Treatment-Resistant Chromoblastomycosis Successfully Managed With Surgical Excision

Chromoblastomycosis is an uncommon, chronic granulomatous fungal infection of the skin and subcutaneous tissue. Chromoblastomycosis is most commonly caused by the traumatic inoculation of dematiaceous (pigmented) fungi, most commonly Fonsecaea species, Phialophora species, and Cladophialophora species. Chromoblastomycosis usually affects agricultural workers in tropical and subtropical climates. The World Health Organization classifies chromoblastomycosis as a neglected tropical and occupational disease that commonly affects middle-aged men in poor to middle-income countries. The cutaneous lesions of chromoblastomycosis typically affect the lower extremities and present as polymorphous, hyperkeratotic, or fungating small papules, plaques, verrucous nodules, or ulcers; therefore, a high degree of clinical suspicion is necessary to consider the diagnosis of chromoblastomycosis. The diagnosis is made by visualization of the thick-walled pigmented structures referred to as sclerotic bodies (also known as Medlar bodies or muriform bodies) or pigmented septate hyphae or both on a biopsy specimen of the lesion. Treatment may consist of locally destructive techniques, prolonged systemic antifungal therapy, and/or surgical excision. In this paper, we present an immunocompetent 80-year-old Caucasian woman who developed an isolated lesion of chromoblastomycosis on the forearm while gardening in Texas, a non-endemic area for the disease. Her infection was refractory to systemic antifungal medications and cryotherapy with liquid nitrogen. Ultimately, her fungal infection was successfully treated with a wide local surgical excision of the infectious cutaneous lesion.