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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 34  |  Issue : 2  |  Page : 126-129

A retrospective study of chromomycosis in a tertiary care institution in South India


Department of Dermatology, Venereology & Leprosy, Father Muller Medical College, Mangalore, Karnataka, India

Date of Submission27-Sep-2014
Date of Acceptance11-Dec-2014
Date of Web Publication29-Jan-2015

Correspondence Address:
Asha Ramayivadakayil
MBBS, Department of Dermatology, Father Muller Medical College, Mangalore - 575 002, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-6530.150272

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  Abstract 

Background
Chromomycosis is a chronic fungal infection that affects the skin and subcutaneous tissue and occurs mainly following trauma. The most frequently isolated agent is Fonsecaea pedrosoi.
Objective
The aim of this study was to analyze the various epidemiological, clinical, mycological, and treatment aspects of chromomycosis in coastal Karnataka.
Materials and methods
This is a retrospective analysis of 20 patients with chromomycosis who attended the dermatology outpatient department of a tertiary care institution in coastal Karnataka, South India, from January 2005 to January 2013.
Results
The disease was found to be more common in male agricultural workers, especially rubber tappers. The lower limbs were more commonly affected (58%), with verrucous lesion being the most common clinical type. The most common species isolated was F. pedrosoi. Histopathological correlation was present in all cases. A good clinical response was seen in patients treated with potassium iodide who were refractory to terbinafine and fluconazole.
Conclusion
Chromomycosis mainly affects male agricultural workers, especially rubber tappers. Potassium iodide is an effective alternative for the treatment of chromomycosis, especially in a developing country like India.

Keywords: Chromomycosis, histopathology, mycology, potassium iodide


How to cite this article:
Bhat RM, Ramayivadakayil A, Monteiro R, Sukumar D, Srinath M K. A retrospective study of chromomycosis in a tertiary care institution in South India. Egypt J Dermatol Venerol 2014;34:126-9

How to cite this URL:
Bhat RM, Ramayivadakayil A, Monteiro R, Sukumar D, Srinath M K. A retrospective study of chromomycosis in a tertiary care institution in South India. Egypt J Dermatol Venerol [serial online] 2014 [cited 2020 May 28];34:126-9. Available from: http://www.ejdv.eg.net/text.asp?2014/34/2/126/150272


  Introduction Top


Chromomycosis is a slowly progressing chronic fungal infection that affects the skin and subcutaneous tissue [1]. Classified as a deep mycosis, the infection occurs following traumatic inoculation of pigmented fungal propagules of various species found in the soil and in decomposing vegetables into the skin [2]. Frequently isolated organisms include Fonsecaea pedrosoi, Phialophora verrucosa, Cladosporium carrioni, and less frequently, Rhinocladiella aquaspersa [3]. Chromomycosis is a worldwide distributed disease and is more prevalent in tropical and subtropical countries, mainly in Brazil, Mexico, Cuba, and the Dominican Republic [1]. We herein report 20 cases of chromomycosis from a tertiary care institution in Coastal Karnataka, South India.


  Materials and methods Top


This retrospective study was conducted at the departments of dermatology, venereology, and leprosy, of a tertiary care institution, located in coastal Karnataka, South India, from January 2005 to January 2013. Patients were diagnosed on the basis of detailed history taking (including demographic data, occupation, and history of trauma), cutaneous and systemic examination, histopathology findings, and fungal culture. Patients were grouped and analyzed on the basis of age, sex, profession, location of lesion, duration of the disease, mycological and histopathological examination, and prior treatment. Other relevant investigations such as complete blood profile, HIV screening test, Mantoux test, and radiographies were performed whenever required. Microscopic examination of scrapings from the surface of black dots was performed using 10% potassium hydroxide. A skin biopsy was obtained and the sample was sent for histopathological examination with hematoxylin and eosin stain. A separate tissue sample was cultured for fungus and acid fast bacilli, whenever possible.


  Results Top


Among the 20 patients diagnosed with chromomycosis, 13 were male (65%) and seven were female patients (35%). The majority (55%) of patients were aged 40-60 years. Seventeen cases were from the areas close to Western Ghats and three were from semiurban areas [Table 1]. Only nine patients gave a previous history of trauma, which was associated with agricultural work and included lacerations and abrasions. An interesting observation made was that most patients (45%) were rubber tappers by occupation. A majority of others (30%) were involved in agricultural work. The course of the disease ranged from 6 months to 10 years. The most frequent location was the lower limb in 12 patients (60%), followed by the upper limb in six patients (30%). On the basis of Carrion's classification, verrucous lesions were the most common presentation (55%), followed by plaque (20%), nodular (15%), and cicatricial (10%) pattern. Scrapings from black dots gave positive results for sclerotic bodies in only 40% of the cases. However, all cases were histopathologically proven with the characteristic features of hyperkeratosis, irregular acanthosis, pseudoepitheliomatous hyperplasia, and brownish thick-walled sclerotic bodies amidst tuberculoid granulomatous infilterate. Thus, histopathology can be considered as the most diagnostically reliable laboratory test in diagnosing chromomycosis. Because of operational difficulties, fungal culture could be performed only in 13 patients. Isolation of the organism was possible in nine cases, and the species identified was F. pedrosoi in all nine cases. In the remaining five cases, the culture report was inconclusive [Figure 1],[Figure 2],[Figure 3] and [Figure 4] and [Table 2],[Table 3],[Table 4] and [Table 5].
Figure 1: Verrucous plaque over the left knee joint.

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Figure 2: Vegetative plaque over the sole of the left foot.

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Figure 3: Fonsacaea pedrosoi (fungal culture).

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Figure 4: Sclerotic body amidst mycotic granuloma (H&E, ×40).

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Table 1: Geographic distribution of cases

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Table 2: Age distribution of patients

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Table 3: Distribution of cases on the basis of sex

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Table 4: Distribution of patients on the basis of occupation

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Table 5: Morphology of lesions

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The treatment regimens included potassium iodide, fluconazole, terbinafine, and combination therapy. The treatment was started after considering their previous antifungal medications that failed to improve the disease. Of the 20 patients, eight patients (40%) were treated with potassium iodide, two (10%) with oral fluconazole, six (30%) with oral terbinafine, and four (20%) with combination therapy (oral terbinafine with cryotherapy). Potassium iodide was administered as a saturated solution, beginning with a dose of five drops three times daily in a glass of milk or fruit juice after meals, increasing gradually by one drop per dose, up to a maximum dose of 40 drops three times a day. It was then gradually reduced.

All except one patient showed clinical improvement on completion of the therapy. The duration of therapy ranged from 6 weeks to 1.5 years. An interesting finding was that patients who did not respond to fluconazole, itraconazole, and terbinafine earlier responded to potassium iodide therapy, highlighting the importance of this age-old molecule.


  Discussion Top


In the present study, the variables were analyzed for better understanding and to obtain further information on epidemiology and clinical and treatment aspects of chromomycosis. In general, the findings were similar to those reported in the literature. The majority of cases are reported from humid tropical and subtropical regions of America, Asia, and Africa. Chromomycosis was originally described by Pedroso e Gomes, in 1914, in the city of Sγo Paulo [1]. It is distributed worldwide and is more prevalent in tropical and subtropical countries, mainly in Brazil, Mexico, Cuba, and the Dominican Republic [1]. It was first reported from India in 1957 by Thomas et al. [4], who reported two cases of chromomycosis from Assam. This was followed by several case reports from the Sub-Himalayan belt and Western and Eastern coasts [5]. In 1997, Rajendran et al. [6] reviewed 30 cases from all over India and reported an additional four cases from Jammu and Kashmir and Bihar. Later on, many cases were reported from different parts of India [5],[6],[7],[8],[9] [Table 6]. All these areas have warm and humid climatic conditions. Our study was conducted in coastal Karnataka with a tropical climate and high humidity, which favors the prevalence of infections. Chromomycosis presents as nodules or verrucous plaques most often over the lower limbs. In our study, the lower limb was the most common site affected, followed by the upper extremity. This reinforces the fact that the exposed areas of upper and lower extremities are commonly exposed to the etiological agent, thus supporting the theory of traumatic implantation.
Table 6: A few case series of chromomycosis reported from different parts of India

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In the majority of cases reported, the infection was found principally among men, in agricultural workers, and in individuals from rural areas of the state who come in contact with soil, wood, and vegetative matter. The fundamental triggering factor of chromomycosis is the transportation of the saprophytic fungus to the host's skin by macrotraumatic or microtraumatic inoculation. Although only nine of our patients reported a history of prior inciting trauma, a majority of affected individuals were manual laborers, agriculturists, and rubber tappers. These occupations involve strenuous physical work; hence, occurrence of trauma may have gone unnoticed. An interesting observation made was that most of the patients were rubber tappers by occupation. Hence, this occupation can be considered as an important risk factor for acquiring chromomycosis.

The prevalence of infection was higher in men than in women, probably because of the fact that men are more involved in activities that expose them to the etiological agent. In other studies performed in Brazil and Japan where women were exposed to the same working conditions as men, the prevalence of infection was almost the same [3],[10].

The characteristic histopathologic features of chromoblastomycosis include pseudoepitheliomatous hyperplasia and mixed granuloma with thick-walled sclerotic or muriform bodies within or outside the giant cells. In our study, histopathological diagnosis of all patients were consistent with chromoblastomycosis. Another characteristic feature observed was the transepidermal elimination. Transepidermal elimination probably occurs because the epidermis plays an active role in eliminating fungi in some types of mycosis, and the presence of a substance in the papillary dermis that is foreign to the organism is more easily removed by the epidermis without causing any major alterations or degeneration through a mechanism that remains to be fully clarified [2]. All cases showed clinical and histopathological correlation.

A majority of our patients had received prior treatment in the form of antibiotics, antifungals, and antitubercular therapy. As many as four patients were administered antitubercular therapy previously for varying durations. This observation stresses on why it is important to differentiate chromomycosis from cutaneous tuberculosis. Similar clinical presentation might easily mislead the clinician, causing undue morbidity to the patient due to treatment-related side effects.

The different modalities of treatment advocated for chromomycosis include chemotherapy, physical treatment (cryotherapy and surgical excision), and combination therapy. The choice of treatment depends upon the causative agent and the type and extent of lesions [11]. Best results have been obtained with oral terbinafine and itraconazole at high doses for long duration - that is, at least 6-12 months [12],[13],[14]. Another option is flucytosine for several months, alone or in association with amphotericin B or ketoconazole. This has been found effective in up to 80% of cases [15]. Potassium iodide is another effective drug [16]. Most of our patients improved with either oral terbinafine or combination therapy, and patients refractory to fluconazole and terbinafine responded well to potassium iodide, thus highlighting the role of this drug in the treatment of chromomycosis.


  Conclusion Top


Chromoblastomycosis is more common in the tropics and areas with high humidity. The incidence of infection is higher among rubber tappers. Potassium iodide is an effective alternative in cases not responding to long-term treatment with fluconazole and terbinafine, especially in a developing country like India.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Correia RT, Valente NY, Criado PR, Martins JE. Chromoblastomycosis: study of 27 cases and review of medical literature. An Bras Dermatol 2010; 85 :448-454.  Back to cited text no. 1
    
2.
Pires CA, Xavier MB, Quaresma JA, Macedo GM, Sousa BR, Brito AC. Clinical, epidemiological and mycological report on 65 patients from the Eastern Amazon region with chromoblastomycosis. An Bras Dermatol 2012; 87 :555-560.  Back to cited text no. 2
    
3.
Silva JP, de Souza W, Rozental S. Chromoblastomycosis: a retrospective study of 325 cases on Amazonic Region (Brazil). Mycopathologia 1998; 143 :171-175.  Back to cited text no. 3
    
4.
Thomas E, Job CK, Hadley CG. Chromoblastomycosis. Indian J Med Sci 1957; 11 :570-573.  Back to cited text no. 4
    
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Chandran V, Sadanandan SM, Sobhanakumari K. Chromoblastomycosis in Kerala, India. Indian J Dermatol Venereol Leprol 2012; 78 :728-733.  Back to cited text no. 5
    
6.
Rajendran C, Ramesh V, Misra RS, Kandhari S, Upreti HB, Datta KK. Chromoblastomycosis in India. Int J Dermatol 1997; 36 :29-33.  Back to cited text no. 6
    
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Sharma NL, Sharma RC, Grover PS, Gupta ML, Sharma AK, Mahajan VK. Chromoblastomycosis in India. Int J Dermatol 1999; 38 :846-851.  Back to cited text no. 7
    
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Kumar B. Chromoblastomycosis in India: two more cases. Int J Dermatol 2000; 39 :800.  Back to cited text no. 8
    
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Sharma A, Hazarika NK, Gupta D. Chromoblastomycosis in sub-tropical regions of India. Mycopathologia 2010; 169 :381-386.  Back to cited text no. 9
    
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Kondo M, Hiruma M, Nishioka Y, Mayuzumi N, Mochida K, Ikeda S, Ogawa H. A case of chromomycosis caused by Fonsecaea pedrosoi and a review of reported cases of dematiaceous fungal infection in Japan. Mycoses 2005; 48 :221-225.  Back to cited text no. 10
    
11.
Queiroz-Telles F, Esterre P, Perez-Blanco M, Vitale RG, Salgado CG, Bonifaz A. Chromoblastomycosis: an overview of clinical manifestations, diagnosis and treatment. Med Mycol 2009; 47 :3-15.  Back to cited text no. 11
    
12.
Bonifaz A, Paredes-Solis V, Saul A. Treating chromoblastomycosis with systemic antifungals. Expert Opin Pharmacother 2004; 5 : 247-254.  Back to cited text no. 12
    
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Bonifaz A, Carrasco-Gerard E, Saúl A. Chromoblastomycosis: clinical and mycologic experience of 51 cases. Mycoses.2001; 44 :1-7.  Back to cited text no. 13
    
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Paniz-Mondolfi AE, Colella MT, Negrin DC, Aranzazu N, Oliver M, Reyes-Jaimes O, Perez-Alvarez AM. Extensive chromoblastomycosis caused by Fonsecaea pedrosoi successfully treated with a combination of amphotericin B and itraconazole. Med Mycol 2008; 46 :179-184.  Back to cited text no. 14
    
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Lortholary O, Denning DW, Dupont B. Endemic mycoses: a treatment update. J Antimicrob Chemother 1999; 43 :321-331.  Back to cited text no. 15
    
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Narendranath S, Sudhakar GK, Pai MR, Kini H, Pinto J, Pai MR. Safety and efficacy of oral potassium iodide in chromoblastomycosis. Int J Dermatol 2010; 49 :341-343.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


This article has been cited by
1 Chromoblastomycosis in India: Review of 169 cases
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PLOS Neglected Tropical Diseases. 2017; 11(8): e0005534
[Pubmed] | [DOI]



 

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