cpc feb 2 2009 dr ruenger
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In the name of ALLAH, the Beneficent the Merciful
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CPC
with
Thomas Ruenger MD Phd
Muhammad Khawar Nazir
BUMC Dermatology2nd Feb. 2009
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History
15 years old boy,
PC: Brown big itchy and painful bumps on facesince last 1 year
h/o trauma with lead pencil on left hand
1 month after trauma, lesions started at facewhich are spreading
No family h/o skin diseases h/o home made topical remedies
No past medical history
Review of systems : Insignificant
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Examination
Face, almost whole central face sparing eyesand chin
Hyperpigmented verrucous induratedplaques, firm, well defined, mild erythema,few erosions, few areas of pus on cheeks and
nose
Peripheral borders are elevated, centralscarring
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Differenital Diagnosis
Cutaneous tuberculosis
Deep Fungal Infection
Leishmaniasis
Atypical Mycobacterial Infection
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Diagnosis
All tests were normal
Skin Biopsy
CHROMOBLASTOMYCOSIS
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TREATMENT
Terbinafin
Fluoconazol
Cryotherapy
Psychological help
Plastic Surgery
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CHROMOBLASTOMYCOSIS
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Synonyms
Chromomycosis
Cladosporiosis
Verrucous dermatitis
Phaeosporotrichosis
Pedroso's disease
Fonseca's disease
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INTRODUCTION
verrucous dermatosis caused by several
genera of dematiaceous, or pigmented, fungi
Typically chronic in nature, an expandingverrucous plaque on the lower, or occasionally
upper, extremity is the classic presentation
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INTRODUCTION
6 fungi are responsible for the vast majority of cases:
Fonsecaea pedrosoi,
Phialophora verrucosa,
Cladosporium carrionii, Fonsecaea compacta,
Fonsecaea monophora and
Rhinocladiella aquaspera.
The clinical presentation and colonial morphologies of each ofthese fungi are very similar, and differentiation is based onmicroscopic and conidial characteristics
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HISTORY
Pedroso first recognized chromoblastomycosis
in 1911
Four years later, Medlar & Lane reported the
first case in the US (in Boston)
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Confusionoverthe propernaming
At one point, chromoblastomycosis was thoughtto be closely related to blastomycosis; however,
cellular division does not occur via budding(blasto-) but rather via internal septation, hencethe preference for the term chromomycosis
Nonetheless, some authors have argued thatchromomycosis is also confusing, because it hasthe same meaning as phaeohyphomycosis, andso they prefer the term chromoblastomycosis
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EPIDEMIOLOGY
Most commonly found in tropical and subtropical climates
Occasionally in temperate zones such as the US, Europeand Canada
Farmers, miners and others working in rural areas are athigher risk than the general population
Men 20 to 60 years of age are more often affected,probably due to their increased occupational exposure
Up to 90% of cases result from occupational exposure
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Pathogenesis
The fungi are found in the soil and in decayingplants and wood
The disease is typically contracted from trauma tothe lower extremities, particularly as a result ofnot wearing shoes
The organism is introduced into the dermis orsubcutis via implantation.
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CLINICAL FEATURES
Usually presents as a papule or nodule on the leg,which progresses to form a verrucous orgranulomatous plaque
Lesion may appear annular as the central portionresolves with scarring
Several lesions may coalesce to form amultinodular mass, or multiple lesions may existas discrete islands scattered within unaffectedskin
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CLINICAL FEATURES
It is thought that autoinoculation, fromscratching, may be responsible for the spread ofinfection
Only one extremity is typically affected.Sometimes, a subcutaneous nodule or tumor isthe presenting lesion
Local or constitutional symptoms are not typical.
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Annular and figurate
plaques due to central
clearing and scarringwith a verrucous surface
on the arm (A) and a
more granulomatous
appearance on the leg
(B).
C Brown-colored
sclerotic body within a
mixed granulomatous
and neutrophilic dermalinfiltrate.
C, CourtesyofJennifer
McNiffMD.
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Pathology
Pseudoepitheliomatous hyperplasia, intraepidermal abscesses, andsuppurative and granulomatous inflammation within the dermis arethe typical histologic findings
Round, pigmented bodies, which are said to resemble copperpennies (6 to 12 mm), are present in the dermis, bothextracellularly and within giant cells
These are unique to chromoblastomycosis and are also known as
Medlar bodies or sclerotic bodies
Detection of organisms via PCR of tissue samples has been reportedfor the more common species.
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Differential Diagnosis
Biopsy is indicated to exclude other granulomatousinfectious diseases such as
Cutaneous tuberculosis,
Tertiary syphilis, Blastomycosis or
Leishmaniasis
that may also have associated scarring
Mycetoma is another implantation mycosis that commonlyaffects the lower extremity, but edema, draining sinusesand grains point to this diagnosis
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If a biopsy is not feasible, a KOH examination
of scrapings from a pigmented portion of the
lesion is performed
The presence of pigmentedMedlarbodies is
diagnostic (excluding diagnoses such asblastomycosis), but hyphae may also be seen
Culture growth (at 2530C) is slow and thedifferent genera produce fairly similar colonial
morphologies
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Major differences between genera are the microscopicfeatures, in particular the type of conidia produced inculture.
3 majortypes ( CPR )
Cladosporium-like (long branching side chainswith shield cells at branch points)
Phialophora-like (conidia resemble overflowing
buds in a vase)
Rhinocladiella-like (overall configuration similar toa mascara brush).
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Treatment
Therapeutic options are limited
Some authors have advocated heat therapy based on evidence that thecausative organisms will not grow at high temperatures
For small lesions, surgical excision (plus systemic antifungal treatment) can beattempted
5-Flucytosine combined with either oral thiabendazole, intravenousamphotericin B or an oral triazole has been reported to be efficacious.
Itraconazole alone (200-400 mg/day) administered for at least 6 months hasproved promising, with up to 80-90% cure rates according to one author
.
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Treatment
The newest triazole, voriconazole, may also proveto be beneficial
In a small series, oral terbinafine (500 mg/day)given for at least 7 months was described aseffective
Cryosurgery and the addition of antibiotics if thelesion is secondarily infected
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THANK YOU