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A 43 year old male presented to the office with an enlarging soft tissue mass of the right hallux. The patient first became aware of the lesion approximately four years prior to presentation in our office. Pain was only evident when the mass was compressed in a closed toe box shoe.
Clinically, one could palpate one large and two small fibrotic nodular lesions. The nodules were freely moveable in the subcutaneous tissue. The skin was intact and there was no bleeding or discoloration. Radiographs were unremarkable, other than the swelling seen in the dorsal tissue.
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| Intraopertively, a curvilinear incision was utilized to obviate complete visualization of the mass: |
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| Three multi lobulated, well encapsulated lesions were identified below the subcutaneous layer. Each was meticulously dissected free of all soft tissue attachments and excised in toto. |
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Within the specimens were multiple blackish/brown specules. |
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At the time of surgery we did not identify any foreign body. The patient healed unremarkably. A prescription for itraconazole 200mg QD was dispensed 24 hours post operatively. |
Subsequent pathology reports revealed the following:
• Chromomycosis with acute suppurative and granulomatous inflammation
• Microscopic Description
Sections reveal portions of soft tissue. They contain a confluence of foci of suppurative necrosis forming abscesses. There is reactive fibrotic tissue and numerous foamy and granular histiocytes at the periphery of the abscesses. Several of the abscesses have collections of organisms in their centers. The organisms consist of aggregates of short fungal hyphae and rounded yeast-like structures. The fungal organisms are inundated and surrounded by foci of suppurative necrosis and abscess walls with mixed infiltrates of neutrophils, plasma cells and histiocytes.
Fragments of splinter shaped wood material were also identified.
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| Chromomycosis (Chromoblastomycosis) is a mycotic infection of skin and subcutaneous tissue characterized by dematiaceous (brown-pigmented), rounded sclerotic bodies. |
Chromomycosis takes its name from the fact the usual etiologic agents have thick, dark-walls and are from the fungi genera Philophora, Cladosporium, and Fonsecaea. The causative fungal elements usually enter exposed skin in a traumatic fashion and growth is slow, chronic, and localized. In time the invading organism causes a suppurative and granulomatous reaction and may further develop into verrucoid, ulcerated, crusted, or flat topped lesions. Satellite lesions can possibly be seen in longer standing infections from lymphatic spread but usually hematogenous dissemination is rare. In some cases brain abscesses occur and are characterized by irregular hyphae in a multilocular distribution. Treatment of early infections is successful with surgical intervention. Medications used currently showing promise includes both itraconazole and terbinafine.
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