Urban chromoblastomycosis: a diagnosis that should not be neglected

Although 90% of cases of chromoblastomycosis are described in individuals with rural activities,1,4,5 the two patients described herein did not report this type of activity. Around the world, there are still cities with preserved native nature, such as the Floresta da Tijuca, the largest urban forest in the world, located in the municipality of Rio de Janeiro. The search for healthy outdoor activities is becoming increasingly frequent in urban centers and diseases related to nature agents must be taken into account in the differential diagnosis, including chromoblastomycosis mainly the verrucous lesions. The location and size of the lesions suggested the moderate verrucous type of the disease in both cases.1 The isolation of Rhinocladiella spp. is another unusual finding since there are few published reports of this species in Brazil.2,5,6 The presence of hyphae in DME may indicate greater potential for invasion with the production of proinflammatory cytokines (TNF, IL1, IL-6).7,8 The best treatment approach is to combine an oral antifungal initially, most often itraconazole, with extensive surgical excision.4,9,10 Cryosurgery is another recommended adjunctive treatment.1,4,10 These two patients were cured with no recurrence and no impairment of their social and professional lives. The authors intend to emphasize the importance of the differential diagnosis in patients with urban activity in case of diseases linked to rural activity, preventing unnecessary treatments and chronicity. Attention to the clinical and laboratory diagnosis and the early treatment can increase the chances of cure.

Case reports Case 1. A 69-year-old healthy male physician who lives in the southern zone of the municipality of Rio de Janeiro reported that after falling from his bicycle during a tropical storm in Parque Lage, an urban forest inside the city of Rio de Janeiro, an open wound appeared on his right knee, caused by trauma from a tree branch. The lesion was a plaque with a verrucous appearance, well-defined borders and small satellite lesions (Fig. 1).
He underwent surgical excision of the lesion with wide margins. Two weeks before the intervention, itraconazole 200 mg/day was started for six months, followed by 100 mg/day for four months. There was no recurrence or complications after three years of follow-up (Fig. 1).

Case 2.
A 67-year-old male patient who lived in the northern zone of the municipality of Rio de Janeiro worked as a manager. Currently, he presented with diabetes mellitus and systemic arterial hypertension, taking losartan, atenolol and metformin. A year ago, a papule appeared on his right calf, progressing into ulceration with purulent discharge (Fig. 3A). He was treated with topical and systemic antibiotics, and topical antifungals and corticosteroids, with no improvement. He denied previous trauma. DME was positive for chromoblastomycosis, and Fonsecaea spp. was isolated in the culture. Itraconazole 200 mg/day was started. Two months later, satellite lesions were observed, as well as lesion enlargement. Wide surgical excision was performed, with the maintenance of oral itraconazole for eight months. There was no recurrence after eight months of follow-up (Fig. 3B).
ଝ Study conducted at the Dermatology Department, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.

Discussion and conclusion
Although 90% of cases of chromoblastomycosis are described in individuals with rural activities, 1,4,5 the two patients described herein did not report this type of activity.
Around the world, there are still cities with preserved native nature, such as the Floresta da Tijuca, the largest urban forest in the world, located in the municipality of Rio de Janeiro. The search for healthy outdoor activities is becoming increasingly frequent in urban centers and diseases related to nature agents must be taken into account in the differential diagnosis, including chromoblastomycosis mainly the verrucous lesions. The location and size of the lesions suggested the moderate verrucous type of the disease in both cases. 1 The isolation of Rhinocladiella spp. is another unusual finding since there are few published reports of this species in Brazil. 2,5,6 The presence of hyphae in DME may indicate greater potential for invasion with the production of proinflammatory cytokines (TNF-␣, IL1-␤, IL-6). 7,8 The best treatment approach is to combine an oral antifungal initially, most often itraconazole, with extensive surgical excision. 4,9,10 Cryosurgery is another recommended adjunctive treatment. 1,4,10 These two patients were cured with no recurrence and no impairment of their social and professional lives.
The authors intend to emphasize the importance of the differential diagnosis in patients with urban activity in case of diseases linked to rural activity, preventing unnecessary treatments and chronicity. Attention to the clinical and laboratory diagnosis and the early treatment can increase the chances of cure.

Financial support
None declared.