Non-healing verrucous plaque over upper limb for 1 year in a tea garden worker
Published Web Locationhttps://doi.org/10.5070/D346449059
Non-healing verrucous plaque over upper limb for 1 year in a tea garden worker1. North Bengal Medical College, Siliguri, West Bengal, India
Rajesh Kumar Mandal1 MD, Sabyasachi Banerjee1 MD, Piyush Kumar2 MD, Indranil Chakrabarti1 MD
Dermatology Online Journal 19 (3): 12
2. Katihar Medical College, Katihar, Bihar, India
A 55-year-old tea garden worker presented with a slowly growing verrucous plaque on the right arm. The diagnosis of chromomycosis was confirmed by the identification of brown sclerotic bodies in a skin biopsy.
|Figure 1||Figure 2|
|Figure 1. Well defined verrucous plaque with scarring, crusting and scales|
Figure 2. Pseudoepitheliomatous hyperplasia with intraepidermal abscess (H&E x100) and copper penny bodies shown with a pointer in the window (H&E x400)
|Figure 3. Brown colored septate sclerotic bodies (H&E x400)|
A 55-year-old tea garden worker presented with a slowly growing, slightly erythematous, verrucous plaque over her right arm (Figure 1). The lesion started one year prior as a small papule and gradually increased in size to the present status. At the same time, some new lesions appeared around the primary site. The surface of the plaque was notable for crusting and scaling; slight skin atrophy was observed. She had been treated with topical steroids without any response and later had received anti-tubercular treatment because of clinical suspicion of cutaneous tuberculosis, again, without any response. The rest of the history and physical examination were unremarkable. Routine hematological and biochemical investigations were within normal limits. A skin biopsy was performed. The histopathological findings are shown in Figures 2 and 3.
Multiple sections stained with hematoxyline and eosin showed pseudoepitheliomatous hyperplasia, marked hyperkeratosis, and dense infiltration of polymorphs in the upper and mid-dermis forming micro-abscesses. Few golden brown round structures showing separation at places were observed focally in the dermis and represented sclerotic bodies. Sclerotic bodies are the small brown fungal forms, which are round with thick bilaminate walls 4-6 μm in diameter, which occur singly or in clusters and are diagnostic of chromoblastomycosis.
Chromoblastomycosis is a chronic fungal infection of the skin and subcutaneous tissue caused by pigmented or dematiaceous fungi, which in infected tissue produce thick-walled,dark brown structures known as sclerotic or muriform bodies. These bodies have vertical and horizontal septa inside and are found singly, in clusters, or within the giant cells [1, 2]. There are several dematiceous fungi causing chromomycosis, amongst them Fonsecaeae pedrosoi is the most common causative organism. Other fungi, which can cause the disease, are Fonsecaeae compacta, Phialophora verrucosa, Cladosporium carionii, Rhinocladiella aquaspersa, Botryomyces caespitosus . The fungi are usually found in soil, wood, and rotting vegetation and the infection usually occurs following trauma with vegetative matter causing direct inoculation of the fungi . The condition mainly affects middle-aged male agricultural workers. The lesions commonly involve the lower limbs, whereas the upper limbs and face are only rarely affected. Our patient, a tea garden worker, was prone to injury over the upper limbs while plucking tea leaves in dense tea bushes. The disease is mainly seen in tropical and subtropical countries, Africa, Australia, and Japan.
Clinically, chromomycosis starts as a nodule over the implantation site, which slowly evolves into a verrucous plaque and may ulcerate. Sometimes, there may be deposition of black dots over the lesion; these are helpful diagnostic clues. Associated lymphadenitis may be present owing to secondary bacterial infection. Rarely, dissemination to brain can occur. Apart from the verrucous presentation, there may be vegetative, fistulous, granulomatous, and squamous presentations .
Chromomycosis may be clinically confused with tubercular verrucosa cutis, sporotrichosis, lupus vulgaris, and even squamous cell carcinoma. Our patient was incorrectly managed for tubercular verrucosa cutis.
Histopathological findings of cutaneous chromoblastomycosis are marked epitheliomatous hyperplasia, intraepidermal abscesses containing inflammatory cells, and the presence of sclerotic (copper penny) bodies. These sclerotic bodies are 5-12 m in diameter and are diagnostic of chromoblastomycosis. The dermis is suppurative and granulomatous with the presence of histiocytes, giant cells, plasma cells, eosinophils, and abscess formation. The diagnosis can be confirmed by direct microscopic examination of a 10 percent KOH preparation of the scrapings taken from crust, which may reveal small, round, thick-walled, brownish septate, sclerotic bodies. Full identification of the fungus needs fungal culture.
Currently chemotherapy has become the first-line of treatment with itraconazole and terbinafine being the drugs of choice, whereas surgery is used only for limited or small lesions .
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