on the size of the lesions and the immune status of the patient. Single small lesions can be excised followed by antifungal therapy. If surgery is not feasible, oral antifungals alone can be given. [3][10] (level V)[3]


  • Image 202 Not availableImage 202 Not available
    Contributed by DermNetNZ
Attributed To: Contributed by DermNetNZ

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Chromoblastomycosis (Chromomycosis) - Questions

Take a quiz of the questions on this article.

Take Quiz
A farmer from the tropics presents with several firm, irregular, skin-colored nodules on his lower legs. The largest has a papillomatous, scaly surface. He says the lesions have been growing over several years and that they are not itchy. Biopsy reveals Medlar bodies. What is the most likely cause?

(Move Mouse on Image to Enlarge)
  • Image 202 Not availableImage 202 Not available
    Contributed by DermNetNZ
Attributed To: Contributed by DermNetNZ



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What area is affected by the chronic fungal infection chromoblastomycosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
How does chromoblastomycosis generally enter the body?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient who is a recent immigrant from a tropical, remote, rural area has a large, raised, colored, cauliflower-like ankle lesion. Darkly pigmented, yeast-like sclerotic bodies are found in the tissue biopsy. Which of the following is the most likely etiology?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the characteristic histologic finding in chromoblastomycosis in addition to granuloma?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following antifungals is most effective and safe in treating chromoblastomycosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is chromoblastomycosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is not a synonym for a sclerotic body?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following does not cause chromoblastomycosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Chromoblastomycosis (Chromomycosis) - References

References

Garzon LM,Rueda LJ,Celis AM,Cardenas M,Guevara-Suarez M, {i}Exophiala psychrophila{/i}: A new agent of chromoblastomycosis. Medical mycology case reports. 2019 Mar;     [PubMed]
Verma S,Thakur BK,Raphael V,Thappa DM, Epidemiology of Subcutaneous Mycoses in Northeast India: A Retrospective Study. Indian journal of dermatology. 2018 Nov-Dec;     [PubMed]
Brito AC,Bittencourt MJS, Chromoblastomycosis: an etiological, epidemiological, clinical, diagnostic, and treatment update. Anais brasileiros de dermatologia. 2018 Jul-Aug;     [PubMed]
Queiróz AJR,Pereira Domingos F,Antônio JR, Chromoblastomycosis: clinical experience and review of literature. International journal of dermatology. 2018 Nov;     [PubMed]
Tawade Y,Gaikwad A,Deodhar A,Bhide D,Romi E,Pradhan A,Satpute M, Uncommon presentation of chromoblastomycosis. Cutis. 2018 Jun;     [PubMed]
de Azevedo CM,Gomes RR,Vicente VA,Santos DW,Marques SG,do Nascimento MM,Andrade CE,Silva RR,Queiroz-Telles F,de Hoog GS, Fonsecaea pugnacius, a Novel Agent of Disseminated Chromoblastomycosis. Journal of clinical microbiology. 2015 Aug     [PubMed]
Bhattacharjee R,Narang T,Chatterjee D, Cutaneous Chromoblastomycosis: A Prototypal Case. Journal of cutaneous medicine and surgery. 2019 Jan/Feb;     [PubMed]
Huang X,Han K,Wang L,Peng X,Zeng K,Li L, Successful treatment of chromoblastomycosis using ALA-PDT in a patient with leukopenia. Photodiagnosis and photodynamic therapy. 2019 Feb 12;     [PubMed]
Rojas-García OC,García-Martínez JM,Carrión-Álvarez D, [Chromoblastomycosis in Mexico. A forgotten disease]. Salud publica de Mexico. 2019 Ene-Feb;     [PubMed]
He L,Ma J,Mei X,Lu S,Li X,Xi L, Successful treatment of chromoblastomycosis of 10-year duration due to Fonsecaea nubica. Mycoses. 2018 Apr;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Dermatology-Pediatric. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Dermatology-Pediatric, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Dermatology-Pediatric, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Dermatology-Pediatric. When it is time for the Dermatology-Pediatric board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Dermatology-Pediatric.