A 21 yr old student presented with 5-year history of warty growth on the
right foot. It started as a small lesion which gradually got bigger.
Pertinent findings on examination were raised hyperkeratotic plaque 5 x 3 cm
on the medial border of the dorsum of the right foot. It has a verrucous
surface with blackish dots. Regional nodes were not palpable.
Clinically he has chromoblastomycosis of the right foot.
A biopsy was done and the epithelium shows marked acanthosis with elongation
of rete ridges and intraepithelial collections of neutrophils. The dermis is
densely infiltrated by lymphocytes, plasma cells and few neutrophils.
Culture of organism was not done.
I may repeat the biopsy and perform fungal culture.
I plan to treat him with liquid nitrogen together with some combination
therapy with antifungals: itraconazole 100mg bd ( 200mg bd??) for several
months together with another antifungals. 5FU or IV amphotericin.
Would appreciate your comments on this patient.
Dear Henry,
ReplyDeleteI think morphology is very much suggestive of Chromoblastomycosis. It is often not possible to demonstrate fungal pathogens in culture or Histopathology. KOH examination of overnight saline soaked gauze can be sometime fruitful. It should respond well to itraconazole 400 mg/day in 8-12 weeks and response should be evident by 2 weeks. Other adjunct therapies can be considered if there is no satisfactory response to Itraconazole alone. There is difference of opinion about optimum duration of antifungal therapy - 1 month or 3 month after clinical resolution of lesion. Though there are some guidelines to monitor response to therapy and test of cure.
Hi Henry,
ReplyDeleteWe do not see much chromoblastomycisis in North America. I found this article on PubMed. I wonder, are the authors still in practice? They may be interested in your patient.
Mycopathologia. 1990 Jan;109 (1):27-31.
Chromoblastomycosis in Malaysia.
Jayalakshmi P, Looi LM, Soo-Hoo TS.
Department of Pathology, Faculty of Medicine, University of Malaya, Kuala Lumpur.
Nine cases of histologically diagnosed chromoblastomycosis are reported from Malaysia. All the patients were males and ranged in age from 56 to 65 years. The duration of symptoms varied from 5 months to 13 years. All the lesions were noted in the lower limbs. Malignancy was suspected clinically in 5 cases. The diagnosis
was established by finding characteristic brown muriform cells in the tissue sections.
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