A Case of Chromomycosis Treated by Surgical Therapy Combined With Preceded Oral Administration of Terbinafine To Reduce The Size of The Lesion
A Case of Chromomycosis Treated by Surgical Therapy Combined With Preceded Oral Administration of Terbinafine To Reduce The Size of The Lesion
A Case of Chromomycosis Treated by Surgical Therapy Combined With Preceded Oral Administration of Terbinafine To Reduce The Size of The Lesion
6-10, 2012
*1
Chromomycosis is a chronic fungal disease of the skin and subcutaneous tissues caused by a group of dematiaceous black fungi [1]. Small lesions can be removed with excision, but other cases are difficult to treat.
We report a case of chromomycosis caused by Fonsecaea pedrosoi (F. pedrosoi). The case involved a 74-yearold man, who had noted a lesion on the back of the right thigh, that was gradually enlarging and reaching up
to 30 cm in diameter, in 20-years. From microscopic examination, sclerotic cells were seen. We diagnosed
this case as chromomycosis caused by F. pedrosoi on mycological examination. The patient was initially
treated with oral terbinafine (250mg/day) as the lesion was very large. After the 18 months treatment, the
size of the lesion reduced to 1cm, then the remaining lesion was excised.
Key words: chromomycosis, Fonsecaea pedrosoi, terbinafine, surgery
INTRODUCTION
Chromomycosis is a term applied to infection with
some black dematiaceous fungi and is characterized
by sclerotic pigmented bodies intermediate between
a yeast and hyphal form in the tissues. Infections
have occurred throughout the world. The fungi are
thought to be present in soil, wood and vegetable
debris. Chromomycosis is particularly seen in farmers
and agricultural workers, because the infection occurs
primarily in skin following trauma [2]. Chromomycosis
is treated with surgery, antifungal agents or local
thermotherapy. The preferred treatment of small and
localized lesions is usually surgical excision with wide
surgical margins to prevent local recurrence. However,
surgical treatment is often not feasible for deep lesions
or for those with extensive cutaneous involvement. For
deep or extensive lesions, prolonged treatment with
systemic antifungal agents alone or in combination
provides the best chance of cure [1].
Here, we report a case of a chromomycosis with a
large lesion, which were treated by oral terbinafine to
reduce size and subsequently excised.
CASEREPORT
A 74-year-old fisherman presented with a 20-year
history of a slowly enlarging lesion on the back of his
right thigh. It had been diagnosed as tinea corporis
by local dermatologists and treated with topical ketoconazole and terbinafine. However, the eruption had
Kana TAMURA, Department of Dermatology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, JapanTel: +81-463-931121 Fax: +81-463-91-9387Email: kana.m@is.icc.u-tokai.ac.jp
c
Fig. 1 Clinical features (on the back
of patient's right thigh)
a First examination
An annular erythema approximately 30 30 cm
in size. The border of the
ring was 2 cm in width,
slightly rose, discontinuous
and accompanied with
scales on the surface.
b 18 months after treatment
Pigmentation and 3 erythematous lesions, each of
1 cm in size, with scaly
surface.
c 3 months after surgical
excision
Postoperative lesion showing no sign of recurrence.
Among 35 reports, 15 cases has been managed surgically, 8 cases treated with only antifungal agent, 6
cases treated by combination of antifungal agent and
local thermotherapy, 2 cases is other treatments and
4 cases are unknown. 11 cases among the surgically
removed 15 cases have showed no recurrence (Table 1).
However, only one case out of the orally treated 8 cases
has been treated successfully.
Chromomycosis recur easily, and is often intractable.
We stopped oral terbinafine 3 weeks after the surgery
because culture of the excised pigmented lesion was
negative. There was no recurrence three months after
surgical excision. Oral administration of terbinafin
250mg/day could reduce in size, however, it could not
completely cure [5, 36, 38]. Monotherapy with orally
administered antifungal agent may not lead to a complete cure. Combination therapy should be considered
taking into account the state of the lesion. Our case
report demonstrated that in the case of large lesions,
oral terbinafine may be administered first to reduce
the size of the lesions prior to surgical removal.
(This report was presented at the 25 th Annual
M e e t i ng of Jap a n O rg a n i z a t i on of C l i n ic a l
Dermatologists)
Table 1 Summary of Japanese cases of chromomycosis caused by F. pedrosoi which were surgically removed.
Patient
No.
Age
Sex
Site of
Lesion
71
knee
2.1 2.5 cm
69
buttock
13 cm
62
foot
71
cheek
68
waist
6 cm
62
hand
2.5 1.7 cm
59
back
3.0 3.5 cm
87
cheek
1.1 0.8 cm
60
arm
1 cm
10
62
foot
3.6 2.5 cm
11
36
arm
2.0 1.8 cm
12
67
arm
1.5 cm
13
84
buttock
2.0 cm
Size
14
78
arm
3.7 3.5 cm
15
74
thigh
30 30 cm
Preoperation
ND
antifungal
agents
local
thermotherapy
antifungal
agents
local
thermotherapy
ND
antifungal
agents
local
thermotherapy
antifungal
agents
local
thermotherapy
antifungal
agents
local
thermotherapy
antifungal
agents
Not done: ND
Not mentioned:
Postoperation
Efffect
Reference
No.
antifungal
agents
antifungal
agents
local
thermotherapy
no
recurrence
11
12
ND
no
recurrence
13
antifungal
agents
recurrence
14
ND
15
ND
no
recurrence
16
17
no
recurrence
no
recurrence
no
recurrence
no
recurrence
no
recurrence
18
20
antifungal
agents
local
thermotherapy
no
recurrence
22
antifungal
agents
no
recurrence
39
antifungal
agents
no
recurrence
this case
antifungal
agents
antifungal
agents
19
37
21
10
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