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Volume 26, Number 6—June 2020

Endemic Chromoblastomycosis Caused Predominantly by Fonsecaea nubica, Madagascar1

Tahinamandranto Rasamoelina, Danièle Maubon, Malalaniaina Andrianarison, Irina Ranaivo, Fandresena Sendrasoa, Njary Rakotozandrindrainy, Fetra A. Rakotomalala, Sébastien Bailly, Benja Rakotonirina, Abel Andriantsimahavandy, Fahafahantsoa Rakato Rabenja, Mala R. Andrianarivelo, Muriel CornetComments to Author , and Lala S. Ramarozatovo
Author affiliations: Université d’Antananarivo, Antananarivo, Madagascar (T. Rasamoelina, N. Rakotozandrindrainy, F.A. Rakotomalala, B. Rakotonirina, A. Andriantsimahavandy, M.Rakato Andrianarivelo); Université Grenoble Alpes, Grenoble, France (D. Maubon, S. Bailly, M. Cornet); Hôpital Universitaire Joseph Raseta Befelatanana, Antananarivo (M. Andrianarison, I. Ranaivo, F. Sendrasoa, F.R. Rabenja, L.S. Ramarozatovo); Centre Hospitalier Universitaire de Befelatanana, Antananarivo (L.S. Ramarozatovo)

Main Article

Table 1

Classification criteria for cases of endemic chromoblastomycosis caused predominantly by Fonsecaea nubica, Madagascar*

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.

Main Article

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Main Article

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.

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