CPC Feb 2 2009 Dr Ruenger

8/8/2019 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

CPC Feb 2 2009 Dr Ruenger

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