Case of Cladophialophora caroinii Chromoblastomycosis

suit of Cladophialophora caroinii ChromoblastomycosisA R atomic number 18 Case of Cladophialophora caroinii Chromoblastomycosis in a Skin join RecipientRoy PK, Dudhat VL, Prasanna SIntroductionChromoblastomycosis, also called chromomycosis is a sub cutaneal inveterate mycosis caused by dematiaceous (black) kingdom Fungi.1 The most frequently isolated organisms are Fonsecaea pedrosoi, Phialophora. verrucosa, Cladosporium carrioni, and little frequently, Rhinocladiella aquaspersa.2 It Progresses slowly and involves exposed body parts. It is characterised by crusted and raised lesions. The fungi establish as sclerotic bodies in the lesions, which is a pathognomic feature of this disease. It is distri scarcelyed worldwide. unless it is most comm all seen in tropical and subtropical regions.1 C. caroinii has been leveled sole(prenominal) sporadically in India in a few case reports.3,4,5,6,7 We present a rare case of chromoblastomycosis by C. caroinii.Case DescriptionA 40 year old male long-suffering, presented to the surgery OPD with cutaneous ulcerationation all over right knee after a fall injury, non associated with fever or pain. The diligent was admitted in a tertiary wish centre, I.V antibiotics and daily dressing had been done. The swabs from the base of the ulcer had been sent for bacterial goal and sensitivity, shown no crop. later on a few daylights of treatment ulcer was healing with good margins and base.Patient was discharged with oral antibiotics and anti-inflammatory agents. After one month patient came back for review to OPD with hypopigmented patch over the right knee. The patient was referred to plastic surgery department and skin ingraft was done. The graft was taken from the right back. The patient was administered with I.V steroids, antibiotics and oral anti-inflammatory agents. The patient was discharged with oral steroids with tapering dose and antibiotics.After two calendar weeks period, patient developed soft non-raised fluctuating swelling post skin graft over the same region (right knee). Differential diagnosis of cutaneous terbium and aspergilloma was made. The FNAC was carried out from the swelling, from which frank pus was aspirated. The pus sample was forwarded for bacterial culture, fungal and mycobacterial culture. The bacterial cultures, both aerobically and anaerobically showed no growth. The sample was negative for acid strong bacilli by Ziehl Neelsen suckering. However, KOH mount and Gomoris methenamine silver (GMS) stain showed septate hyaline hyphae. The GMS stain revealed few grey black round structures bar around 6-10 m, suggestive of Medlar or sclerotic or strapper cent bodies.The culture of the pus sample, on Lowenstein-Jensen medium showed no growth after eight weeks of incubation. However, culture on Sabouraud dextrose agar with chloramphenicol revealed slow growing fungus, which was first of all observed on the tenth day and gradually matured over next three weeks. Th e growth was ab initio grey-green which slowly turned to olive-green with cottony folded out texture and with a jet-propelled plane black reverse after three weeks of incubation at 25C. The lacto phenol cotton blue (LPCB) preparation, from the culture showed septate hyaline hyphae with acropetal long chains of conidia suggestive of Chladophialophora species. The fungus showed growth at 37C, but not at 42-45C and urease negative. Based on these findings the fungus was identified as Chladophialophora carrionii.The patient was diagnosed to have subcutaneous mycosis (chromoblastomycosis) with the presence of sclerotic bodies and the activating(prenominal) organism was identified as Chladophialophora carrionii. The patient was started on oral itraconazole and he showed good improvement in the condition.DiscussionAs first described by Medlar in 1915, the term chromoblastomycosis is used for cases in which sclerotic bodies are present in tissue. Sclerotic bodies, also know as Medlar bod ies, are globe-shaped, cigar-colored, thick-walled structures that are 4-12 m in diameter.8 The trump name to define the disease was recommended as chromoblastomycosis by the planetary decree for Human and Animal Mycology (ISHAM).9 The term chromoblastomycosis (chromo coloured, blasto budding, mycosis fungal) was coined by Terra et al in 1922 to define a polymorphic fungal disease located on lower limbs, consisting of nodular or verrucous plaques which could probably ulcerate and develop into hyperkeratosis and acanthosis of the touch epithelial tissues.10 This condition is often misdiagnosed as it is clinically indistinguishable from terbium verrucosa cutis, squamous cell carcinoma, palmo-plantar psoriasis, and sporotrichosis.11,12,13 In this case also, a differential diagnosis of cutaneous tuberculosis was kept in mind. The typical histopathological findings of cutaneous chromoblastomycosis are mark epitheliomatous hyperplasia, microabscesses, chronic granulomatous infilt rates with multinucleate giant cells, epithelioid cells, histiocytes and lymphocytes and presence of copper penny bodies.14 in this case we found septate hyphae and sclerotic bodies on GMS stain of FNAC sample. Certain non-pathogenic or contaminant fungi such as Paecilomyces spp and genus Penicillium spp. may be sometimes confused with Cladophialophora carrionii. Although both these fungi develop long chains of elliptical conidia, the conidia arise from structures such as metula and phialides, which are not seen in C. carrionii. Both these fungi are rapid growers, unlike C. carrionii, which grows very slowly. Moreover, these non-pathogenic fungi usually form greenish white or greenish brown colonies with no pigment on the reverse, in strain to the jet black reverse of C. carrionii, which helps in correct identification of this fungi.15 However, C. carrionii should be differentiated from other similar dematiaceous fungi such as Cladophialophora bantiana and Fonsecaea pedrosoi. C. bantiana has the faculty to grow at 42-43C, which can be used to differentiate it from C.carrionii. unlike Cladophialophora spp., Fonsecaea spp. produce short chains of five or less conidia. Moreover, in Fonsecaea spp. At least two of the three types of anamorphic conidiation (rhinocladiella, phialophora, cladosporium) will be seen.15 Slide culture technique will be useful for comme il faut identification of the above-mentioned features.15 Surgery was considered the treatment of choice for chromoblastomycosis before the orgasm of triazole antifungal agents.16 However, currently with the availability of potent antifungal agents, chemotherapy has become the first-line of treatment with itraconazole and terbinafine being the drugs of choice, while surgery is used moreover for limited or small lesions.17 As there have been only few and sporadic case reports of chromoblastomycosis caused by C. caroinii from India, this case reports finds its importance.3,4,5,6,7ReferencesKalabhavi AS. Chromoblastomycosis Review article. International Journal of Current Research 2013 5(7)1691-5Silva JP, de Souza W, Rozental S. Chromoblastomycosis a retrospective subscribe to of 325 cases on Amazonic Region (Brazil). Mycopathologia 1998-1999143171-5.Pradeepkumar NS, Joseph NM. Chromoblastomycosis caused by Cladophialophora carrionii in a child from India. J Infect Dev Ctries 2011 5(7)556-560.APTE G, GEDAM JR, POOJARY S, GURU N, PAI VV. Chromoblastomycosis in a case of borderline lepromatous leprosy with recurrent graphic symbol II lepra reaction. Lepr Rev (2011) 82, 3105Shanthala GB, Rudresh SM, Nagarathnamma T. Chromoblastomycosis A Case Report. Journal of clinical and Diagnostic Research 20115(4) 865-6Mandal RK, Banerjee S, Kumar P, Chakrabarti I. Non-healing verrucous plaque over upper limb for 1 year in a tea garden worker. Dermatology Online Journal 19 (3) 12Kindo AJ, Ramalakshmi S, Giri S, Abraham G. A Fatal Case of Prostatic Abscess in a Post-Renal Transplant Recipien t Caused by Cladophialophora carrionii. Saudi J Kidney Dis Transpl 201324(1)76-9Medlar EM. A cutaneous infection caused by a new fungus Phialophora verrucosa with a consume of the fungus. J Med Res. 1915 32507-22.Odds FC, Arai T, Disalvo AF, et al. Nomenclature of fungal diseases a report and recommendations from a Sub-Committee of the International Society for Human and Animal Mycology (ISHAM). J Med warhorse Mycol. 1992 30(1)1-10.Terra F, Torres M, Fonseca Filho O. Novo tipo de dermatite verrucosa micose por Acrotheca com associado de leishmaniose. Brasil Medico. 1922 36363-8.Pradhan SV, Talwar OP, Ghosh A, Swami RM, Shiva Raj KC, Gupta S. Chromoblastomycosis in Nepal a study of 13 cases. Indian J Dermatol Venereol Leprol 2007 73 176-8Mohanty L, Mohanty P, Padhi T, Samantray S. Verrucous growth on leg. Indian J Dermatol Venereol Leprol2006 72 399-400.Nair PS, Sarojini PA. Chromoblastomycosis resembling sporotrichosis. Indian J Dermatol Venereol Leprol 1993 59 125-6.Nirmala V, Ch acko CJ, Job CK. Tuberculoid leprosy and tuberculosis skin a comparative histopathological study. Lepr India 1977 49 65-9Fisher F, Cook NB. basics of Diagnostic Mycology. Philadelphia W.B.Saunders Company 1998 372Sayal SK, Prasad GK, Jawed KZ, Sanghi S, Satyanarayana S. Chromoblastomycosis. Indian J Dermatol Venereol Leprol 200268 233-4.Gupta AK, Taborda PR, Sanzovo AD. Alternate week and combination itraconazole and terbinafine therapy for chromoblastomycosis caused by Fonsecaea pedrosoi in Brazil. Med Mycol 200240 529-534