Volume 26, Number 6—June 2020
Endemic Chromoblastomycosis Caused Predominantly by Fonsecaea nubica, Madagascar1
|Major||1) Nodular: moderately elevated, fairly soft, dull to pink violaceous growth; surface is smooth, verrucous, or scaly.|
|2) Verrucous: hyperkeratosis is the outstanding feature; warty dry lesions; frequently encountered along the border of the foot.|
|3) Tumorous: tumor-like masses, prominent, papillomatous, sometimes lobulated; cauliflower like; surface is partly or entirely covered with epidermal debris and crusts; more exuberant on lower extremities.|
|4) Cicatricial: nonelevated lesions that enlarge by peripheral extension with atrophic scarring, while healing takes place at the center; might expand centrifugally, usually with an annular, arciform, or serpiginous outline; tends to cover extensive areas of the body.|
|5) Plaque: least common type; slightly elevated with areas of infiltration of various sizes and shapes; red to violet color; a scaly surface, sometimes showing marked lines of cleavage; generally found on the higher portions of the limbs, shoulders, and buttocks.|
|6) Mixed form: association of the 5 basic types of lesions; usually observed in patients showing severe and advanced stages of the disease.|
|7) Clinical form on the face: erythematosquamous cup, central plate, atrophic, cicatricial, retractile, papular on the face, edema on the lips.|
||Pseudovacuolar and eczematous types in patients with a short time of evolution (<3 mo)
|Mycological and histological|
|Major||1) Muriform cells found by direct microscopic examination or histological analysis.|
|2) Molecular evidence of Fonsecaea spp., Cladophialophora carrionii, or Rhinocladiella aquaspersa by PCR with specific primers or internal transcribed spacer, BT2, or TF1 sequencing directly from clinical samples or a positive fungal culture of a melanized fungus morphologically reminiscent of Fonsecaea spp., C. carrionii, or R. aquaspersa.|
|3) Nonambiguous identification (score >2) of Fonsecaea spp., C. carrionii, or R. aquaspersa by MALDI-TOF MS with a validated main spectra profile.|
||Positive fungal culture of a melanized fungus morphologically reminiscent of Fonsecaea sp., C. carrionii, or R. aquaspersa from a clinical sample without molecular confirmation or ambiguous identification (score <2) of Fonsecaea spp., C. carrionii, or R. aquaspersa by MALDI-TOF MS with a home-made validated main spectra profile.
|Confirmed||>1 of the major clinical criteria and >1 of the major mycological criteria or 1 minor clinical criterion and >1 of the major mycological criteria|
|Probable||>1 of the major clinical criteria and 1 minor mycological or histological criterion and a complete or partial response to antifungal therapy|
||>1 of the major clinical criteria without any (major or minor) mycological or histological criteria or >1 of the minor clinical criteria without any (major or minor) mycological or histological criteria and a complete or partial response to antifungal therapy
|Mild||Solitary plaque or nodule <5 cm in diameter|
|Moderate||Solitary or multiple lesions as nodular, verrucous, or plaque types existing alone or in combination, covering 1 or 2 adjacent cutaneous regions and measuring <15 cm in diameter|
||Any type of lesion alone or in combination covering extensive cutaneous regions whether adjacent or nonadjacent
|Clinical response during antifungal therapy|
|Major||Resolution of lesions with no relapse after 6 mo of follow-up. Reduction in the thickness/induration of lesions by 75% or reduction of the surface area affected by palpable lesions by 75%|
|Minor||Resolution of all cutaneous symptoms (i.e., pruritus) referable to the lesions and some objective improvement of lesions, less than a major response|
|Failure||Minor improvement or no change, worsening of lesions on therapy|
*Adapted from Queiroz-Telles et al. (1). MALDI-TOF MS, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry.
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1Preliminary results from this study were presented at the 20th International Society for Human and Animal Mycology Conference; June 29–July 5, 2018; Amsterdam, the Netherlands.