Section 7: Deep Fungal Infections

Chromoblastomycosis The granulomatous process shown in Fig. 7-1, which is variegated in color, is of 12 years' duration. It started as a small nodule, developed slowly into a verrucous mass, and acquired satellite extensions. The condition, so reminiscent of a tuberculous process, is a deep fungal infection caused by the species of Phialophora, Fonsecaea, and Cladosporium, which are indigenous to parts of South America and other regions with warm climates. Lesions that are too large for surgical excision are treated with combinations of systemic flucytosine, amphotericin B, and ketoconazole.

Coccidioidomycosis This disease, caused by the dimorphic fungus Coccidioides immitis, is endemic to the southwestern United States and parts of Central and South America. Most individuals in those areas develop the disease as an inconsequential upper-respiratory infection.

Severe disseminated disease can follow pulmonary infection and may involve the skin. In Figs. 7-2 and 7-3, the lesions are typically abscesses, nodules, or verrucous and inflammatory plaques. Primary infection of the skin, which is rare, is accompanied by regional lymphadenopathy. Amphotericin B, with or without itraconazole or fluconazole, is the customary treatment.

Sporotrichosis Cutaneous infection with Sporothrix schenckii is a disease with worldwide distribution. The majority of cases are seen in Central and South America but outbreaks occur in the United States. The disease affects both children and adults and occurs when the causative fungus, in either contaminated soil or plant materials, contacts traumatized skin.

The thorn of a rose bush may provide both the organism and a site of entry, and there have been outbreaks among children playing among bales of hay. Pictured here is the most common form of sporotrichosis, the lymphocutaneous type. It causes an ulcerated lesion at the site of inoculation (Fig. 7-4) and a string of nodules or ulcerations along the lines of lymphatic drainage (Fig. 7-5).

Sporotrichosis This is an example of fixed cutaneous sporotrichosis on the face. Lesions of this type are usually attributed to exposure during outdoor play. Specifically, acquisition of S schenckii has been attributed to playing in bales of hay or in sphagnum moss. Transmission from a cat has also been described.

These tender secondary lesions may become chronic and extend into subcutaneous tissues. Very rarely, and especially in the immunocompromised host, disseminated or systemic sporotrichosis follows cutaneous infection. Diagnosis of sporotrichosis can ...