Case Presentation: A 91-year-old healthy Taiwanese female presented with a worsening skin lesion on her right forearm. Initially, she had mild skin breakdown, which progressed to redness, swelling and increased warmth to the touch. The patient noted some purple spots in her lower extremities, especially around her right knee. The female patient denied any swollen lymph nodes, fever, chills, night sweats or weight loss. In addition, the patient stated her cheeks developed redness but attributed this to her high blood pressure. Per family, it was unknown the exact chronicity of the rash as she usually wore long sleeves and pants. The patient, originally from Taiwan, immigrated to the United States in 1995. The patient’s home medications included hydrochlorothiazide, meloxicam for arthritis and hydrocodone/acetaminophen as needed. On exam, the patient was afebrile and had normal vital signs. Present, there was a large fungated/crusted lesion in the right forearm with a scabbed area and surrounding redness without signs of infection noted. The lesion was mildly warm to touch. On her lower extremities there were non-blanching purple macules, the largest, around her right knee and right thigh. No clavicular or inguinal swollen nodes were noted. The Initial CBC workup was unrevealing. PT, PTT, SPEP and UPEP were negative. ANCA and cryoglobulins were negative. A skin biopsy of the thigh showed non-specific purpura. The nodular erythematous area on her arm was biopsied with findings consistent with Fonsecaea species. The infectious disease team was consulted and the patient started on Itraconazole twice a day. About a week later, she was discharged with close clinic follow up and inflammatory markers routinely monitored. Two months later when evaluated for follow up, the patient’s rash was persistent but moderate improvement was noted.
Discussion: Chromoblastomycosis is a chronic granulomatous disease caused by transcutaneous inoculation of fungal spores. It is caused by the Fonsecaea and Cladophialophora species found in tropical and subtropical regions of developing countries in Asia, Africa and Latin America. Chromoblastomycosis is considered an occupational disease and it primarily affects immunocompetent individuals. The available data suggests that the incidence of this condition in the United States is 1:8,625,000 patients. Treatment for chromoblastomycosis can be challenging as it includes surgical excision to systemic antifungals such as Itraconazole and even laser therapy in severe cases. Long term assessment with histology is needed up to two years to confirm cure. Inadequate treatment can result in fibrosis, chronic lymphedema, secondary infection or malignancy.
Conclusions: Chromoblastomycosis is a common infection in tropical and subtropical regions; it is rare that these cases are reported in the United States. Workers from developing countries are at risk of exposure to contaminated soil or plants. Diagnosis is made by identification of muriform cells from clinical samples. Treatment for chromoblastomycosis ranges from surgical removal to systemic itraconazole.