Case for diagnosis. Pruritic erythematosquamous lesion in the auricle,

AnBrasDermatol.2020;95(4):521---523

Anais

Brasileiros

de

Dermatologia

WHAT

IS

YOUR

DIAGNOSIS?

Case

for

diagnosis.

Pruritic

erythematosquamous

lesion

in

the

auricle

夽,夽夽

Elaine

Dias

Melo

_,

_Patrícia

_Motta

_de

_Morais

_,

Débora

Cristina

de

Lima

Fernandes

_,

_Paula

_Frassinetti

_Bessa

_Rebello

a_{TeachingandResearchDepartment,Fundac¸ãodeDermatologiaTropicaleVenereologiaAlfredodaMatta,Manaus,AM,Brazil} b_{DepartmentofHistopathology,Fundac¸ãodeDermatologiaTropicaleVenereologiaAlfredodaMatta,Manaus,AM,Brazil} c_{LaboratoryofMycology,Fundac¸ãodeDermatologiaTropicaleVenereologiaAlfredodaMatta,Manaus,AM,Brazil}

d_{DepartmentofTropicalDermatology,Fundac¸ãodeDermatologiaTropicaleVenereologiaAlfredodaMatta,Manaus,AM,Brazil}

Received4October2019;accepted24November2019 Availableonline11May2020

KEYWORDS

Auricle;

Chromoblastomycosis; Ear,external;

Mycosis

Abstract Chromoblastomycosisisasubcutaneousmycosiswithchronicevolutionthatmainly affectsthelowerlimbsand,lessfrequently,theauricles.Clinically,itpresentswithpapillary verrucous,nodular, and/ortumorallesions,whetherisolatedorinfiltrated, formingplaques and,sometimes, atrophicinsomeareas.Histopathologically,itischaracterizedbyadermal granulomatousinflammatoryinfiltrate, andthediagnosis canbeconfirmedby thepresence of fumagoidbodiesin anatomopathological ordirect mycological exams. The treatment to beindicatedwilldependontheextentandlocationofthelesions,usingsystemicantifungals, surgicalremoval,cryotherapy,thermotherapy,andimmunoadjuvants.Thepresentstudyreports anatypicalpresentationofchromoblastomycosisontheauricle.

©2020SociedadeBrasileira deDermatologia.PublishedbyElsevierEspa˜na,S.L.U.Thisisan openaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

Case

report

A 57-year-old male farmer presented a pruritic lesion on the left auricle, with 20 years of evolution. He did not

夽 _{Howtocitethisarticle: MeloED,MoraisPM,FernandesDCL,} RebelloPFB.Casefordiagnosis.Pruriticerythematosquamouslesion intheear.AnBrasDermatol.2020;95:521---3.

夽夽_{StudyconductedattheFundac¸ãodeDermatologiaTropicale} VenereologiaAlfredodaMatta,Manaus,AM,Brazil.

∗_{Correspondingauthor.}

E-mail:[email protected](E.D.Melo).

recall local trauma at the onset of the condition. Upon examination,aninfiltrated,erythematosquamouslesionwas observed on the left ear. The histopathological examina-tionpresentedagranulomatousinflammatoryinfiltratewith suppurativefoci(Fig.1AandB).

Whatisyourdiagnosis?

1. JorgeLobo’sdisease 2. Sarcoidosis

3. Paracoccidioidomycosis 4. Chromoblastomycosis https://doi.org/10.1016/j.abd.2019.11.011

0365-0596/©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC BYlicense(http://creativecommons.org/licenses/by/4.0/).

522 MeloEDetal.

Figure1 (A and B)Erythematous, infiltrativelesion inthe leftear.Histopathologicalexamination:granulomatous inflam-matoryinfiltratewith suppurativefoci (Hematoxylin&eosin, ×400).

Figure 2 (A and B) Direct examination: fumagoid bodies. Microculture:septatedemaceoushyphaeandellipticalconidia intheupperportionofsimpleorslightlybranchedconidiophores --- phenotypic characteristics compatible with Rhinocladiella

spp.(KOH-20%,×400;blue,lactophenol,×400).

Thereviewofthesectionsforhistopathological examina-tionevidencedthepresenceoffumagoidbodies,compatible withchromoblastomycosis.

In the direct examination of biopsy fragments in 20% KOH,septatedemaceoushyphaeandisolatedyeastcellsin pairswereobserved,aswellassomegemmulestructures.In culture,onMycoselagar(DIFCO®_{)andSabourauddextrose} agar(DIFCO®_{)withchloramphenicol(0.05g/L),ablackened} colony growth wasobserved; in microculture, phenotypic findingscompatiblewithRhinocladiellasp.wereobserved (Fig.2AandB).

R.aquaspersawasconfirmedthroughamplificationand

sequencing of the intergenic spacer (ITS) region of the

Figure3 (AandB)After25daysoftreatment,andattheend oftenweeks.

ribosomalDNA(rDNA)usingthepolymerasechainreaction (PCR)technique.

Afterconfirmation ofthediagnosisof chromoblastomy-cosis,itraconazole(300mg/day)wasinitiated;thepatient presentedsignificantimprovementafter25daysandalmost completeremissionintenweeks(Fig.3AandB).Thepatient remainsunderoutpatientfollow-up.

Discussion

Chromoblastomycosis is a subcutaneous mycosis caused by demaceous fungi of the order Chaetothyriales, family Herpotrichiellaceae, found in decomposing soil, vegeta-bles, plants,andwood.1,2 _{The mainetiological agentsare}

fromthegeneraFonsecaea,Cladophialophora,Phialophora,

Rhinocladiella, and Exophiala. Inoculation occurs after

traumawithcontaminatedmaterial.1,3,4

Theconditionmost frequentlyaffectsmenbetween 40 and50yearsofage, beingconsidered acosmopolitan dis-ease, with greater prevalence in tropical and subtropical regions.2_{InBrazil,itoccursinmoststates,witha}

predom-inance in the Amazon region, particularly in the state of Pará.2,5

Thediseasemainlyaffectsthelowerlimbs.Incaseswith longevolution,associationwithlymphedemaiscommon.1,4,6

InJapan,themostcommonlocationsinvolvedaretheupper limbs,face,andcervicalregion.2_{Reportsofmanifestations}

exclusivelyontheauriclearerare.1,3,6---10 _{Amongthecases}

reported in this topography, Fonsecaea pedrosoi1,3,10 _and

Phialophoraverrucosa7_{werethemostcommonlyidentified}

agents, followed byFonsecaea nubica6 _{and Rhinocladiella}

aquaspersa.8

Accordingtotheliteratureconsulted,thisisthesecond casewithisolatedinvolvementoftheauriclecausedbyR. aquaspersa.

In the Amazon region, the differential diagnosis must include Jorge Lobo’s disease, leprosy, anergic leishmani-asis, cutaneous tuberculosis, and paracoccidioidomycosis. Histopathologicaland mycologicalexams areessentialfor diagnosis.

Several treatments are indicated for chromoblastomy-cosis.Forlocalizedlesions,surgical excision,cryotherapy, or thermotherapy are recommended; for more exten-sive cases, systemic and immunoadjuvant antifungals are recommended.2,4_{Amongsystemicantifungals,itraconazole,}

Casefordiagnosis.Pruriticerythematosquamouslesionintheauricle 523 posaconazole, voriconazole, and isavuconazole are used.4

Theliteraturereportstwocasesofchromoblastomycosisin auricular locations, which presented complete regression aftertreatment withflucytosine3_{and itraconazole}1 _{for 12}

and10weeks,respectively.

Therearereportsofagoodtherapeuticresponsewiththe association ofsystemicantifungalsandtopical immunoad-juvants,suchasimiquimod.4

Financial

support

Nonedeclared.

Authors’

contributions

Elaine Dias Melo: Conception and planning of the study; elaborationandwritingofthemanuscript;obtaining, ana-lyzing,andinterpretingthedata;intellectualparticipation in propaedeutic and/or therapeutic conduct of studied cases;criticalreviewoftheliterature.

PatríciaMottadeMorais:Approvalofthefinalversionof the manuscript;intellectual participation in propaedeutic and/ortherapeuticconductofstudiedcases;criticalreview oftheliterature;criticalreviewofthemanuscript.

DéboraCristinadeLimaFernandes:Elaborationand writ-ingofthemanuscript;criticalreviewoftheliterature.

Paula Frassinetti Bessa Rebello: Approval of the final version of the manuscript; intellectual participation in propaedeuticand/ortherapeuticconductofstudiedcases.

Conflicts

of

interest

Nonedeclared.

Acknowledgements

Thanks toprofessorAntônio Pedro Mendes Schettini, der-matopathologist, head of the histopathology laboratory

at the Fundac¸ão deDermatologia Tropicale Venereologia AlfredodaMatta;Dr.SinésioTalhari,dermatologist atthe Fundac¸ãodeDermatologia TropicaleVenereologiaAlfredo daMatta;andDr.MariaZeliMoreiraFrota,biochemical phar-macistattheUniversidadeFederaldoAmazonas.

References

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2.BritoAC,BittencourtMJS.Chromoblastomycosis:anetiological, epidemiological,clinical,diagnostic,andtreatmentupdate.An BrasDermatol.2018;93:495---506.

3.IwatsuT,TakanoM,OkamotoS.Auricularchromomycosis.Arch Dermatol.1983;119:88---9.

4.Queiroz-TellesF,deHoogS,SantosDW,SalgadoCG,Vicente VA,BonifazA,etal.Chromoblastomycosis.ClinMicrobiolRer. 2017;30:233---76.

5.TalhariS,CunhaMG,SchettiniAP,TalhariAC.Deepmycosesin Amazonregion.IntJDermatol.1988;27:481---4.

6.ChenY, Yin S, Li M, ChenR, WeiL, Ma H, et al.A caseof chromoblastomycosisbyFonsecaeanubicaindicatingapossible insectrouteoftransmission.Mycoses.2016;59:662---7.

7.BittencourtAL,LonderoAT,AndradeJA.Auricular chromoblas-tomycosis. A case report. Rev Inst Med Trop São Paulo. 1994;36:381---3.

8.ArangoM,JaramilloC,Cortés A,RestrepoA. Auricular chro-moblastomycosis caused by Rhinocladiella aquaspersa. Med Mycol.1998;36:43---5.

9.MinottoR,BernardiCD,MallmannLF,EdelweissMI,Scroferneker ML.Chromoblastomycosis:areviewof100casesinthestateof RioGrandedoSul,Brazil.JAmAcadDermatol.2001;44:585---92.

10.Franc¸a K, Villa RT, Bastos VR, Almeida AC, Massucatti K, Fukumaru D, et al. Auricular chromoblastomycosis: a case report and review of published literature. Mycopathologia. 2011;172:69---72.