Chromoblastomycosis Case Study at Aceh Province Referral

Hospital: Study in 8 Cases for 7 Years

Reno Keumalazia Kamarlis

Departement of Anatomical Pathology, Medical Faculty, Zainoel Abidin Hospital, Syiah Kuala University, Banda Aceh,

Indonesia

Keywords : Chromoblastomycosis, Pathological Anatomy, Histopathology, Department Surgery, Department

Dermatology and Venereology

Abstract : Chromoblastomycosis is a chronic fungal infection that occurs in the skin and subcutaneous tissue caused

by dematiaceous fungi. This study uses a case study approach obtained from medical record data of patients

in the pathology anatomy laboratory of Dr. Zainoel Abidin Hospital, Aceh Province within 7 years (2012-

2018). Information was obtained that reported cases of chromoblastomycosis tend to increase, especially in

the last 2 years (2017-May 2018). During 2013 to 2015 there were no cases of chromoblastomycosis. The

dominant patients in the age group above 50 years (62.50%) and the age group 0-10 years as much as

25.00%. The number of male and female chromoblastomycosis sufferers is the same. Localization of

dominant lesions (50.00%) is found in the lower limbs (extremities). Specimens were received from the

Surgery Department (62.50%) and the Department Dermatology and Venereology (37.50%). The cases

obtained were predominantly given a clinical diagnosis as malignant tumors. Initial suspicion and

appropriate laboratory diagnosis will assist in initiation of therapy in the early stages and specific isolation

of the etiology of the agent can help prevent latent complications.

1. INTRODUCTION

Chromoblastomycosis is a chronic fungal infection

that occurs in the skin and subcutaneous tissue

caused by dematiaceous fungi (Mukesh et al, 2012).

Usually the infecting fungi are Fonsecaea Pedrosoi,

Cladophialophora carrionii and Phialophora

verrusoca (Pawel et al, 2014) (Padmanaban et al,

2016). The prevalence of this disease is reported

from humid and tropical subtropics, one of which is

Asia (Agarwal et al, 2017) (Bobba, 2014). Men are

often experience chromoblastomycosis disease than

women (Mariani et al, 2015).

Dermal lesions can be shaped like small nodules

until a large eruption resembling a papilla. Clinical

features that often appear in the area of the neck,

legs, lower limbs, face and arms. In the early stages

can appear papules, such as warts then enlarge to

form hypertrophic plaques. In the lesions also appear

plaque with a flat surface and grow slowly in the

middle and then after a few years, the lesions can be

thickened to 3cm. The nature of

Chromoblastomycosis lesions is polymorphic and

must be distinguished from several clinical

conditions (Queiroz et al, 2009).

Diagnosis that can be done is by observing

muriform cells in tissue and isolation and

identification of causative agents (Murthy, 2011).

The success of healing is influenced by the causative

agent, the clinical form and the severity experienced

by the patient. In general, patients who experience

chromobalstomycosis are treated with itraconazole,

terbinafine or a combination of both. It is important

to evaluate individual resistance to drugs. The

treatment process requires the direction of clinical

criteria, mycology and histopathology (Queiroz et al,

2009). The following in this study will be reported

cases of chromoblastomycosis at the Anatomy

Pathology Laboratory of the Hospital Public Service

Agency Dr. Zainoel Abidin Aceh Province

2. METHOD

This study uses medical record data at the Anatomy

Pathology Laboratory of the Hospital of the Dr.

Zainoel Abidin Hospital, Aceh Province within 6

Kamarlis, R.

Chromoblastomycosis Case Study at Aceh Province Referral Hospital: Study in 8 Cases for 7 Years.

DOI: 10.5220/0008789002050210

In Proceedings of the 2nd Syiah Kuala International Conference on Medicine and Health Sciences (SKIC-MHS 2018), pages 205-210

ISBN: 978-989-758-438-1

205

years (2012-2018). Descriptive data analysis by

describing cases then discussed. The data displayed

includes examination year, age group, gender,

specimen sender department, clinical diagnosis

established and microscopic examination results.

3. CASE REPORT

Based on medical record data, the patient's reference

to the Anatomical Pathology Laboratory of the

Hospital Public Service Agency Dr. Zainoel Abidin

Aceh Province, found as many as 8 cases after the

examination was made diagnosis with

Chromoblastomycosis within 6 years (2012-2018),

as follows:

3.1 Case 1

Specimens from a male with an initial Ih 83 years

old were examined on May 3, 2012. Specimens were

sent from

Department Dermatology and Venereology.

Localization of complaints is in the Dorsum pedis

section with a differential diagnosis of

Chromoblastomycosis and eumycetoma.

3.2 Case 2

Specimens from a man with the initials Nc aged 67

years were examined on August 3, 2016. The

specimen was sent from the surgical department,

with a clinical diagnosis of a tumor os femur

malignant suspect.

3.3 Case 3

Specimens from a woman with an initial NFR of 9

years of age were examined on March 13, 2017.

Specimens were sent from the department of

Dermatology and Venereology. Localization of

complaints was in the part of the left arm with a

diagnosis of differential deep mycosis, Bacterielag

infection and TB cutis.

3.4 Case 4

Specimens from a woman with the initials Br 67

years old, were examined on August 7, 2017.

Specimens were sent from the surgical department.

Localization of complaints in the anterior thoracic

section with clinical diagnosis established is anterior

thoracic papilloma.

3.5 Case 5

Specimens from a man with the initials Sm, 55 years

old, were examined on November 14, 2017.

Specimens were sent from the surgical department.

Localization of complaints is at the side of the left

pedis with a clinical diagnosis established is a

malignant suspected skin tumor.

3.6 Case 6

Specimens from a woman with an initial Hm, 89

years old, were examined on February 9, 2018.

Specimens are sent from the

Department Dermatology

and Venereology

. Complaint localization is in the

cruris dextra with a differential diagnosis of

Chromomycosis, TB cutis, Blastomycosis,

Sporotricosis and Squamous cell carcinoma.

3.7 Case 7

Specimens from a man with initial Mh age 4 years

old, examined on May 16, 2018. Specimens were

sent from the surgical department, with a clinical

diagnosis of abscess at colli regio.

3.8 Case 8

Specimens from a woman with the initials Lb aged

27 years, were examined on May 17, 2018.

Specimens were sent from the surgical department,

with a clinical diagnosis is a malignant occipital

suspect tumor.

4. RESULT AND DISCUSSION

Based on the data collected, information was

obtained that reported cases of chromoblastomycosis

tend to increase, especially in the last 2 years (2017-

May 2018). Throughout 2013 to 2015 there were no

cases of chromoblastomycosis. These conditions

conclude that the discovery of chromoblastomycosis

cases tends to increase in the Anatomical Pathology

Laboratory of the Hospital Public Service Agency

Dr. Zainoel Abidin Hospital, Aceh Province.

The results of this study are in line with

Agarwal's (2017) study which stated that there was

an increase in the discovery of cases of

chromoblastomycosis between 2011-2016.

Throughout 1955-2016 found 169 cases of

chromoblastomycosis in India, where in the period

2011-2015 found 81 cases. In addition, in 2016 until

May there were 25 cases

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Figure 1. Distribution of specimen examinations of patients with a

diagnosis of chromoblastomycosis at the Anatomical Pathology

Laboratory of the Hospital Public Service Agency Dr. Zainoel Abidin

Aceh Province in 2012-2018

Figure 2. Distribution of age groups (in years) of patients with a diagnosis of

chromoblastomycosis at the Anatomical Pathology Laboratory of the

Hospital Public Service Agency Dr. Zainoel Abidin Aceh Province in 2012-

2018.

Chromoblastomycosis patients are dominant in

the age group above 50 years, as many as 5 cases

(62.50%). The age group of 0-10 years is the age

group where this case is found to be the second

largest, namely as many as 2 cases or 25.00%. The

information above shows that young age groups

(children) and parents are the most common age

group where chromoblastomycosis is found.

This phenomenon is not in line with Sarangi's

research (2017) which states that

chromoblastomycosis cases tend to be found more in

the age range of 21-35 years (45.4%) than 11 cases.

Research Agarwal (2017) also found that those who

stated that chromoblastomycosis cases were more

prevalent in the age range of 31-50 years (35%).

Based on gender, it was found that the number of

male and female chromoblastomycosis sufferers was

the same, where in each sex there were 4 cases

(50.00%). This condition shows that in 8 cases that

have been found there has not been a tendency for

Chromoblastomycosis Case Study at Aceh Province Referral Hospital: Study in 8 Cases for 7 Years

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this case to be dominant in one sex only.

Localization of the dominant lesion (50.00%) was

found in the lower limb (extremity) area, where 1

case (12.50%) was in the thigh section and 3 other

cases in the pedis and cruris area (37.50%). The

neck, back of the head, upper extremities and chest

area were found in 1 case each.

Research conducted by Agarwal (2017) found

that 81.10% of patients were men so they had a

higher risk than women at 4.2: 1. The study

conducted by Sarangi (2017) also found that men

were more predominantly suffering from this disease

with a risk of 1.4: 1 compared to women. Based on

research conducted by Pawel et al (2014) states that

infection can occur in all parts of the body. The legs

and shin are the dominant parts of the body. This is

in line with the results obtained in this study that

found dominant lesions in the lower limbs (inferior

extremities).

Specimens received by the Anatomical

Pathology Laboratory of the Hospital Public Service

Agency Dr. Zainoel Abidin, the dominant province

of Aceh, came from the Surgical Section with 5

cases (62.50%). Three other cases (37.50%) were

sent from the

Dermatology and Venereology. Clinical

diagnosis sent from the Department of Dermatology

and Venereology is clinically diagnosed with

chromoblastomycosis or cases of deep mycosis.

Cases obtained from the dominant surgical

department were given a clinical diagnosis with

malignant tumors (4 malignancies) (80.00%) and 1

case (20.00%) were abscesses.

The term 'chromoblastomycosis' is exclusively

used for typical fungal lesions resulting in 'sclerotic'

bodies caused by dematiaceous fungi in the

'phaeohyphomycosis' group. The agents that cause

this disease are Fonsecea, Cladosporium, and

Rhinocladiella species. Most cases are limited to

localized disorders of the skin and subcutaneous

tissue. Initial suspicion and appropriate laboratory

diagnosis will assist in initiation of therapy in the

early stages and specific isolation of the etiology of

the agent can help prevent latent complications

(Chavan SS and Reddy P, 2013).

The histopathological features are described

below:

Case 1

Microscopic examination results showed that

preparations of tissue without epithelial lining were

seen in groups of glandular structures of round oval

shape with cuboidal epithelial linings, basophil

spherical nuclei, fine chromatin,

cytoplasmaeosinophilyl. The stroma consists of

collagen connective tissue, as it appears

multinucleated giant cells and lymphocyte cells.

There is no sign of malignancy in the preparation, so

it can be concluded to support a

chromoblastomycosis.

Case 2

Based on the results of microscopic examination

performed, tissue preparations with layered sterile

epithelial linings with hyperkeratosis, acantosis,

hypergranulosis, intact basal membrane appear. Intra

epithelium appears pseudohorncyst. The sub

epithelium consists of fibromycsoid connective

tissue with a lymphocyte cell, multinucleated giant

cell, PMN cells, neutrophils and a golden brown

pigment. There is no sign of malignancy in this

preparation, so it can be concluded that

chromoblastomycosis.

Case 3

Based on the results of microscopic examination

carried out, it was found that tissue preparations

from specimen 3 with epithelial linings lay flat

within normal limits. Sub epithelials appear

granulomatous-granulomatous consisting of

epithelioid cells, histiocytes and multinucleated

giant cells between fibromycsoid connective tissue.

In some places a brownish pigment appears. There is

no sign of malignancy in this preparation, it can be

concluded as chromoblastomycosis.

Case 4

Based on the results of microscopic examination,

tissue preparations with layered epithelial lining, sub

epithelial appearance, granulomatous features

consisting of epitheloid cells, multinucleated giant

cells, lymphocytes and a brownish pigment between

fibromycsoid connective tissue were seen. There is

no sign of malignancy in the preparation, it can be

concluded a chromoblastomycosis.

Case 5

Based on the results of microscopic examination

performed, tissue preparations with layered sterile

epithelial linings that experience hyperkeratosis are

obtained. Sub epithelials appear to group

lymphocytic inflammatory cells, epithelial cells and

multinucleated giant cells accompanied by copper

bodies; between fibromycsoid connective tissue.

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There is no sign of malignancy in this preparation.

So that can be concluded is chromoblastomycosis.

Case 6

Based on the results of microscopic examination

carried out, obtained tissue preparations with

epithelial coating layered within normal limits. The

local sub epithelial cells appear lymphocytic

inflammatory cells, epithelioid cells and brownish

pigments between fibromycsoid tissues. There is no

sign of malignancy in the preparation, it can be

concluded to support chromoblastomycosis.

Case 7

Based on the results of microscopic examination

carried out, obtained tissue preparations with sub

epithelial layered epithelial coating, fibromycsoid

tissue with an inflammatory cell PMN, neutrophils

and lymphocytes appear. In some places epitheloid

cells, multinucleated giant cells and copper bodies

are seen. There is no sign of malignancy in the

preparation, it can be concluded as

chromoblastomycosis with secondary infection.

Case 8

Based on the results of microscopic examination

carried out, obtained tissue preparations with

epithelial coating layered within normal limits. The

sub epithelial consists of fibromycsoid tissue with

the distribution of inflammatory cells of PMN,

neutrophils and lymphocytes. Found groups of

epithelioid and multinucleated giant cell and copper

bodies. There is no sign of malignancy, so it can be

concluded as chromoblastomycosis.

Many cases are not diagnosed cytologically

because of a lack of clinical suspicion that is

undiagnosed. In the preparation often found mixed

inflammatory cells and scattered fungal sclerotic

bodies. The sclerotic bodies look orange to reddish

brown round to polyhedral, about the size of red

cells (approximately 5-8 mm), show mature thick

wall (just like outer border of copper penny), and

characteristic intracellular septations (Chavan SS

and Reddy P , 2013).

Histopathologic examination with hematoxylin

eosin (HE) staining on chromoblastomycosis will

show inflammatory granuloma in the form of

pseudoepiteliomatous epidermal hyperplasia with

parakeratosis, spongiosis, and extensive dermal

infiltrate consisting of numerous epithelioid

histiocytes. Another component of infiltrates is the

presence of multinucleated giant cells in which there

are sclerotic bodies, neutrophils, lymphocytes,

plasma cells, and eosinophils.

Figure 3. Histopathological features of specimen examination of patients with a diagnosis of chromoblastomycosis

at the Anatomical Pathology Laboratory of the Hospital Public Service Agency Dr. Zainoel Abidin Hospital, Aceh

Province in 2012-2018 (A) pseudoepitheliomatous hyperplasia of per capplasia (B) Pigmented sclerotic bodies

(Medlar bodies or Copper bodies)

A B B

Chromoblastomycosis Case Study at Aceh Province Referral Hospital: Study in 8 Cases for 7 Years

209

Fungal species that cause chromoblastomycosis

cannot be distinguished from histopathological

examination so that identification of tissue culture is

needed. Macroscopically, the results of tissue culture

from fungi generally give a similar picture, namely

blackish colonies. Microscopic identification of

culture depends on the presence of different types of

sporulation. Accurate differentiation of various fungi

is difficult to do (Mariani et al, 2015).

5. CONCLUSION

Based on medical record data of patients at the

Anatomy Pathology Laboratory of Dr. Zainoel

Abidin, Nanggroe Aceh Province, has 8 cases of

chromoblastomycosis throughout 2012-2018.

Chromoblastomycosis cases tend to increase in the

last 2 years (2016-2018). Most sufferers in the

elderly and young with localization of dominant

lesions in the extremities. Gender there is no

difference in this case study. Specimens received

predominantly from the Surgery and

Dermatology and

Venereology Department. Clinical diagnosis of

dominant malignant tumors (malignancy). Initial

suspicion and appropriate laboratory diagnosis will

assist in initiation of therapy in the early stages and

specific isolation of the etiology of the agent can

help prevent latent complications.

ACKNOWLEDGMENT

Anatomical Pathology Laboratory Hospital Public

Service Agency Dr. Zainoel Abidin Hospital,

Nanggroe Aceh Darussalam Province

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