Cromoblastomicosis verrugosa-cicatricial multifocal: una entidad desatendida en Colombia / Multifocal verrucous-cicatricial chromoblastomycosis: a neglected disease in Colombia

La cromoblastomicosis es una micosis subcutánea crónica de presentación clínica heterogénea que afecta principalmente a poblaciones de escasos recursos, lo que sumado al acceso limitado a los servicios de salud condiciona el retraso en el diagnóstico y tratamiento, ocasionando secuelas físicas graves. Se describe el caso de un hombre de 50 años con lesiones cutáneas verrugosas y cicatriciales de 30 años de evolución en la extremidad inferior y mano izquierda, además en cara en los últimos cinco años. Se realizó el diagnóstico de cromoblastomicosis de presentación multifocal y clínica mixta, con examen directo e histopatología compatibles, y cultivo para hongos positivo para Fonsecaea pedrosoi. Se indicó tratamiento oral con itraconazol y seguimiento clínico. Reconocer esta entidad es crucial para un diagnóstico y tratamiento oportunos, con el fin de evitar secuelas físicas y estigmatización secundaria. Se debe fortalecer en la atención primaria el reconocimiento de patologías desatendidas y de incidencia subestimada en Colombia, con una presentación multifocal mixta atípica y de un tiempo de evolución prolongado. El examen directo KOH es un herramienta accesible y económica en los primeros niveles de atención que puede contribuir al enfoque diagnóstico.

Chromoblastomycosis is a chronic subcutaneous mycosis with heterogeneous clinical presentation. It mainly affects low-income populations, which added to limited access to health services delays diagnosis and treatment, causing serious physical sequelae. We describe the case of a 50-year-old man with warty and cicatricial skin lesions of 30 years of evolution, at the level of left lower limb and left hand, with face involvement in the last five years. A diagnosis of chromoblastomycosis with multifocal and mixed clinical presentation was made, based on compatible direct examination and histopathology, and positive fungal culture for Fonsecaea pedrosoi. Oral treatment with itraconazole and clinical followup were stablished. Recognizing this entity is crucial for timely diagnosis and treatment, to avoid physical sequelae and secondary stigmatization. Primary health care should be strengthened for the recognition of neglected diseases whose incidence is underestimated in Colombia, with an atypical mixed multifocal presentation and a long evolution time. The KOH direct examination is an accessible and economical tool in the first levels of care that can contribute to the diagnostic approach.

Study of tissue inflammatory response in different mice strains infected by dematiaceous fungi Fonsecaea pedrosoi

Abstract: Background: Diseases caused by melanized fungi include mycetoma, chromoblastomycosis and phaeohyphomycosis. This broad clinical spectrum depends on the dynamic interactions between etiologic agent and host. The immune status of the host influences on the development of the disease, as, an exemple. phaeohyphomicosis is more frequently observed in immunocompromised patients. Objectives: Examine the histological inflammatory response induced by Fonsecaea pedrosoi in several different strains of mice (BALB/c, C57BL/6, Nude and SCID, and reconstituted Nude). Methods: Fonsecaea pedrosoi was cultivated on agar gel and a fragment of this gel was implanted subcutaneously in the abdominal region of female adult mice. After infection has been obtained, tissue fragment was studied histopathologically. Results: There were significant changes across the strains, with the nodular lesion more persistent in Nude and SCID mice, whereas in immunocompetent mice the lesion progressed to ulceration and healing. The histopathological analysis showed a significant acute inflammatory reaction which consisted mainly of neutrophils in the initial phase that was subsequently followed by a tuberculoid type granuloma in immunocompetent mice. Study limitations: There is no a suitable animal model for chromoblastomycosis. Conclusions: The neutrophilic infiltration had an important role in the containment of infection to prevent fungal spreading, including in immunodeficient mice. The fungal elimination was dependent on T lymphocytes. The re-exposure of C57BL/6 mice to Fonsecaea pedrosoi caused a delay in resolving the infection, and appearance of muriform cells, which may indicate that re-exposure to fungi, might lead to chronicity of infection.

Clinical, epidemiological and mycological report on 65 patients from the Eastern Amazon region with chromoblastomycosis / Relato clínico, epidemiológico e micológico de 65 pacientes com cromoblastomicose procedentes da Amazônia oriental

BACKGROUND: Chromoblastomycosis is a chronic fungal infection caused by fungi from the Dematiaceae family. According to several studies, Fonsecaea pedrosoi is the most common of these fungi. The infection is more common in tropical countries, with the Brazilian state of Pará having one of the largest infected populations worldwide. The disease is difficult to treat and recurrences are common. OBJECTIVES: To describe the epidemiological and mycological aspects of cases of chromoblastomycosis and its clinical forms in the state of Pará, Brazil. METHODS: Mycological exams (direct mycological examinations, culture and microculture) were performed and a clinical/epidemiological evaluation was made of 65 patients receiving care at the Dermatology Department of the Federal University of Pará between 2000 and 2007. The clinical classification proposed by Carrión in 1950 was used in this study. RESULTS: The majority of the patients were male (93.8%), agricultural workers (89.2%) of 45 to 55 years of age, and the majority of lesions (55.4%) were of the verrucous type, located principally on the lower limbs (81.5%). In the majority of the cases investigated (61.5%), the infection had been present for a long time, with a mean duration of 11 years. Direct mycological examination was performed in 86.2% of the patients (n=56). Of these, 96.4% (n=54) tested positive. Culture and microculture were performed in vitro in 47 cases of those that tested positive at direct microscopy, results showing Fonsecaea pedrosoi to be the only agent present in this sample. CONCLUSION: This study highlighted the extent to which chromoblastomycosis still affects the quality of life of the local population, principally individuals working in agriculture. This is a chronic disease for which there is no effective treatment. The importance of continuing to investigate this disease should be emphasized, as further studies may lead to new clinical or epidemiological findings.

FUNDAMENTOS: A cromoblastomicose é uma infecção fúngica crônica, causada por fungos da família Dematiaceae, sendo Fonsecaea pedrosoi a mais comum, segundo vários estudos. É mais frequente em países tropicais e o estado do Pará possui grande casuística mundial. A doença é de difícil tratamento e apresenta recorrência frequente. OBJETIVOS: Descrever os aspectos epidemiológicos, micológicos e formas clínicas dos casos de cromoblastomicose procedentes do estado do Pará - Brasil. MÉTODOS: Foram realizados exames micológicos (direto, cultura e microcultivo) e observação clinicoepidemiológica em 65 pacientes do Serviço de Dermatologia da Universidade Federal do Pará, atendidos no período de 2000 a 2007. Empregou-se a classificação clínica proposta por Carrión em 1950. RESULTADOS: Os pacientes eram, em sua maioria, homens (93,8%), lavradores (89,2%), faixa etária entre 45-55 anos, com predominância de lesões verruciformes (55,4%), localizadas principalmente nos membros inferiores (81,5%). A maioria dos casos pesquisados (61,5%) apresentou um longo tempo de doença, com uma média de 11 anos. O exame micológico direto foi realizado em 86,2% (n=56) dos pacientes; destes, 96,4% (n=54) apresentaram resultado positivo. Foram realizados cultura e microcultivo in vitro de 47 pacientes com exame micológico positivo e os resultados mostraram o Fonsecaea pedrosoi como único agente etiológico identificado nesta amostra. CONCLUSÃO: Este estudo mostrou o quanto a cromoblastomicose ainda compromete a qualidade de vida da população local, principalmente a de indivíduos que trabalham em lavouras, cursando com evolução crônica e sem tratamento eficaz. Observa-se a importância de dar continuidade a este estudo, o que poderá proporcionar novas contribuições clínicas ou epidemiológicas.

Treatment of severe chromoblastomycosis with itraconazole and 5-flucytosine association / Tratamento de cromoblastomicose severa com a associação itraconazole e 5-flucitosina

Chromoblastomycosis is a chronic human melanized fungi infection of the subcutaneous tissue caused by traumatic inoculation of a specific group of dematiaceous fungi through the skin, often found in barefooted agricultural workers, in tropical and subtropical climate countries. We report the case of a male patient presenting a slow-growing pruriginous lesion on the limbs for 20 years, mistreated over that time, which was diagnosed and successfully treated as chromoblastomycosis. Besides the prevalence of this disease, treatment is still a clinical challenge.

Cromoblastomicose é uma infecção fúngica crônica do tecido subcutâneo causada pela inoculação traumática de um grupo específico de fungos através da pele, encontrados eventualmente em trabalhadores do campo descalços em países de clima tropical e subtropical. Relatamos aqui o caso de um paciente do sexo masculino com uma lesão dermatológica de crescimento lento e pruriginosa nos membros inferiores por 20 anos, diagnosticada e tratada com sucesso para cromoblastomicose. Apesar da prevalência desta doença em nossa região, o tratamento ainda é um desafio.