# A Case of Recurrent Chromoblastomycosis Treated with Multiple Surgical Management Options

## TL;DR

A case study shows how a rare fungal skin disease was successfully managed with surgery when antifungal drugs couldn't be used.

## Contribution

This paper presents a novel surgical approach for chromoblastomycosis in patients with contraindications to antifungal therapy.

## Key findings

- Surgical excision and cryotherapy successfully managed chromoblastomycosis in a patient unable to take antifungals.
- Repeat biopsies proved effective in monitoring recurrence and confirming treatment success.
- The case highlights the need for multiple surgical interventions due to the disease's high recurrence rate.

## Abstract

Chromoblastomycosis is prevalent in tropical and subtropical regions such as Australia. It should be considered in patients presenting with chronic verrucous, plaque, or ulcerated skin lesions unresponsive to conventional therapies. Typically, treatment is combination therapy or oral antifungal agents for a prolonged period. It has a high recurrence rate. Presentation is typically in the lower limbs, unlike the case presented here. This case highlights the importance of multiple surgical options in patients who have contraindications to oral antifungals, including both surgical excision and cryotherapy. It also highlights the importance of follow-up visits after treatment cessation to ensure lesion clearance and no recurrence.

Chromoblastomycosis is a chronic mycosis of the skin and subcutaneous tissue typically caused by traumatic inoculation of dematiaceous fungi of the Herpotrichiellaceae. A 59-year-old male presented with a 12-month history of an asymmetrical, scaly plaque on the left forearm that has been slowly increasing in size. Past medical history included atrial fibrillation on apixaban, hypertension and a cardiac stent. A 4 mm punch biopsy of the left forearm revealed superficial dermal fibrosis with mild pseudoepitheliomatous hyperplasia and granulomatous inflammation with scattered multinucleate histiocytes. There were giant cells with dark brown, somewhat round, yeast-like structures, some with internal septation exhibiting moderate staining for PAS, compatible with Medlar bodies suggestive of chromoblastomycosis. The patient was on rosuvastatin, rendering itraconazole not a possible treatment option, and instead the patient underwent curettage and cautery with two bouts of cryotherapy freeze and thaw cycles. A twelve-month follow-up noted a crusted area on the distal aspect of the scar. A shave biopsy of this area revealed pigmented organisms suggesting a recurrence of chromoblastomycosis. A further excisional biopsy was performed, with no evidence of chromoblastomycosis. This case highlights multiple surgical options for the management of chromoblastomycosis in patients where medical management is contraindicated. It highlights the therapeutic challenge of this disease due to frequent recurrence of lesions and that repeat biopsy may be efficacious in monitoring for recurrence.