Chromoblastomycosis mimicking Squamous Cell Carcinoma: a case report

Chromoblastomycosis (CM), a chronic subcutaneous mycosis, is caused by several dematiaceous fungi, the most common being Fonsecaea pedrosoi . It usually occurs in the lower extremities following traumatic implantation of the organisms. We are reporting a case of rapidly developing case of CM on the unilateral lower limb with a fungating mass like ulcerative lesion and hyperkeratotic waIiy growth. We could not explain the pattern of this rapid growth which seems to be one of the rare presentations. Scraping from a verrucous lesion in potassium hydroxide preparation revealed mycelia arising from sclerotic bodies The histopathology from the warty lesion showed granulomatous lesion without muriform or medlar bodies. The histopathology from the ulcerative lesion did not show any malignant changes. Our case responded very well to itraconazole. This case is presented here for the rapidity of growth and the development of a fungating mass and bleeding that simulated the behaviour of squamous cell carcinoma. Introduction Chromoblastomycosis (CM) is a chronic granulomatous mycotic infection of the skin and subcutaneous tissue caused by pigmented fungi, the most common being F pedrosoi. It typically occurs on the exposed surfaces of the lower leg following traumatic implantation of the organisms. The lesions can involve other sites either by direct spread, autoinoculation or, or, by hematogenous spread. Treatment of CM is frequently difficult and unsatisfactory. We are reporting a case of CM with rapid evolution that responded very well to the treatment with itraconazole. Case Report A 50-year-old male agricultural worker of low socioeconomic status from Ramechhap district of Nepal, weighing 52 kg, presented with intensely pruritic hyperkeratotic warty nodules involving the whole of left leg and dorsum of foot with a fungating ulcerated mass over lateral malleollus of the same leg for three months. On enquiry the patient did not recall any history of trauma. The lesion had started as a warty nodule on left midshin. As it was extremely pruritic he shaved it off with a blade only to reappear with multiple small satellite lesions around the original lesion. It grew in size rapidly rapidly in size to involve almost whole of the left leg below knee down to the anterior and lateral aspects of ankle and dorsal aspect of foot to the base of toes. On examination the lesions were discrete as well as confluent with islands of normal skin; and, there was cauliflowerlike fungating mass with oozing of serosanguinous and purulent foul smelling discharge with rolled out border on the lateral malleolar region with maggots wriggling within the lesion ( Figures I & 2). There was ipsilateral inguinal lymphadenopathy. Two lymph nodes of 2x2 cm each were palpable which were non-tender,discrete, hard and fixed with the underlying structure. Systemic examination revealed no abnormality. Fig.I. Irregular warty plaques and nodules involving whole of left leg and proximal part of dorsal foot. · Fig. 2. A fungating ulcerated mass with maggots around left Fig. 3. After 1 week of itraconazole therapy.