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Fungal Foes: Presentations of Chromoblastomycosis Post–Hurricane Ike

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Fungal Foes: Presentations of Chromoblastomycosis Post–Hurricane Ike Close enCounters With the environment Fungal Foes: Presentations of Chromoblastomycosis Post–Hurricane Ike Catherine E. Riddel, MD; Jamie G. Surovik, MD; Susan Y. Chon, MD; Wei-Lien Wang, MD; Jeong Hee Cho-Vega, MD, PhD; Jonathan Eugene Cutlan, MD; Victor Gerardo Prieto, MD, PhD hromoblastomycosis, also known as chromo- A Gomori methenamine-silver stain was positive mycosis, is a chronic cutaneous and subcuta- for fungal organisms. He returned 2 weeks later for Cneous mycotic infection caused by a family of definitive excision of the entire lesion. Pathology of dematiaceous fungi. These species are found in the the excised tissue confirmed pigmented fungal organ- soil and on a variety of plants, flowers, and wood, isms consistent with chromoblastomycosis with clear primarily in tropical and subtropical regions. Infec- surgical margins. The patient had no evidence of tion typically results from implantation of spores into recurrence at a follow-up visit 6 months later. the subcutaneous tissue following trauma from plants, The patient resided on 10 acres of land in thorns, or wood splinters. We describe 3 patients Plantersville, Texas, a rural area approximately with chromoblastomycosis who presented to the 55 miles northeast of Houston. He reported clear- dermatology department at TheCUTIS University of Texas ing brush and downed trees from his property after MD Anderson Cancer Center in Houston in the Hurricane Ike in September 2008 with multiple months following Hurricane Ike, which occurred in episodes of trauma to the skin. He reported travel to September 2008. the Caribbean and Hawaii prior to the appearance of the lesion; however, he did not note any particular Case Reports trauma to the area of skin during those travels. The Patient 1—A 60-year-old white man developed a patient had been in remission for several years prior 1.2-cmDo red plaque on the left forearmNot concerning for to the appearanceCopy of the lesion. basal cell carcinoma. He had a history of renal cell Patient 2—A 64-year-old white man with a history carcinoma with right partial nephrectomy in 2002 of prostate cancer in 2003 but no evidence of recurrent and squamous cell carcinoma of the scalp treated with surgery and radiation therapy in 2005 with no recurrence of either malignancy. He presented in November 2008, 2 months after Hurricane Ike. A shave biopsy was performed and pathology revealed epidermal hyperplasia, a dermal granulomatous reac- tion, and pigmented fungal organisms morphologi- cally consistent with chromoblastomycosis (Figure). Dr. Riddel is from The University of Texas Health Science Center, Houston. Dr. Surovik is from Advanced Dermatology Skin Cancer and Laser Surgery Center, Denver, Colorado. Dr. Chon is from the Department of Dermatology and Drs. Wang and Prieto are from the Department of Pathology, The University of Texas MD Anderson Cancer Center. Dr. Cho-Vega is from St. Joseph Dermatopathology, Houston. Dr. Cutlan is from Marshfield Clinic, Wisconsin. The authors report no conflict of interest. Correspondence: Susan Y. Chon, MD, 1515 Holcombe Blvd, Faculty Pathology revealed pigmented fungal organisms mor- Center Tower, 11th Floor, Box 1452, Houston, TX 77030 phologically consistent with chromoblastomycosis (H&E, ([email protected]). original magnification 320). WWW.CUTIS.COM VOLUME 87, JUNE 2011 269 Copyright Cutis 2011. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Close Encounters With the Environment disease presented with an erythematous plaque of have the highest number of reported cases from 4 months’ duration on his left medial ankle in the American continent.1 Other notable regions January 2009. This lesion developed in the months with a high incidence of reported cases include following Hurricane Ike. On examination, a 1-cm Madagascar, Venezuela, Costa Rica, and Japan. The pink plaque with superficial scale was present on the first reported case in the United States occurred in left medial ankle. A shave biopsy of the lesion was Boston, Massachusetts, in 1915,2 followed by a sec- performed, revealing pigmented fungal organisms ond case in Fort Worth, Texas, in 1933.3 Located with associated pseudoepitheliomatous hyperplasia 50 miles inland from the Gulf of Mexico, Houston and underlying multinucleated giant cells. A Gomori and the surrounding areas of southeast Texas are methenamine-silver stain highlighted the fungal situated in a subtropical climate. However, reported organisms. The patient returned to the clinic approx- cases of chromoblastomycosis in Texas4-8 and other imately 1 month later and underwent definitive Gulf Coast regions are quite infrequent.9-15 Our cases excision of the entire lesion. Pathology of the excised of chromoblastomycosis were reported in the same tissue confirmed the presence of numerous pigmented region following a natural disaster. fungal organisms with clear surgical margins. Among the species associated with chromoblas- The patient resided in Highlands, Texas, a rural tomycosis in the Dematiaceae family are Fonsecaea area approximately 30 miles east of Houston. After pedrosoi, Fonsecaea compacta, Cladosporium carrionii, Hurricane Ike in September 2008, he sustained mul- Cladophialophora arxii, Phialophora verrucosa, tiple ant bites on the lower legs after clearing brush Rhinocladiella aquaspersa, Exophiala spinifera, Wangiella and multiple downed trees on his property. After dermatitidis, and Botryomyces caespitosus. Globally the ant bites healed, he continued to have a persis- as well as in the United States, infection with tently erythematous plaque on his left medial ankle, F pedrosoi is most frequently reported.1 The disease is which prompted him to seek evaluation. This plaque more common in men who work as rural laborers in intermittently developed scale, but he denied any agricultural fields or wooded areas without adequate associated itching or pain. The patient denied travel protective clothing or footwear. The most common outside of the country prior to the development of the sites of infection are the extremities, particularly the lesion. He was not being treatedCUTIS for cancer and was lower limbs.16 not taking any immunosuppressive medications. Following accidental inoculation of the host, the Patient 3—A 74-year-old white man with a his- dimorphic fungus transforms into the parasitic stage tory of colon cancer in 1988 and recurrence in 2003 consisting of round brown cells referred to as muri- presented in April 2009 with a 1-cm hyperkeratotic form cells, sclerotic bodies, or copper pennies.17 The nodule of 7 months’ duration on the dorsum of the muriform cells then form septa that are capable of right arm that was 4 cm proximal to the elbow. Clini- forming new muriform cells, which results in a dense cal examinationDo was suspicious Not for squamous cell car- fibrous reactionCopy in the skin with a mixed granuloma- cinoma. A shave biopsy of the lesion was performed tous response, multinucleated giant cells, and pseu- and pathology revealed epidermal hyperplasia, a doepitheliomatous hyperplasia. The macrophages dense lymphocytic infiltrate, and pigmented fun- and neutrophils present in the subcutaneous tissue gal organisms consistent with chromoblastomycosis. demonstrate frustrated phagocytosis of the muriform The patient returned to the clinic in June 2009 for cells.17 The persistence of fungal organisms in the skin definitive excision of the entire lesion. Pathologic eventually results in a flesh-colored or erythematous examination of the tissue showed a focal scar but no papule that may progress to a verrucous or scaly nod- remaining organisms were identified. ule or plaque.16 If untreated, the infection progresses The patient resided in Magnolia, Texas, a rural very slowly but may eventually form large verrucous area located 40 miles northwest of Houston. He masses or vegetations involving entire limbs. Aside reported working outdoors on his property after from pruritus, the lesions are relatively asymptomatic Hurricane Ike clearing brush and downed trees. and patients typically do not report pain or any other The patient denied travel outside of the country in disability, resulting in a delay in diagnosis. Although the preceding months. He had been healthy prior hematogenous dissemination has been reported, the to the appearance of the lesion with no evidence of organisms typically are not invasive in immuno- recurrent colon cancer in the last 6 years. competent patients and remain in the subcuta- neous tissue.16 Comment On September 13, 2008, Hurricane Ike made Clinical infection and demonstration of chro- landfall at Galveston, Texas, as a category 2 hur- moblastomycosis by culture was first described in ricane, devastating much of the island and caus- São Paulo, Brazil, in 1911, and Brazil continues to ing an estimated $24.9 billion in total damage to 270 CUTIS® WWW.CUTIS.COM Copyright Cutis 2011. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Close Encounters With the Environment Texas, Louisiana, and Arkansas, making it one of these fungi. Although the fungal species associated the costliest hurricanes in US history.18 Most of the with chromoblastomycosis typically are not invasive damage occurred on Galveston Island, Texas, and in immunocompetent hosts such as our patients, life- the surrounding areas including Houston. Natural threatening and fatal infections have been reported disasters, such
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