Single Plaque-Type Chromoblastomycosis: Great
and Sustained Response with Itraconazole
Mariana Costa Garcia1, Bruna Moretto1, Marta Vainchenker3, Roberto Moreira Amorim Filho2 and Gustavo Moreira Amorim1,2*
1Faculty of Medicina of South Santa Catarina Universisty, Brazil
2 Santa Tereza Sanitary Dermatology Hospital / Santa Catarina Health Secretary, Brazil
3Anatomical Pathology Institute / Santa Catarina Health Secretary, Brazil
Submission: February 04, 2020;Published: February 14, 2020
*Corresponding author: Gustavo Moreira Amorim. Dermatologist from Federal University of Rio de Janeiro. Master’s Degree in Anatomical Pathology from Federal University of Rio de Janeiro. Dermatology Professor from Faculty of Medicina of South Santa Catarina Universisty. Dermatology from Santa Tereza Sanitary Dermatology Hospital da Faculdade de Medicina da Universidade do Sul de Santa Catarina. Médico Dermatologista, Brazil
How to cite this article: Mariana Costa Garcia, Bruna Moretto, Marta Vainchenker, Roberto Moreira Amorim Filho, Gustavo Moreira Amorim. Single
Plaque-Type Chromoblastomycosis: Great and Sustained Response with Itraconazole Plus Cryosurgery. JOJ Dermatol & Cosmet. 2020; 2(2): 555585. DOI: 10.19080/JOJDC.2020.02.555585
We present a 72-years-old male patient, resident in a urban area, with a chronic cutaneous ulcer on the left forearm, diagnosed with chromoblastomycosis, treated with a combination therapy of oral itraconazole and cryocirurgery, with 6-months follow up after treatment.
The Chromoblastomycosis (CBM) is a chronic fungal infection caused by the traumatic implantation of demeaceous fungi of the Herpotrichiellaceae family on the skin and subcutaneous cellular tissue [1-3]. These fungi are more common in tropical and subtropical areas, and can be found in the soil, in vegetation and decomposing wood [1,2]. It is more common in male rural workers, lumbermen or sellers of agricultural products . Brazil is the second country in number of cases, being found throughout its entire territory [2,5].
Male pacient, 72 years, urban dweller, retired (former bricklayer), sought medical attention due to injury to the left forearm. It started 6 months earlier as a papulo-pustular lesion, wich progressed slowly and progressively to an erythematous plaque, with a rough surface; asymptomatic. Upon examination, an infiltrated, erythetous-keratotic plaque was indentified, with well-defined edges and an irregular, slightly verrucous surface, measuring about 5.0cm in the largest diameter (Figure 1). Dermoscopy indentified black dots (Figure 2). When questioned, he associated the injury
with a sharp puncture trauma during the repair of the house fence. With the hypothesis of subcutaneous mycosis (chromomycosis and sporotrichosis), tuberculosis, in addition to neoplasia (squamous cell carcinoma), an incisional biopsy was performed.
Histopathological examination showed chronic granulomatous
dermatitis associated with pseudoepitheliomatous hyperplasia of
the epidermis. In the dermis, the presence of sclerotic cells (Figure
3), confirming the diagnosis of Chromoblastomycosis. Fungal
culture isolated the demeaceous fungus Fonsecaea Pedrosoi.
Treatment with Itraconazole 200mg/day for 6 months, associated
with 4 sessions of Cryosurgery (local infiltrative anesthesia, tip B,
intermittent jets, 2 cycles, thawing time 2 times that of freezing) at
1-month intervals. Apparent clinical cure 6 months after the end of
treatment (Figure 4).
CBM begins with a primary lesion at the traumatic fungus
inoculation site, usually oligosymptomatic, delaying the demand
for care [2,4]. A papule is noted, usually in areas of exposed skin,
wich grows in a centrifugal manner. There may be progression
of the condition due to contiguity, in addition to lymphatic and/
or hematogenic dissemination [1,2,6]. It is classified clinically
in 5 types: nodular, verrucous or verruciform, plaque, tumor and
scar or atrophic. Possible complications are secondary bacterial
infection, elephantiasis and carcinomatous degeneration [2,6].
The differential diagnosis is made with paracoccidioidomycosis,
sporotrichosis, lacaziosis, leishmaniasis, mycetomas, leprosy,
tuberculosis, atypical mycobacteriosis, prototecosis, in addition to
squamous cell carcinoma .
Epidemiology assists in diagnosis, especially in endemic
areas.4 This can be confirmed by visualization of the fungus in
direct examination, in tissues with histopathological examination,
in addition to culture isolation.5 The sclerotic (muriform) cells are
pathognomonic for CBM, regardless of the causative species . The
treatment is difficult, with recurrence and chronic lesions being
common.6 There is no gold standard of treatment. Some options
are cryosurgery, carbon, dioxide laser, itraconazole, flucytosine,
terbinafine, amphotericin B, fluconazole, posaconazole, imiquimod,
super-satured potassium iodide and thermotherapy, used alone or
in combination. The choice depends on the age and comorbidities
of the pacient, as well as the location of the lesions . Cryosurgery
with liquid nitrogen and thermotherapy are suitable options for
isolated and limites lesions . Already the antifungals that have
shown greater effectiveness are itraconazole and terbinafine for 6
to 12 months, preferably in higher doses, if tolerated .
We present an illustrative case of CBM, plaque shape, in an
elderly man from an urban area, with a report after questioning
trauma involving a wooden and wire fence, seeking to draw
attention to this entity in the day-to-day of the dermatologist even if
outside endemic area and without typical epidemiology. In parallel,
a good therapeutic result is demonstrated with the association of
surgical and medication techniques, which are accessible and well