2/20/2006 Alternative names ◦ chromomycosis ◦ cladosporiosis ◦ verrucous dermatitis Presentation Developed by: Tom Mariani ◦ phaeosporotrichosis Katie Forte ◦ Pedroso’s disease Jenee Thurston Terra Runyon ◦ Fonseca’s disease http://doctorsgates.blogspot.com/2011/03/case-of- chromoblastomycosis.html BIOL 4849: Medical Mycology 1 2 ◦ Kingdom: Fungi Most common: ◦ Phialophora verrucosa ◦ Phylum: Ascomycota ◦ Fonsecaea compacta ◦ Class: Euascomycetes ◦ Fonsecaea pedrosi Only species isolated from evergreen forests in tropical ◦ Order: Chaetothyriales regions ◦ Family: Herpotrichiellaceae ◦ Cladosporium carrionii Found only in spiny desert areas ◦ Genus: Fonsecaea, Rhinocladiella Phialophora, Cladophialophora, ◦ Rhinocladiella aquaspersa (Ramichloridium cerophilum) 3 4 Mainly tropical and Fonsecaea -no known subtopic regions (Brazil & phase Madagascar) Primary conidia Costa Rica function as sympodial conidiogenous cells to Because of gradual rising form the secondary of temperature and conidia increased immigration travel, cases have been spreading from tropical In vivo morphism to temperate areas. Form ascospores by Rare reports from sexual reproduction Canada and U.S. 5 6 1 2/20/2006 Predominant in males Fungus breaks through ages 30-60 cutaneous tissue and metastasizes to Increased cases in subcutaneous agricultural workers such lymphocytes as farmers Transforms to parasitic Rarely seen in adolescence stage Fibrosis leads to increase of infection impairing lymphatic flow causing lack Can occur in patients who Chromoblastomycosis of circulation are immunosuppressed agents elicit dense after renal transplants fibrous response in Leads to skin atrophy, dermis deformity, and ankylosis of joints. 7 8 . Diagnosis Histopathology ◦ Microscopy in 10% potassium ◦ Mycotic granuloma hydroxide Examining lesions covered with “black dots” Testing of skin scrapings, crusts, aspirated ◦ Neutrophilic dermal infiltrate debris ◦ Biopsy ◦ Epithelial hyperplasia Enhance positive culture results, due to decrease of bacterial contamination Epithelium involved in transepidermic (a) Direct examination of skin scrapings in a potassium Assess standards for disruption of treatment Culture of Fonsecaea pedrosoi hydroxide mount Source:http://web.ebscohost.com/ehost/pdfviewer/p elimination of fungus Source: dfviewer?vid=3&hid=10&sid=ead00456-ffa8-41be- http://web.ebscohost.com/ehost/pdfviewer/ 9269-08e52e1978c1%40sessionmgr11 pdfviewer?vid=3&hid=10&sid=ead00456- ffa8-41be-9269- ◦ PCR Assays 08e52e1978c1%40sessionmgr11 ◦ Presence of muriform cells, medlar (b) Close-up of Medlar bodies Identification of Fonsecaea species and C. Source: carrionii http://emedicine.medscape.com/article/109 bodies or “Copper Pennies” 2695-overview ◦ ELISA 9 10 Treatment ◦ Itraconazole, possibly combined with Clinical Manifestations ◦ Tumorous, sclerotic lesions in terbinafine cutaneous and subcutaneous tissue ◦ Flucytosine ◦ Elephantiasis Figure: Cryotheraphy Source: Source: http://www.mold.ph/fonsecaea.htm ◦ Posaconazole & Voriconazole http://fromyourdoctor.com/topic.do?title=Cryo ◦ Cauliflower-like masses, sclerotic therapy+Liquid+Nitrogen&t=2225 plaques or keloids Expensive & long-term ◦ Chemotherapy ◦ Lesions classified as Nodular ◦ Local Heat therapy Tumorous Verrucous F. predrosoi is vulnerable in high temperatures Cicatricial ◦ Cryotherapy Source: http://www.usnon.com/treatment- of-invasive-aspergillosis-itraconazole.htm Plaque Source: //http://www.nejm.org/doi/pdf/10.1056/NEJMicm040848 ◦ Surgery 11 12 2 2/20/2006 16 year old boy from Assam, Laboratory examinations India History of thorn prick in including haemogram, and dorsum of right foot 6 years ago. blood chemistry were normal, except for slightly 8 month history of numerous raised ESR well-defined papulated plaques over both upper and lower extremities, trunk, and both ears, Patient was tested and found scalp and genitalia negative for HIV1 and HIV2 by ELISA Lesions appeared initially on dorsum of right foot, radiated Biopsy and skin scrapings superiorly were collected for direct microscopy and cultures. Lesions appeared on trunk and forearm 2 months later Histopathological Fig. 2 examination of stained During first 6 months, plaques biopsy tissue showed extended from dorsum of feet to Mycopathologia (2010) 169:381–386) right knee and mid calf of left leg epitheliomatous hyperplasia, with marked chronic inflammation and sclerotic bodies. (Fig 2) • Microscopic examination of A slide culture was also performed, microscopy skin scraping in 10% KOH showed conidiophores bearing revealed oval, brown, outwardly spreading, sparsely septate sclerotic bodies (Fig branching. Long acrepetal 6) chains of ellipsoidal, smooth- walled, symmetrical, one- Fig 6 celled conidia. (Fig 4) • Patient was treated with Fluconazole 150mg PO/day Isolate was also tested for for 6 months thermotolerance, failing to grow at 37°C and 42°C • Patient returned for follow The isolate was identified as Fig. 4 Mycopathologia (2010) 169:381–386 up showing slight reduction Cladophialophora carrionii of the lesions of his arms, Fig 7 with no reduction in size of rest of the lesions (Fig 7) Mycopathologia (2010) 169:381–386) • Laboratory examinations 55 year old Male working in a tea garden in including haemogram, and Assam, India blood chemistry were also normal Presented with Cauliflower like painless mass in left leg above ankle with 9 years duration • A biopsy was taken for direct microscopy and incubation. History of trauma due to burn of left leg from motorcycle silencer pipe 10 years ago • Direct microscopy in 20% KOH showed brown, septate, Fig 3 Scaly papule first appeared 6 months after the sclerotic bodies injury Mycopathologia (2010) 169:381–386) Lesion spread, first becoming wart like, then • An Olivaceous-black, velvety forming a cauliflower like mass colony appeared after 10 days of incubation at 25°C and 37°C, increasing in size to 3cm after 1 month (Fig 3) 3 2/20/2006 Two early cases of Chromoblastomycosis have been reported from Assam, the isolates were Hormodendrum compectum and F. Pedrosoi A slide culture was also performed, microscopy The two more recent cases shown here from Assam were C. carrionii and F. showed cylindrical pedrosoi, this is the first case of C. carrionii in Assam, India. conidiogenous cells usually with an irregularly swollen The most common causative agent of Chromoblastomycosis is F. pedrosoi apex, that is studded with The most common sight of infection are the lower extremities, however one of scars from conidial the cases showed extensive involvement of the whole body in a short amount of attachment. (Fig 5) time Chromoblastomycosis infection follows traumatic implantation of the etiologic Patient was treated with agent beneath the epidermis via penetration by foreign bodies Fluconazole 150mg PO/day for Fig 5 6 months Early stages of treatment involve surgery, electrodesiccation, cryosurgery or Mycopathologia (2010) 169:381–386) topical antifungals. More advanced cases require systemic antifungals for long periods of time Patient was seen for follow up after 1 month with decrease in Intraconazole and Terbinafine are the drugs of choice size of the lesion on foot Fluconazole is said to be a poorly effective drug for these agents, however, both patients were treated with Fluconazole due to the expensiveness of the above antifugals. Ameen M. (2009). Chromoblastomycosis: clinical presentation and 1. What phylum do the etiological agents of chromoblastomycosis belong to? a) Zygomycota management. Clinical And Experimental Dermatology, 34(8), 849-54 b) Ascomycota c) Deuteromycota d) Basidiomycota DR. FUNGUS, 27 JAN. 2007. WEB. 20 JULY 2011. 2. What is another name for chromoblastomycosis? <HTTP://WWW.DOCTORFUNGUS.ORG/THEFUNGI/INDEX.PHP> a) Elephantitis b) Epithelial hyperplasia c) chromomycosis Queiroz-Telles F;Esterre P;Perez-Blanco M;Vitale RG;Salgado CG;Bonifaz d) Euascomycetes A. (2009). Chromoblastomycosis: an overview of clinical manifestations, 3. Who is most likely to be affected by chormoblastomycosis? a) Infants diagnosis and treatment. Medical Mycology: Official Publication Of The b) Businessmen International Society For Human And Animal Mycology, 47(1), 3-15. c) Farmers d) Women 4. Treatment of chromoblastomycosis does not include: SCHWARTZ, ROBERT. "CHROMOBLASTOMYCOSIS." MEDSCAPE. 2011. a) Chemotherapy b) Cryotherapy WEB. 21 JULY 2011 c) Continual shots*** d) Itraconazole 5. Lesions are classified as all except: Sharma, A., Hazarika, N., & Gupta, D. (2010). Chromoblastomycosis in sub- a) Tumorous tropical regions of India. Mycopathologia, 169(5), 381-386. Retrieved from b) Scalar** EBSCOhost. c) Nodular d) Verrucous 21 BIOL 4849: Medical Mycology 2/20/2006 22 4.