New possibilities for chromoblastomycosis and phaeohyphomycosis treatment: identification of two compounds from the MMV Pathogen Box® that present synergism with itraconazole.

BACKGROUND: Black fungi of the Herpotrichiellaceae family are agents of chromoblastomycosis and phaeohyphomycosis. There are few therapeutic options for these infections and it is common to associate antifungal drugs in their treatment. OBJECTIVES: To investigate the Medicines for Malaria Venture (MMV) Pathogen Box® for possible compounds presenting synergism with antifungal drugs used to treat black fungal infections. METHODS: An initial screening of the Pathogen Box® compounds was performed in combination with itraconazole or terbinafine at sub-inhibitory concentrations against Fonsecaea pedrosoi. Hits were further tested against eight Herpotrichiellaceae using the checkerboard method. FINDINGS: No synergism was observed with terbinafine. MMV687273 (SQ109) and MMV688415 showed synergism with itraconazole against F. pedrosoi. Synergism of these compounds was confirmed with some black fungi by the checkerboard method. SQ109 and itraconazole presented synergism for Exophiala dermatitidis, F. pedrosoi, F. monophora and F. nubica, with fungicidal activity for F. pedrosoi and F. monophora. MMV688415 presented synergism with itraconazole only for F. pedrosoi, with fungicidal activity. The synergic compounds had high selectivity index values when combined with itraconazole. MAIN CONCLUSIONS: These compounds in combination, particularly SQ109, are promising candidates to treat Fonsecaea spp. and E. dermatitidis infections, which account for most cases of chromoblastomycosis and phaeohyphomycosis.

Successful treatment of chromoblastomycosis of 10-year duration due to Fonsecaea nubica.

We report a case of chromoblastomycosis due to the presence of large plaque and verrucous hyperplasia lesions on the left upper limb, with elbow abnormal activities, in a 56-year-old male. The diagnosis of chromoblastomycosis was based on gross and microscopic morphologies, histopathological examination and clinical manifestation. Molecular tools were applied to identifying the causative agent Fonsecaea nubica, which is rarely reported to be associated with chromoblastomycosis. The patient was initially treated orally with terbinafine (250 mg/day) and itraconazole (200 mg/day), subsequently patient received thermotherapy (45-50°C, 3 h/day) for 1 month. The patient was successfully cured. A literature review was performed to assess general features, treatment and outcome of chromoblastomycosis due to F.  nubica. All the 5 reviewed patients were male, over 30 years old and their lesions occurred after traumatic inoculation.

A refractory case of chromoblastomycosis due to Fonsecaea monophora with improvement by photodynamic therapy.

Chromoblastomycosis is one of the most frequently encountered mycoses in tropical and temperate regions caused by the implantation of the infectious structures and one which is associated with low cure and high relapse rates. The etiologic agents play a critical role affecting clinical outcome and in southern China, Fonsecaea pedrosoi and F. monophora are the main causative agents of chromoblastomycosis. We treated, for two years, a 55-year-old male patient with chromoblastomycosis caused by F. monophora with itraconazole and terbinafine, two antifungals recommend in earlier papers in the literature but without any positive response. As a result we introduced the photodynamic therapy (PDT) employing 5-aminolevulinic acid (ALA) irradiation. The lesions were improved after two periods of ALA-PDT treatment, each consisting of exposures at weekly intervals for 5 weeks but new lesions developed with the cessation of ALA-PDT treatment. Thereafter, positive clinical improvement was obtained when voriconazole at 200 mg was combined with terbinafine at 250 mg in treating the patient. The in vitro susceptibility of the F. monophora isolate to terbinafine, itraconazole, and voriconazole was assessed and the fungus was found to be sensitive to all three, with the minimal inhibitory concentrations of 0.125, 1, 0.0625 µg/ml, respectively. However, the determination of in vitro susceptibility profiles may not predict clinical response.

[Chromoblastomycosis caused by Fonsecaea monophora].

Fonsecaea species are major etiologic agents of Chromoblastomycosis (CBM). By genetic analysis, the genus Fonsecaea has recently been revised and classified into F. pedorosoi, F. monophora and F. nubica. Here we report a severe chronic case of CBM caused by F. monophora. A 55-year-old Filipino male developed progressive skin lesions on the left lateral ankle in 1973, when he worked at a coconut plantation in the Philippines. In 1999, he received medical treatments for enlarged, multiple lesions on the left lower limb. When he moved to Japan in 2005, the lesions were remarkably improved and he discontinued taking the medicine. On our first examination in October 2008, a large, reddish, cicatricial plaque was observed on the left lower aspect of his leg. Several tumorous lesions surrounded the plaque, indicating that the therapies performed before had been insufficient. In addition, there were many patchy scars scattered on the thigh and the upper part of the lower leg. The diagnosis of CBM was made by the presence of muriform cells. Black, pulverulent colonies were yielded in culture of skin scrapings and tissues. Although the fungus could not be identified by microscopic morphology, r-RNA ITS sequence analysis enabled identification of Fonsecaea monophora. The patient responded well to oral voriconazole combined with local thermotherapy using pocket warmers. The tumoral masses subsided in 6 months, leaving pink scars with negative fungal culture. Voriconazole treatment was continued for 18 months. It seems that drugs are insufficiently delivered in the cicatricial lesions because of the paucity of blood flow, suggesting that a long-term follow-up is necessary for such a case.

Antifungal activity of Pterocaulon alopecuroides (Asteraceae) against chromoblastomycosis agents.

Plants of the genus Pterocaulon (Asteraceae) are popularly used in the treatment of skin diseases caused by fungi and bacteria. The aim of this work was to investigate the in vitro activity of the crude methanolic extract obtained from the aerial parts of Pterocaulon alopecuroides (Lam.) against some agents of chromoblastomycosis, a chronic fungal infection of the skin and of the subcutaneous tissue caused by traumatic inoculation of the aetiological agent. The extract was active against all the strains tested showing a minimum inhibitory concentration between 625 and 2500 microg ml(-1). The assessment of fungistatic/fungicidal activity demonstrated that the extract was fungistatic against Fonsecaea spp. and fungicidal against all the other fungi. Our results indicate that the identification of bioactive components present in the crude methanolic extract of P. alopecuroides against chromoblastomycosis agents can be an important strategy to manage this mycosis in the future.

[Sporotrichosis and dematiaceous fungal skin infections].

Sporotrichosis is a chronic infectious granuloma of skin. The detection of fungal elements in pathological examination and the isolation of Sporothrix schenckii from the lesion are requisite for diagnosis. The sporotrichin test is useful as an auxiliary examination, but a false-negative reaction might occur in some cases. Oral potassium iodide is first choice of treatment, because of its modest cost and usefulness, although gastrointestinal disorder is a frequent side effect. Itraconazole should be the second selection, and then terbinafine. Local thermotherapy is also effective as an additional therapy. Dematiaceous fungal skin infections are divided into two groups by their parasitic form, chromoblastomycosis and phaeohyphomycosis. Chromoblastomycosis is also called chromomycosis in Japan. It is most important for clinical diagnosis to detect dark brown spores in the scale of chromoblastomycosis and dark brown hyphae in the pus of phaeohyphomycosis by microscopic examination. Both morphological and molecular biological approaches are recommended for identification of fungi. In treatment, the drug appropriate in each case should be selected, and the combination of surgical excision, local thermotherapy, laser therapy or cryotherapy must be considered.

[A case of chromomycosis caused by Fonsecaea pedrosoi presenting as a small plaque on the left upper arm: a review of reported cases of dematiaceous fungal infection in Japan].

We report a case of a 67-year-old woman with chromomycosis on the left upper arm. The plaque was a very small, erythematous and scaly lesion with a diameter of 1.5 cm. Fonsecaea pedrosoi was isolated as the causal fungus, and a number of Phialophora type conidia, the formation of which is considered rare, were observed. Treatment involved surgical excision of the lesion with a 5 mm margin. Follow up three years later revealed no recurrence. In Japan, 536 patients with chromomycosis were reported from 1955 to 2004. This consisted of 296 cases from 1955 to 1981 as reported by Fukushiro, and 240 cases from 1982 to 2004 as reviewed by us. Our examination of data showed that the most common causal fungi was F. pedrosoi with 137 cases (57.15%), followed by Exophiala jeanselmei with a total of 41 cases (17.15%), other fungal species comprised of 16 cases (6.7%), Phialophora verrucosa in 9 cases ( 3.8%) and E. dermatitidis in 4 cases (1.7%). Compared to the previous report by Fukushiro, the incidence of infection with E. jeanselmei had increased. Of the 235 cases we reported, the site of infection involved: upper extremities in 91 (38.7%), face and neck in 42 (17.9%), buttocks in 41 (17.4%), lower extremities in 33 (14%) and body in 23 (9.8%). Compared to Fukushiro's report, cases affecting the lower extremities had decreased, whilst cases involving the buttocks had increased. Overall, the treatment for chromomycosis was either oral administration of antifungal agents, excision, thermotherapy, or a combination of these methods.

Ajoene and 5-fluorouracil in the topical treatment of Cladophialophora carrionii chromoblastomycosis in humans: a comparative open study.

Ajoene and 5-fluorouracil (5-FU) are compounds that have shown in-vitro activity against Cladophialophora carrionii, an important etiologic agent of chromoblastomycosis. An open comparative trial was conducted to assess safety and effectiveness of topical ajoene and 5-FU in the treatment of localized chromoblastomycosis. Thirty-seven patients with a clinically and mycologically confirmed diagnosis were randomly distributed into two groups allocated to ajoene (0.5% gel; n = 19) or 5-FU (1% cream; n = 18). Topical treatment was applied to localized lesions (< or = 2.5-cm diameter) once a day, with occlusion, for 12-16 weeks. Complete clinical and mycological remission was achieved in 14/19 patients (74%) treated with ajoene and 14/18 patients (78%) treated with 5-FU. All 5-FU-treated patients developed a post-treatment scar at the site of the lesion, while ajoene-treated patients showed only a slight depigmentation of the skin. The differences observed in cure rate between ajoene and 5-FU are not statistically significant. Follow-up of all patients for 4 years revealed no relapses in the ajoene-treated group, while one patient in the 5-FU-treated group had a relapse 6 months after the end of therapy. This trial represents the first clinical use of ajoene in the control of a deep mycosis.

Alternate week and combination itraconazole and terbinafine therapy for chromoblastomycosis caused by Fonsecaea pedrosoi in Brazil.

Patients with long-standing chromoblastomycosis may respond poorly to standard treatments such as amphotericin B, oral antifungals, surgical measures or thermotherapy. The objective of this study was to determine the potential of alternate week and combination therapy with itraconazole and terbinafine in the treatment of poorly responsive, or non-responsive, chromoblastomycosis. Four patients with longstanding chromoblastomycosis (8-23 years) caused by Fonsecaea pedrosoi had responded poorly to standard therapies including monotherapy with the oral antifungal agents. In order to try and improve the response to oral itraconazole and terbinafine, alternate week or combination therapy with itraconazole and terbinafine was initiated. Bloodwork including complete blood count and liver function tests were performed every 3-8 weeks to ensure patient safety. Reduction or resolution of lesions of chromoblastomycosis was noted with alternate week or combination treatment using oral itraconazole and terbinafine. Three of four patients experienced no clinical side-effects; the third reported mild, transient gastric discomfort which responded to antacids. Bloodwork generally remained within normal limits throughout the entire course of treatment with no clinically significant changes. The combination therapy was considered effective in treating the poorly responsive chromoblastomycosis of all four patients. Some success with alternative week therapy was also noted in one patient. The favorable response and lack of significant adverse effects suggests that these regimens may be an option for some patients with chromoblastomycosis.

Case report. A case of chromoblastomycosis effectively treated with terbinafine. Characteristics of chromoblastomycosis in the Kitasato region, Japan.

A 38-year-old male with history of trauma in the left gluteal region 20 years ago presented with a dark red skin eruption at the traumatized area. It gradually grew to form an erythematous plaque with a well-defined border. Clinical findings and mycological cultures resulted in the diagnosis of chromoblastomycosis due to Fonsecaea pedrosoi. After initial administration of 5-fluorocytosine and local heat an almost complete cure was achieved with terbinafine combined with local heat therapy. A review is given on the chromoblastomycosis cases observed in the Kitasato region in Japan.

Auricular chromoblastomycosis caused by Rhinocladiella aquaspersa.

An unusual case of chromoblastomycosis localized in the ear and caused by R. aquaspersa is presented. The patient was a 60-year-old male urban resident, who had had the disease for 5 years. The lesion was darkly pigmented, infiltrative and crusty. Sclerotic cells were seen on direct examinations and the fungus was recovered in culture and identified on the basis of the characteristic sporulation. Itraconazole therapy at a dose of 200 mg day-1 for 7 months produced complete healing.

In vitro sensitivity to 5-fluorocytosine of strains isolated from patients under treatment for chromomycosis.

In vitro 5-fluorocytosine sensitivity tests of strains were isolated from chromomycosis patients undergoing therapy. Tests were rountinely performed for 0.1, 1.0, 5.0 and 10.0 mug/ml 5-fluorocytosine concentrations. In two cases resistance could be demonstrated up to 60.0 and 100.0 mug/ml. Fungistatic activity of 5-fluorocytosine against the agents of chromomycosis was confirmed. Sensitivity tests are useful to detect resistance which may occur during treatment. They are also helpful for guiding the clinician in the establishment of new therapeutic schedules.