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Chromomycosis: A Rare Cutaneous Fungal Infection on the Upper Extremity Frequently Mistaken for Squamous Cell Carcinoma
Institution where the work was prepared: Mayo Clinic, Jacksonville, FL, USA
Katherine J. Willard, MD; Mark A. Cappel, MD; Mayo Clinic, Jacksonville, FL

Background: Chromomycosis is an uncommon, subcutaneous fungal infection of the skin caused by a variety of dematiaceous fungal species (most commonly, Fonsecaea pedrosoi, Cladophialophora carrionii, Fonsacaea compacta, Phialophora verrucosa, and Rhinocladiella aquaspersa). It is contracted following direct inoculation of the fungus into the skin and most commonly occurs in tropical regions, particularly among rural workers with occupational exposures to contaminated soil or decaying plants. The most common presentation is a verrucous papule or nodule on an extremity, thus it is often clinically suspected to represent squamous cell carcinoma. Additionally, histopathology frequently shows pseudoepitheliomatous hyperplasia, which also can mimic squamous cell carcinoma.
Purpose: Identify patients treated at our facility with chromomycosis, and review the clinical and histopathologic characteristics of this disease.
Methods: A pathology record search was performed from January 2004 to May 2013 at our institution using search terms, ‘chromomycosis' and ‘chromoblastomycosis'. Medical records were then reviewed to examine the clinical presentation and management of these patients.
Results: 7 cases were identified at a single institution over a 10 year period. 5 of 7 cases (71.43%) occurred on the upper extremity. 5 of 7 patients (71.43%) had a history of solid organ transplantation and thus were on immunosuppressive medications. 6 of 7 patients (85.71%) were male. 5 of 7 cases (71.43%) were suspected to represent squamous cell carcinoma prior to biopsy. All 7 specimens revealed histopathology consistent with chromomycosis, including pseudoepithiomatous hyperplasia with granulomatous and suppurative inflammation surrounding the diagnostic pigmented sclerotic bodies. 3 cases (42.86%) had negative fungal cultures. 3 patients had fungal cultures positive for dematiaceous fungi: 1 each of Exophiala species, Wangiella species, and Alternaria species. 5 of 7 patients (71.43%) were treated with surgical excision. 2 of these patients received supplemental oral itraconazole. 1 patient was treated with oral itraconazole as monotherapy. 1 patient was recently diagnosed and started on monotherapy with oral terbinafine.
Conclusion: Chromomycosis presents as verrucous papules or nodules and may clinically and histopathologically mimic squamous cell carcinoma. In our series, chromomycosis had a predilection for the upper extremity and tended to occur in male patients. Immunosuppression may play a role in pathogenesis. In most cases, surgical excision is curative, however oral antifungal therapy may have a benefit as well, particularly to prevent dissemination in immunosuppressed patients.


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