Preliminary Report
Revisiting the Clinical and Histopathological Aspects of Patients with Chromoblastomycosis from the Brazilian Amazon Region

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Background and Aims

Chromoblastomycosis is a chronic fungal infection caused by species of the family Dematiaceae. Fonsecaea pedrosoi is the most common etiological agent. The objective of this study was to describe the epidemiological and mycological profile of patients with chromoblastomycosis from the Amazon region of Brazil and to correlate the clinical forms with the histopathological findings and severity criteria.

Methods

Sixty-five patients were submitted to mycological (direct, culture, and microculture) and histopathological (hematoxylin-eosin staining) examination. Severity of the disease was classified according to the criteria proposed by Carrión in 1950.

Results

Most patients were males (93.8%) and laborers (89.2%). There was a predominance of verrucous lesions (55.4%), which were mainly found on the lower limbs (81.5%). Two major types of tissue reaction were observed: a granulomatous reaction characterized by the formation of suppurative granulomas rich in fungal cells, which were almost always seen in verrucous lesions, and a reaction characterized by the formation of tuberculoid granulomas with few parasites, which were mainly found in well-delimited erythematous plaque-like and cicatricial lesions (p = 0.0001). A peculiar type of organized mycotic granuloma was observed in 20 subjects. Suppurative granulomas were more frequently detected in severe lesions (p = 0.0189) and in lesions with a duration of >10 years (p = 0.0408).

Conclusions

These results suggest that verrucous lesions present a less competent inflammatory tissue response than patients who develop a well-formed tuberculoid reaction. The latter is associated with a more effective immune response as observed in the limited clinical forms of chromoblastomycosis.

Introduction

Chromoblastomycosis (CBM) is a chronic fungal disease that affects the skin and subcutaneous tissue. Classified as a deep mycosis, infection occurs by traumatic implantation into the skin of pigmented fungi of different species of the family Dematiaceae, which are found in soil and plants 1, 2, 3, 4, 5.

The Amazon region concentrates the largest number of cases of CBM in Brazil (2). This fact can be explained by social and environmental factors that contribute to maintain the fungus viable in nature, as well as by work activities during which individuals have frequent contact with plants and fruits and thus remain exposed to the pathogen. Despite its chronic evolution, in the last 5 years few studies have characterized the clinical, histopathological and inflammatory features of CBM, and these investigations only involved small samples. In this respect, studies are needed to better understand the range of CBM and the clinical, mycological, inflammatory and histopathological features of the disease in the Amazon region where the number of cases is significant.

Therefore, the objective of the present study was to describe the clinical and histopathological profile of patients with CBM from the State of Para, Amazon region, and to correlate the clinical forms with the inflammatory and histopathological findings and severity criteria.

Section snippets

Patients

A descriptive study was conducted on 65 patients with CBM seen at the outpatient clinic of the Dermatology Service, Núcleo de Medicina Tropical, Universidade Federal do Pará (UFPA) between January 2000 and July 2007.

The criteria proposed by Carrión in 1950 were used for the clinical diagnosis, which divide CBM lesions into five different types: verrucous, nodular, plaque-like, cicatricial and tumorous (6).

We excluded patients with immunosuppressive diseases, negative mycological examination and

Results

In the present study, most patients were male (93.8%) and laborers (89.2%) from the countryside of Para State. Patient ages ranged from 45 to 65 years (49.2%). The lesions most frequently affected the lower limbs (81.5%).

According to the classification of Carrión (1950), there was a predominance of verrucous lesions found in more than half the cases (55.4%), followed by plaque-like (26.2%), nodular (7.7%), cicatricial (6.2%), and tumorous lesions (4.6%) (Figures 1A and 1B).

Direct mycological

Discussion

Analysis of aspects related to the prevalence of CBM showed a preference of the disease for male workers from rural areas. This finding might be related to the natural habitat of the pathogen, which is found in soil and vegetations, and to the activities of the population that mainly works in the agricultural sector. The lesions most frequently affected the lower limbs. These areas are classically more exposed to traumatic inoculation of the fungus into the skin, especially when unprotected,

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