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with just a few exceptions &#40;e&#46;g&#46;&#44; mucormycosis&#41;&#46; Epidemiological data on the prevalence and incidence of mycoses in Spain are lacking&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Subcutaneous Mycoses</span><p id="par0010" class="elsevierStylePara elsevierViewall">The subcutaneous mycoses comprise several clinical entities caused by invasion of the skin and subcutaneous tissue by saprophytic fungi that live in soil and vegetation&#46; However&#44; even though cuts and wounds are very common in people living in rural areas&#44; overall&#44; there are very few cases of subcutaneous mycoses&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The typical route of entry for the fungus is traumatic inoculation through contaminated material such as splinters&#44; thorns&#44; or other sharp objects&#44; explaining why subcutaneous mycoses are also referred to as <span class="elsevierStyleItalic">mycoses of implantation</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although the fungi responsible for subcutaneous mycoses are taxonomically heterogeneous&#44; they are unified by the fact that they share the same route of entry&#46; Any of these infections can affect people who have traveled to endemic areas&#44; even years after their return&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The most common subcutaneous mycoses are sporotrichosis&#44; chromoblastomycosis&#44; and mycetoma&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">1</span></a> Other less common entities are lacaziosis&#44; phaeohyphomycosis&#44; hyalohyphomycosis&#44; and conidiobolomycosis&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Sporotrichosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Sporotrichosis is a subacute or chronic infection caused by dimorphic fungi&#44; the most common of which is <span class="elsevierStyleItalic">Sporothrix schenckii&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">4&#44;5</span></a> These fungi are universal&#44; although they are more common in tropical and subtropical areas&#46; The estimated incidence of sporotrichosis in South America is between 48 and 60 cases per 100<span class="elsevierStyleHsp" style=""></span>000 population a year&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">6&#44;7</span></a> Only a few autochthonous cases have been reported in Spain and other parts of Europe&#44;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">8</span></a> and the majority of cases in these areas are imported&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The causative agents belong to a species complex known as <span class="elsevierStyleItalic">S schenckii</span>&#44;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">10&#44;11</span></a> which comprises <span class="elsevierStyleItalic">Sporothrix brasiliensis</span>&#44; <span class="elsevierStyleItalic">Sporothrix mexicana</span>&#44; <span class="elsevierStyleItalic">Sporothrix luriei</span>&#44; <span class="elsevierStyleItalic">Sporothrix pallida</span> &#40;previously <span class="elsevierStyleItalic">Sporothrix albicans</span>&#41;&#44; and <span class="elsevierStyleItalic">Sporothrix schenckii</span> sensu lato &#40;sl&#46;&#41;&#44; which is the most common of the five&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">After an incubation period of 15 to 30 days&#44; traumatic inoculation by <span class="elsevierStyleItalic">Sporothrix</span> spp&#46; results in a chronic infection characterized by nodular lesions in the cutaneous and subcutaneous tissue associated with lymphangitis in the affected area&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Sporothrix</span> spp<span class="elsevierStyleItalic">&#46;</span> live in vegetation&#44; plants&#44; or plant debris in the soil&#44; and therefore infections are more common in agricultural workers and people working in open areas&#46; Sporotrichosis is considered an occupational disease in forest wardens&#44; horticulturists&#44; gardeners&#44; and farm workers in general&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">4&#44;13</span></a> Alcoholism and diabetes have also been described as risk factors&#46; Immunosuppression&#44; regardless of the cause&#44; is also a predisposing factor for disseminated or systemic disease&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">1</span></a> The disease can also be acquired through manipulation of the fungus in a laboratory setting&#46; Finally&#44; there was an interesting epidemic in southern Brazil in which sporotrichosis was transmitted to humans through cat scratches&#44; suggesting that it might be a zoonotic infection&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">14</span></a> Most of the species isolated in these cases were <span class="elsevierStyleItalic">S brasiliensis</span>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinical Forms<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">5</span></a></span><p id="par0050" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Lymphocutaneous sporotrichosis&#46;</span> Also known as <span class="elsevierStyleItalic">lymphangitic sporotrichosis</span>&#44; this clinical form accounts for over 75&#37; of all cases of sporotrichosis&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">15</span></a> The lesions occur in exposed areas&#44; such as the hands&#44; face&#44; and feet&#46; The disease starts as a painless purple or blackish nodule that erodes into a small ulcer &#40;sporotrichotic chancre&#41; with swollen edges&#44; a painful granulomatous center&#44; and minimal discharge&#46; This is followed by lymphangitis with secondary nodules along the line of lymphatic drainage that can progress to ulcers&#59; this characteristic pattern is known as <span class="elsevierStyleItalic">sporotrichoid spread</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">6</span></a> The patient&#39;s general health is not affected&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">15</span></a> The course of disease varies according to the host&#39;s immune response&#44; the virulence of the strain&#44; the size of the inoculum&#44; and the depth of the lesion&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Fixed sporotrichosis&#46;</span> This variant is characterized by the presence of a solitary lesion&#46; The infection is limited and generally presents as a slow-growing&#44; less progressive verrucous plaque&#46; Fixed sporotrichosis does not normally affect the lymph vessels and is more common in endemic areas&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Other clinical forms</span>&#58;</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Osteoarticular sporotrichosis&#46;</span> This is a disseminated form of sporotrichosis that affects the bones and joints&#59; it is the most common form of systemic involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">17</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Primary pulmonary sporotrichosis&#46;</span> This variant preferentially affects immunosuppressed patients and is acquired by inhalation&#46; It mimics cavitary tuberculosis&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">16</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Metastatic pulmonary sporotrichosis&#46;</span> The metastatic form of pulmonary sporotrichosis is uncommon and has only been described in isolated cases&#46; It occurs in immunocompromised patients&#44; particularly those with human immunodeficiency virus &#40;HIV&#41; infection in the AIDS stage&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">18</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Widespread invasion&#46;</span> Disseminated disease is rare in sporotrichosis&#44; although meningeal and ocular involvement have been described in immunosuppressed patients with uncontrolled diabetes or chronic alcoholism&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In Mexico&#44; like other countries in Latin America &#40;home to the largest case series and the most experience with sporotrichosis&#41;&#44; lymphocutaneous sporotrichosis accounts for 60&#37; to 80&#37; of all cases of sporotrichosis&#44; fixed cutaneous sporotrichosis for 10&#37; to 30&#37;&#44; and other clinical forms for 1&#37; to 2&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">16</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Sporotrichosis must be distinguished from tuberculosis&#44; leishmania&#44; tularemia&#44; cutaneous nocardiosis&#44; nontuberculous mycobacterial infections&#44; mycetoma&#44; chromoblastomycosis&#44; and lepromatous leprosy&#46; Sporotrichoid &#40;lymphangitic&#41; spread can be seen in many of these conditions&#44; which must be contemplated in the differential diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">19</span></a></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Diagnosis</span><p id="par0100" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Pus &#40;aspirated from nodules&#41;&#46; Direct microscopic examination is of no value in sporotrichosis&#44; as lesions contain very few yeast forms&#46; Sabouraud dextrose agar &#40;SDA&#41; and SDA with antibiotics &#40;chloramphenicol and cycloheximide&#41; can be used for culture&#44; which produces yeast colonies that are initially white and then darken &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Growth is characteristically quick &#40;3-5 days&#41;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">20</span></a> but 2 weeks are needed to identify the fungus and confirm diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">16</span></a> Molecular identification by polymerase chain reaction &#40;PCR&#41; analysis is also possible&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">10&#44;21</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Histology&#46; Histologic examination reveals a nonspecific mixed granulomatous reaction with neutrophilic microabscesses&#46; The fungus presents as a small cigar-shaped yeast form sometimes surrounded by characteristic radiating eosinophilic material known as an <span class="elsevierStyleItalic">asteroid body</span>&#46; While asteroid bodies can aid diagnosis&#44; they are not pathognomic&#44;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">16&#44;20</span></a> as they are also found intracellularly in sarcoidosis&#44; silicosis&#44; and lacaziosis &#40;lobomycosis&#41;&#46; Extracellular asteroid bodies&#44; however&#44; are more characteristic of sporotrichosis&#46; Several specimens may be needed to visualize the microorganisms&#44; although they are easier to find in the case of disseminated or visceral disease&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Treatment</span><p id="par0115" class="elsevierStylePara elsevierViewall">Sporotrichosis may resolve spontaneously in some cases&#44; such as during pregnancy&#44; although paradoxically dissemination has also been reported in pregnant women&#46;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">1&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Saturated solution of potassium iodide&#46;</span> Treatment with potassium iodide&#44; as a saturated solution&#44; is started at 5 drops per meal&#46; This initial dose is then gradually increased to 20 or 30 drops per meal according to tolerance levels&#46; The treatment should be maintained for 3 to 4 weeks after resolution of the clinical manifestations&#46; The mechanism of action is unknown&#44; although potassium iodide is thought to act as an immunostimulant&#46; Adverse effects include a metallic taste in the mouth&#44; rhinitis&#44; expectoration&#44; urticaria&#44; petechiae&#44; bullous or acneiform rash&#44; vasculitis&#44; and induction of hypothyroidism or hyperthyroidism&#46; Potassium iodide is contraindicated during pregnancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">20&#44;22</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">2&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Itraconazole</span> 200<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 3 to 6 months&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">22</span></a> This is the first-line treatment recommended in most treatment guidelines&#46; It tends to be a little more expensive than potassium iodide&#44; but it has fewer adverse effects&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">3&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Other options</span>&#46; Terbinafine 250-1000<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 3 to 6 months<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">23&#44;24</span></a>&#59; fluconazole 400<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 3 to 6 months<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">22</span></a>&#59; amphotericin B &#40;deoxycholate&#41; 0&#46;5-1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d for systemic disease or liposomal or lipid formulations of amphotericin B at a dose of 3-5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">22</span></a>&#59; local heat or thermotherapy for 2 or 3 months&#44;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">22</span></a> or a combination of the above treatments &#40;potassium iodide with itraconazole&#44; itraconazole with terbinafine&#44; and terbinafine with potassium iodide&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">25</span></a> The addition of photodynamic therapy with methyl aminolevulinate or even better intralesional methylene blue 1&#37; &#40;combined or not with itraconazole&#41; has produced good results in vitro and in 1 patient&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">26</span></a></p></li></ul></p><p id="par0135" class="elsevierStylePara elsevierViewall">Surgery can have an important role in osteoarticular sporotrichosis&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">22</span></a> Debridement and arthrodesis were traditionally considered the treatments of choice but prosthetic joint replacement followed by long-term antifungal treatment has also been described as a viable option</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">1&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0060">Chromoblastomycosis &#40;Chromomycosis&#41;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Chromoblastomycosis&#44; also known as <span class="elsevierStyleItalic">chromomycosis</span>&#44; is a chronic polymorphic fungal infection of the skin and subcutaneous tissue&#46; It is caused by several species of melanized or dematiaceous fungi&#44; which produce a dark pigment&#46; The parasitic forms of these fungi are called <span class="elsevierStyleItalic">fumagoid</span> or <span class="elsevierStyleItalic">muriform</span> cells &#40;sclerotic bodies&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">27&#8211;30</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The most common species that cause chromoblastomycosis are <span class="elsevierStyleItalic">Fonsecaea pedrosoi</span>&#44; <span class="elsevierStyleItalic">Fonsecaea monophora&#44; Cladophialophora carrionii&#44; Phialophora verrucosa</span>&#44; and <span class="elsevierStyleItalic">Rhinocladiella aquaspersa</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">5&#44;27&#44;28</span></a> Most patients have a history of a traumatic injury involving wood or vegetation&#44; and over 80&#37; are rural workers in Africa&#44; Asia&#44; and South America who tend to walk barefoot&#46; The fungi responsible for chromoblastomycosis have been found worldwide&#44; though they are more common in tropical and subtropical countries&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">27</span></a></p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Clinical Forms</span><p id="par0150" class="elsevierStylePara elsevierViewall">The fungus generally penetrates the skin through a skin injury&#44; typically located on the lower limbs&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">31</span></a> About 1 or 2 months later&#44; the infected individual develops a papule that progresses to a slow-growing warty nodule &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The infection is limited to the subcutaneous tissue and does not spread to either muscle or bone&#44; except in immunocompromised patients&#46; Individual lesions can develop a thick cauliflower-like appearance and bacterial superinfection is common&#46; Secondary lymphedema&#44; possibly progressing to elephantiasis&#44; and squamous cell carcinoma may occur&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">27</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Diagnosis</span><p id="par0155" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">1&#46;</span><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Direct examination&#46;</span> Direct examination of crusts and fragments of skin can reveal parasitic forms that occur in isolation or form characteristic septa &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The microscopic structures observed are common to all species&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">27&#44;28</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">2&#46;</span><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Culture&#46;</span> The fungi that cause chromoblastomycosis grow slowly when cultivated on SDA with or without antibiotics &#40;chloramphenicol and cycloheximide&#41;&#59; they produce dark olivaceous or black colonies with a flat velvety surface and a raised center&#46; Distinction between species is difficult and is based on reproductive structures and molecular identification&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">30</span></a> Molecular biology techniques &#40;PCR&#41;&#44; in particular targeting internal transcribed spacer &#40;ITS&#41; regions of ribosomal DNA &#40;rDNA&#41;&#44; are also useful&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">32&#44;33</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">3&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Histology&#46;</span> Histologic examination shows characteristic pseudoepitheliomatous hyperplasia in the epidermis and a mixed granulomatous inflammatory infiltrate with giant cells containing characteristic round fungal structures &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; in the dermis&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">27</span></a></p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Treatment</span><p id="par0175" class="elsevierStylePara elsevierViewall">Chromoblastomycosis is extremely difficult to treat and is often refractory to diverse options&#44; including nonpharmacological treatments such as curettage&#44; electrocoagulation&#44; and cryosurgery&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">5</span></a> Antifungals must be maintained for at least 6 months&#44; and while they may produce a favorable clinical outcome&#44; recurrences during or after therapy are common&#46; Treatment should be terminated when all the lesions disappear&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">27</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Other treatments include surgical resection of small lesions&#59; local cryosurgery &#40;in association with an antifungal to prevent lymphatic spread&#41;&#59; itraconazole 200-400<span class="elsevierStyleHsp" style=""></span>mg&#47;d alone or combined with 5-fluorocitosine 30<span class="elsevierStyleHsp" style=""></span>mg&#47;kg 4 times a day for 6 months&#59; terbinafine 250-500<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 12 months&#44; and in the case of systemic involvement intravenous amphotericin B at a dose of 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg or liposomal or lipid formulations of amphotericin B at a dose of 3-5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">27</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Mycetoma</span><p id="par0185" class="elsevierStylePara elsevierViewall">Mycetoma is a chronic local infection caused by several species of fungi and bacteria&#46; The infection is called <span class="elsevierStyleItalic">actinomycetoma</span> when it is caused by aerobic filamentous bacteria and <span class="elsevierStyleItalic">eumycetoma</span> when it is caused by fungi&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">34</span></a> It is characterized by the formation of aggregates of the causative microorganisms in abscesses&#46; These aggregates are known as <span class="elsevierStyleItalic">grains</span> or <span class="elsevierStyleItalic">granules</span>&#46; Granules can drain through sinuses opening onto the skin or affect adjacent bones&#46; The disease advances via direct spread&#44; with very few cases of dissemination to distant sites&#46; The causative agents are generally found in the soil and they enter the body through broken skin&#46; Most cases involve rural workers&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Etiology</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">1&#46;</span><p id="par0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Fungi&#46;</span> The fungi that cause eumycetoma produce white or dark granules&#46; They are particularly common in Africa&#44; India&#44; and Mexico&#46; Dark granules are formed by <span class="elsevierStyleItalic">Madurella mycetomatis&#44; Trematosphaeria grisea</span>&#44; and <span class="elsevierStyleItalic">Leptosphaeria</span> senegalensis&#44;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">35</span></a> while white granules are formed by <span class="elsevierStyleItalic">Fusarium</span> spp<span class="elsevierStyleItalic">&#46;</span>&#44; <span class="elsevierStyleItalic">Acremonium</span> spp<span class="elsevierStyleItalic">&#46;</span>&#44; and <span class="elsevierStyleItalic">Aspergillus nidulans&#46;</span></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">2&#46;</span><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Filamentous bacteria or aerobic actinomycetes</span>&#46; The granules formed by these species are red &#40;<span class="elsevierStyleItalic">Actinomadura pelletieri</span>&#41;&#44; white-yellow &#40;<span class="elsevierStyleItalic">Actinomadura madurae</span>&#44; <span class="elsevierStyleItalic">Nocardia brasiliensis</span>&#44; and <span class="elsevierStyleItalic">Nocardia</span> spp&#46;&#41;&#44; or yellow-brown &#40;<span class="elsevierStyleItalic">Streptomyces somaliensis</span>&#41;&#46; Actinomycetes are found all over the world&#44; not just in tropical countries&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">36</span></a></p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Clinical Forms</span><p id="par0205" class="elsevierStylePara elsevierViewall">The clinical characteristics of mycetoma caused by fungi and actinomycetes are very similar&#46; Lesions are more common on the feet&#44; shins&#44; and hands&#46; The earliest clinical manifestation is a hard painless nodule that spreads slowly to produce papules and sinuses that discharge fluid containing granules onto the skin surface&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">35&#44;36</span></a> The original site of infection is distorted by local tissue swelling&#44; formation of chronic sinuses&#44; and late bone involvement &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Lesions are rarely painful&#44; except in late stages&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Diagnosis</span><p id="par0210" class="elsevierStylePara elsevierViewall">Mycetoma granules &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; are a key diagnostic finding and are generally found on examining discharge from sinuses or on crushing a crust taken from a lesion&#46; Microscopic examination will show whether these granules are formed by small actinomycetes or wider mycotic filaments&#46; Definitive identification requires culture&#44; which is normally carried out on SDA with or without antibiotics &#40;chloramphenicol and cycloheximide&#41;&#59; chloramphenicol alone is preferred in the case of hyaline fungi&#46; The agents can also be identified by molecular biology testing&#44; particularly PCR analysis using different markers<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">37</span></a> depending on the causative agents &#40;e&#46;g&#46;&#44; ITS regions of rDNA&#44; &#946;-tubulin&#44;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">38</span></a> and D1&#47;D2&#41;&#46; Partial ribosomal RNA gene sequence analysis&#44; by contrast&#44; can be used to identify <span class="elsevierStyleItalic">Nocardia</span> and <span class="elsevierStyleItalic">Actinomadura</span> species&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">36</span></a> Histologic findings are similar in all forms of mycetoma&#44; and include an inflammatory center rich in polymorphonuclear cells &#40;true abscesses&#41;&#44; epithelioid cells&#44; giant cells&#44; and fibrosis&#46; The granules are located in the center of the inflammation&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">35&#44;39</span></a> Imaging studies&#44; while complementary&#44; can aid diagnosis by showing soft tissue swelling&#44; osteolytic lesions&#44; and cortical thickening&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">The differential diagnosis should include bacterial osteomyelitis&#44; tuberculous osteomyelitis&#44; hidradenitis suppurativa&#44; Kaposi sarcoma&#44; and cutaneous tuberculosis&#44; among others&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">35&#44;39</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Treatment</span><p id="par0220" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Actinomycetoma</span>&#46; The treatment regimen with the strongest evidence base for nocardial mycetoma is trimethoprim-sulfamethoxazole plus diaminodiphenyl sulfone &#40;dapsone&#41; for 6 months to 2 years&#46; Amoxicillin-clavulanic acid&#44; administered over 6 months&#44; can be used for refractory cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0540"><span class="elsevierStyleSup">40&#8211;42</span></a> The treatment of choice for extensive infection and&#47;or visceral involvement is amikacin combined with trimetoprim-sulfametoxazol<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">39</span></a> or meropenem&#46;<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">43&#44;44</span></a> There have been isolated reports of successful outcomes with other agents in patients who do not respond to these treatments&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">36&#44;39&#44;45</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Eumycetoma</span>&#46; Unlike in actinomycetoma&#44; where pharmacological treatment is associated with good outcomes&#44; the standard treatment in eumycetoma is a combination of medical treatment and surgery&#46; Acceptable results have been reported for the use of last-generation triazoles&#44; such as itraconazole and fluconazole used alone or in combination with terbinafine&#46; These drugs are administered over a long period and only after exhausting all surgical options&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">35&#44;45</span></a></p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Phaeohyphomycosis</span><p id="par0230" class="elsevierStylePara elsevierViewall">Phaeohyphomycosis is a heterogeneous group of mycoses caused by dark-walled &#40;dematiaceous&#41; fungi&#46;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">46&#44;47</span></a> These fungi are found in all climates&#44; although they are more common in tropical climates&#46; There has been a recent rise in cases among immunosuppressed patients with HIV infection or AIDS&#44; transplant recipients&#44; and diabetic patients&#44; among others&#46;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">46&#44;48</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">The most common causative agents are <span class="elsevierStyleItalic">Exophiala</span> spp<span class="elsevierStyleItalic">&#46;&#44; Bipolaris</span> spp&#46;<span class="elsevierStyleItalic">&#44; Curvularia</span> spp&#46;&#44; <span class="elsevierStyleItalic">Pleurophomopsis</span> spp<span class="elsevierStyleItalic">&#46;</span>&#44; <span class="elsevierStyleItalic">Phaeoacremonium</span> spp&#44; and <span class="elsevierStyleItalic">Alternaria</span> spp&#46; The fungi are found mainly in organic debris&#46;</p><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Clinical Forms</span><p id="par0240" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">1&#46;</span><p id="par0245" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Subcutaneous phaeohyphomycosis</span>&#46; Following local trauma or inoculation with foreign material&#44; patients develop a slow-growing solitary lesion &#40;generally a cyst or a nodule&#44; or possibly a plaque or abscess&#41; normally located on the extremities &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">48&#44;49</span></a> The differential diagnosis should include lipomas&#44; epidermal or synoviale cysts&#44; fibromas&#44; foreign body cysts&#44; and bacterial abscesses&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">2&#46;</span><p id="par0250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Systemic or disseminated phaeohyphomycosis</span>&#46; While very rare&#44; systemic phaeohyphomycosis is very serious in immunosuppressed patients&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">50</span></a></p></li></ul></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Diagnosis</span><p id="par0255" class="elsevierStylePara elsevierViewall">Wet-mount microscopy shows diagnostic dark septate hyphae forming branches or chains &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Growth is slow &#40;3-4 weeks&#41; on SDA and colonies acquire an olivaceous or dark brown color&#46; PCR analysis of markers such as &#946;-tubulin and ITS regions can be used for molecular identification&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">51&#44;52</span></a> Biopsy reveals a cyst wall formed by palisading macrophages with mycotic hyphae&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">49</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Treatment</span><p id="par0260" class="elsevierStylePara elsevierViewall">Treatment of infections caused by <span class="elsevierStyleItalic">Exophiala</span> spp&#46; is controversial&#44; and one option that has been proposed is surgical resection&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">48</span></a> There are also no standard protocols for the treatment of <span class="elsevierStyleItalic">Alternaria</span> infections&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">53</span></a> The best option for phaeohyphomycosis appears to be a combination of antifungal therapy &#40;itraconazole&#44; ketoconazole&#44; or terbinafine&#41; and surgery&#46; <span class="elsevierStyleItalic">Exophiala</span> spp&#46; strains tend to be resistant to fluconazole&#46; Disseminated infections are treated with amphotericin B&#46;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">48&#44;49</span></a></p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Hyalohyphomycosis</span><p id="par0265" class="elsevierStylePara elsevierViewall">Hyalohyphomycosis is caused by hyaline fungi &#40;Hyphomycetes&#41; that form septate hyphae in tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">47</span></a> This classification&#44; however&#44; is rather arbitrary as there are many types of terrestrial and aquatic Hyphomycetes&#46; Just a few organisms&#44; however&#44; can cause infections&#44; most of which are opportunistic&#44; in humans&#46;<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">54&#44;55</span></a> Most of the genera involved in hyalohyphomycosis are morphologically identical when observed in tissue sections and they trigger the same pathologic response&#46; Fungi that frequently cause infections or have another particularly distinctive characteristic are assigned to a different category &#40;e&#46;g&#46;&#44; aspergillosis&#41;&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">The most common agents involved in hyalohyphomycosis are <span class="elsevierStyleItalic">Aspergillus &#40;fumigatus&#44; niger&#44; flavus&#41;</span>&#44; <span class="elsevierStyleItalic">Scopulariopsis</span> spp&#46;&#44; <span class="elsevierStyleItalic">Fusarium</span> spp&#46;&#44; <span class="elsevierStyleItalic">Acremonium recifei</span>&#44; <span class="elsevierStyleItalic">Paecilomyces</span> spp&#46;&#44; <span class="elsevierStyleItalic">Purpureocillum</span> spp&#46;&#44; and <span class="elsevierStyleItalic">Neoscytalidium</span> spp&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">55</span></a> They are all widely distributed in nature&#44; and can be found in any type of soil&#44; wood&#44; or decomposing plant material&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">56</span></a> They affect individuals of either sex and at any age&#44; and immunosuppression is not a necessary condition for infection&#46;</p><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Clinical Forms</span><p id="par0275" class="elsevierStylePara elsevierViewall">Hyalohyphomycosis can be classified as superficial&#44; subcutaneous&#44; or systemic&#46;<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">1&#46;</span><p id="par0280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Superficial hyalohyphomycosis&#46;</span> Superficial infections include dermatomycosis and onychomycosis&#46; They are common in rural workers&#44; fishermen&#44; patients with severe burns&#44; and premature neonates&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">57&#44;58</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">2&#46;</span><p id="par0285" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Subcutaneous hyalohyphomycosis&#46;</span> Traumatic inoculation causes abscesses&#44; cysts&#44; and tumor-like lesions similar to those seen in mycetoma &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">56</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">3&#46;</span><p id="par0290" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Systemic hyalohyphomycosis</span>&#46; Systemic infections&#44; while uncommon&#44; are very serious&#46; They affect immunosuppressed patients and can be fatal&#46; Hematogenous and lymphatic spread leads to involvement of the lungs and central nervous system&#46;<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">55&#44;57</span></a></p></li></ul></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Diagnosis</span><p id="par0295" class="elsevierStylePara elsevierViewall">Identification of septate hyaline hyphae by microscopic examination of skin scales&#44; nail fragments&#44; secretions&#44; or fragments provides a presumptive diagnosis&#44; which is then confirmed by culture &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Most fungi grow on SDA without antibiotics or inhibitors&#46;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">47&#44;59</span></a> As in the cases described above&#44; molecular identification is also possible&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">60</span></a></p><p id="par0300" class="elsevierStylePara elsevierViewall">The differential diagnosis should include other dermatomycoses&#44; epidermal cysts&#44; actinomycetoma&#44; eumycetoma&#44; histoplasmosis&#44; and cryptococcosis&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Treatment</span><p id="par0305" class="elsevierStylePara elsevierViewall">In immunocompetent individuals&#44; the treatments of choice are triazoles&#44; terbinafine&#44; or surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">61</span></a> When the immune system is compromised&#44; the first-line treatment is amphotericin B combined with a triazole &#40;itraconazole 200<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 6 months or fluconazole 150<span class="elsevierStyleHsp" style=""></span>mg twice a week for 6 months&#41;&#46;</p></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Lacaziosis &#40;Lobomycosis&#41;</span><p id="par0310" class="elsevierStylePara elsevierViewall">Lacaziosis&#44; which was formerly known as <span class="elsevierStyleItalic">lobomycosis</span>&#44; is a chronic granulomatous fungal infection of the skin and subcutaneous tissues first described under the name of <span class="elsevierStyleItalic">keloidal blastomycosis</span> in 1930 by Jorge Lobo in Recife&#44; Brazil&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">62</span></a> It is a rare infection found in Central and South America&#59; it is caused by <span class="elsevierStyleItalic">Lacazia loboi</span>&#44;<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">62&#44;63</span></a> a yeast that cannot be grown in culture&#46; The source of infection is thought to be in soil and vegetation&#46; The fungus probably enters through the skin following a penetrating injury&#44; such as a thorn prick or insect bite&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Lacaziosis is characterized by keloidal lesions with well-defined lobulated edges in exposed areas of the body &#40;frequently the face&#44; arms&#44; or legs&#41;&#46; The lesions spread to contiguous sites&#44; although transmission to distant sites is also possible via autoinoculation&#46;</p><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Diagnosis</span><p id="par0320" class="elsevierStylePara elsevierViewall">Diagnosis is facilitated by the identification of abundant fungal structures during direct examination and chains of diffuse round cells connected by small tubular structures in biopsy samples&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">62</span></a> Causative agents can also be identified in tissue by PCR analysis&#44; in particular assays targeting the 18S rDNA fragment&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">64</span></a></p><p id="par0325" class="elsevierStylePara elsevierViewall">The differential diagnosis should include keloids&#44; lepromatous leprosy&#44; and anergic leishmania&#46;</p></span></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Treatment</span><p id="par0330" class="elsevierStylePara elsevierViewall">Antifungals are not effective in lacaziosis and the definitive treatment is surgical resection&#46;<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">62&#44;63</span></a></p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Zygomycosis</span><p id="par0335" class="elsevierStylePara elsevierViewall">Zygomycosis is a heterogeneous group of fungal infections caused by opportunistic Zygomycetes of the orders Mucorales &#40;<span class="elsevierStyleItalic">Rhizopus&#44; Lichtheimia&#44; Mucor</span>&#44; and <span class="elsevierStyleItalic">Rhizomucor</span>&#41; and Entomophthorales &#40;<span class="elsevierStyleItalic">Basidiobolus</span> and <span class="elsevierStyleItalic">Conidiobolus</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">65</span></a> In this section&#44; we will only discuss Entomophthorales fungi&#44; as the Mucorales are addressed in the second part of this review&#44; which looks at systemic mycoses&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">Entomophthoromycosis is characterized by the appearance of a hard&#44; progressive mass that affects the subcutaneous tissues&#46; There are 2 variants&#46; The first is caused by <span class="elsevierStyleItalic">Basidiobolus ranarum</span> and is more common in children&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">66</span></a> Lesions generally appear in the shoulder and pelvic girdles&#44; and present as a slowly spreading woody cellulitis&#46; The second variant is caused by <span class="elsevierStyleItalic">Conidiobolus coronatus</span> and affects adults&#46; The primary infection starts in the lower turbinates of the nose and then spreads to the center of the face&#44; causing painful indurated swelling and severe deformation of the nose&#44; lips&#44; and cheeks&#46;<a class="elsevierStyleCrossRefs" href="#bib0665"><span class="elsevierStyleSup">65&#8211;68</span></a></p></span></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conclusion</span><p id="par0345" class="elsevierStylePara elsevierViewall">We have reviewed the main characteristics of the subcutaneous mycoses and the main diagnostic and treatment methods available &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conflicts of Interest</span><p id="par0350" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Conclusion"
        ]
        8 => array:2 [
          "identificador" => "sec0145"
          "titulo" => "Conflicts of Interest"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-01-07"
    "fechaAceptado" => "2016-05-29"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec764389"
          "palabras" => array:6 [
            0 => "Deep mycosis"
            1 => "Subcutaneous mycosis"
            2 => "Systemic mycosis"
            3 => "Sporotrichosis"
            4 => "Chromoblastomycosis"
            5 => "Mycetoma"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec764390"
          "palabras" => array:6 [
            0 => "Micosis profundas"
            1 => "Micosis subcut&#225;neas"
            2 => "Micosis sist&#233;micas"
            3 => "Esporotricosis"
            4 => "Cromoblastomicosis"
            5 => "Micetomas"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The deep mycoses are uncommon in our setting&#46; These fungal infections occur mainly in immunosuppressed patients or in tropical climates&#44; and include subcutaneous infections and systemic infections&#46; The skin is always involved in the former&#46; In the first part of this review&#44; we describe the main subcutaneous mycoses&#58; sporotrichosis&#44; chromoblastomycosis&#44; mycetoma&#44; phaeohyphomycosis&#44; hyalohyphomycosis&#44; and lacaziosis&#46; Early recognition and treatment is important&#44; as these infections are frequently associated with high morbidity&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Las micosis profundas son infecciones poco frecuentes en nuestro medio&#46; Se presentan principalmente en pacientes inmunodeprimidos o en regiones de climas tropicales&#44; que abarcan las micosis subcut&#225;neas y las micosis sist&#233;micas&#46; Las micosis subcut&#225;neas o por implantaci&#243;n siempre producen signos de afectaci&#243;n cut&#225;nea&#46; En la primera parte de esta revisi&#243;n se realizar&#225; una revisi&#243;n de las principales micosis subcut&#225;neas&#58; esporotricosis&#44; cromoblastomicosis&#44; micetomas&#44; feohifomicosis&#44; hialohifomicosis y lacaziosis&#46; Reconocer y tratar estas micosis subcut&#225;neas de forma precoz es importante&#44; ya que a menudo est&#225;n asociadas a una alta morbilidad&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Carrasco-Zuber JE&#44; Navarrete-Dechent C&#44; Bonifaz A&#44; Fich F&#44; Vial-Letelier V&#44; Berroeta-Mauriziano D&#46; Afectaci&#243;n cut&#225;nea en las micosis profundas&#58; una revisi&#243;n de la literatura&#46; Parte 1&#58; micosis subcut&#225;neas&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;806&#8211;815&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Abbreviation&#58; PCR&#44; polymerase chain reaction&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mycosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Main Causative Agent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sporotrichosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Sporothrix schenckii</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cultivation of pus aspirated from nodules&#59; histology&#59; PCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Saturated solution of potassium iodide for 3 wk&#59; itraconazole 200<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 3&#8211;6 mo&#59; combinations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chromoblastomycosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Fonsecaea pedrosoi</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Microscopic examination&#59; culture&#59; histology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Very difficult&#46; Itraconazole 200<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 6 mo&#59; terbinafine for 12 mo&#59; amphotericin B&#59; combinations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mycetoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Filamentous actinomycetes and filamentous fungi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Identification of mycetoma granules&#59; culture&#59; histology&#59; PCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Antibiotics for actinomycetoma&#59; antifungals<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>surgery for eumycetoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phaeohyphomycosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Exophiala jeanselmei</span><br><span class="elsevierStyleItalic">Alternaria</span> spp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Microscopic examination and culture&#59; histology&#59; PCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Controversial&#46; Surgery<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>combination of antifungals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hyalohyphomycosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Opportunistic <span class="elsevierStyleItalic">Aspergillus</span> &#40;<span class="elsevierStyleItalic">fumigatus&#44; niger&#44; flavus</span>&#41;&#44; <span class="elsevierStyleItalic">Fusarium</span> spp&#46;&#44; <span class="elsevierStyleItalic">Paecilomyces</span>&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Microscopic examination and culture&#59; PCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Immunocompetent patients&#58; triazoles&#59; terbinafine&#59; ciclopirox olamine&#59; surgery<br>Immunosuppressed patients&#58; amphotericin B combined with a triazole for 6 mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lacaziosis &#40;lobomycosis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Lacazia loboi</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Microscopic examination&#59; histology&#59; PCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Entomophthoromycosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Conidiobolus coronatus</span><br><span class="elsevierStyleItalic">Basidiobolus ranarum</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Direct examination and culture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery and systemic antifungals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Summary of the Characteristics of the Subcutaneous Mycoses&#46;</p>"
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                      "titulo" => "Subcutaenous mycoses"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "O&#46; Welsh"
                            1 => "R&#46; Arenas"
                          ]
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                    0 => array:2 [
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                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22682182"
                            "web" => "Medline"
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                        ]
                      ]
                    ]
                  ]
                ]
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              "identificador" => "bib0350"
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              "etiqueta" => "4"
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                          ]
                        ]
                      ]
                    ]
                  ]
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                        0 => array:2 [
                          "etal" => false
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                            0 => "A&#46; Bonifaz"
                            1 => "D&#46; V&#225;zquez-Gonz&#225;lez"
                            2 => "A&#46;M&#46; Perusqu&#237;a-Ortiz"
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Review
Cutaneous Involvement in the Deep Mycoses: A Literature Review. Part I—Subcutaneous Mycoses
Afectación cutánea en las micosis profundas: una revisión de la literatura. Parte 1: micosis subcutáneas
J.E. Carrasco-Zubera,
Corresponding author
juaneduardocarrasco@gmail.com

Corresponding author.
, C. Navarrete-Dechentb, A. Bonifazc, F. Fichb, V. Vial-Letelierb, D. Berroeta-Maurizianob
a Unidad de Dermatología, consultorio adosado de especialidades, Hospital Regional de Valdivia, Valdivia, Chile
b Departamento de Dermatología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
c Departamento de Micología, Hospital General de México, Ciudad de México, Mexico
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The deep mycoses are uncommon infections caused by fungi&#59; they are divided into subcutaneous and systemic mycoses&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">1</span></a> While skin manifestations always occur in subcutaneous mycoses&#44; or <span class="elsevierStyleItalic">mycoses of implantation</span>&#44; as they are also known&#44; they are only occasionally seen in systemic mycoses&#46; In such cases&#44; the skin is affected either directly&#44; by the penetration of the fungus into the dermis&#44; or indirectly&#44; by an infection that has spread from a deeper focus&#46; According to Rezusta et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">2</span></a> the majority of subcutaneous and systemic mycoses in Spain are imported&#44; with just a few exceptions &#40;e&#46;g&#46;&#44; mucormycosis&#41;&#46; Epidemiological data on the prevalence and incidence of mycoses in Spain are lacking&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Subcutaneous Mycoses</span><p id="par0010" class="elsevierStylePara elsevierViewall">The subcutaneous mycoses comprise several clinical entities caused by invasion of the skin and subcutaneous tissue by saprophytic fungi that live in soil and vegetation&#46; However&#44; even though cuts and wounds are very common in people living in rural areas&#44; overall&#44; there are very few cases of subcutaneous mycoses&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The typical route of entry for the fungus is traumatic inoculation through contaminated material such as splinters&#44; thorns&#44; or other sharp objects&#44; explaining why subcutaneous mycoses are also referred to as <span class="elsevierStyleItalic">mycoses of implantation</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although the fungi responsible for subcutaneous mycoses are taxonomically heterogeneous&#44; they are unified by the fact that they share the same route of entry&#46; Any of these infections can affect people who have traveled to endemic areas&#44; even years after their return&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The most common subcutaneous mycoses are sporotrichosis&#44; chromoblastomycosis&#44; and mycetoma&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">1</span></a> Other less common entities are lacaziosis&#44; phaeohyphomycosis&#44; hyalohyphomycosis&#44; and conidiobolomycosis&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Sporotrichosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Sporotrichosis is a subacute or chronic infection caused by dimorphic fungi&#44; the most common of which is <span class="elsevierStyleItalic">Sporothrix schenckii&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">4&#44;5</span></a> These fungi are universal&#44; although they are more common in tropical and subtropical areas&#46; The estimated incidence of sporotrichosis in South America is between 48 and 60 cases per 100<span class="elsevierStyleHsp" style=""></span>000 population a year&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">6&#44;7</span></a> Only a few autochthonous cases have been reported in Spain and other parts of Europe&#44;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">8</span></a> and the majority of cases in these areas are imported&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The causative agents belong to a species complex known as <span class="elsevierStyleItalic">S schenckii</span>&#44;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">10&#44;11</span></a> which comprises <span class="elsevierStyleItalic">Sporothrix brasiliensis</span>&#44; <span class="elsevierStyleItalic">Sporothrix mexicana</span>&#44; <span class="elsevierStyleItalic">Sporothrix luriei</span>&#44; <span class="elsevierStyleItalic">Sporothrix pallida</span> &#40;previously <span class="elsevierStyleItalic">Sporothrix albicans</span>&#41;&#44; and <span class="elsevierStyleItalic">Sporothrix schenckii</span> sensu lato &#40;sl&#46;&#41;&#44; which is the most common of the five&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">After an incubation period of 15 to 30 days&#44; traumatic inoculation by <span class="elsevierStyleItalic">Sporothrix</span> spp&#46; results in a chronic infection characterized by nodular lesions in the cutaneous and subcutaneous tissue associated with lymphangitis in the affected area&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Sporothrix</span> spp<span class="elsevierStyleItalic">&#46;</span> live in vegetation&#44; plants&#44; or plant debris in the soil&#44; and therefore infections are more common in agricultural workers and people working in open areas&#46; Sporotrichosis is considered an occupational disease in forest wardens&#44; horticulturists&#44; gardeners&#44; and farm workers in general&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">4&#44;13</span></a> Alcoholism and diabetes have also been described as risk factors&#46; Immunosuppression&#44; regardless of the cause&#44; is also a predisposing factor for disseminated or systemic disease&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">1</span></a> The disease can also be acquired through manipulation of the fungus in a laboratory setting&#46; Finally&#44; there was an interesting epidemic in southern Brazil in which sporotrichosis was transmitted to humans through cat scratches&#44; suggesting that it might be a zoonotic infection&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">14</span></a> Most of the species isolated in these cases were <span class="elsevierStyleItalic">S brasiliensis</span>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinical Forms<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">5</span></a></span><p id="par0050" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Lymphocutaneous sporotrichosis&#46;</span> Also known as <span class="elsevierStyleItalic">lymphangitic sporotrichosis</span>&#44; this clinical form accounts for over 75&#37; of all cases of sporotrichosis&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">15</span></a> The lesions occur in exposed areas&#44; such as the hands&#44; face&#44; and feet&#46; The disease starts as a painless purple or blackish nodule that erodes into a small ulcer &#40;sporotrichotic chancre&#41; with swollen edges&#44; a painful granulomatous center&#44; and minimal discharge&#46; This is followed by lymphangitis with secondary nodules along the line of lymphatic drainage that can progress to ulcers&#59; this characteristic pattern is known as <span class="elsevierStyleItalic">sporotrichoid spread</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">6</span></a> The patient&#39;s general health is not affected&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">15</span></a> The course of disease varies according to the host&#39;s immune response&#44; the virulence of the strain&#44; the size of the inoculum&#44; and the depth of the lesion&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Fixed sporotrichosis&#46;</span> This variant is characterized by the presence of a solitary lesion&#46; The infection is limited and generally presents as a slow-growing&#44; less progressive verrucous plaque&#46; Fixed sporotrichosis does not normally affect the lymph vessels and is more common in endemic areas&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#41;</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Other clinical forms</span>&#58;</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Osteoarticular sporotrichosis&#46;</span> This is a disseminated form of sporotrichosis that affects the bones and joints&#59; it is the most common form of systemic involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">17</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Primary pulmonary sporotrichosis&#46;</span> This variant preferentially affects immunosuppressed patients and is acquired by inhalation&#46; It mimics cavitary tuberculosis&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">16</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Metastatic pulmonary sporotrichosis&#46;</span> The metastatic form of pulmonary sporotrichosis is uncommon and has only been described in isolated cases&#46; It occurs in immunocompromised patients&#44; particularly those with human immunodeficiency virus &#40;HIV&#41; infection in the AIDS stage&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">18</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Widespread invasion&#46;</span> Disseminated disease is rare in sporotrichosis&#44; although meningeal and ocular involvement have been described in immunosuppressed patients with uncontrolled diabetes or chronic alcoholism&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In Mexico&#44; like other countries in Latin America &#40;home to the largest case series and the most experience with sporotrichosis&#41;&#44; lymphocutaneous sporotrichosis accounts for 60&#37; to 80&#37; of all cases of sporotrichosis&#44; fixed cutaneous sporotrichosis for 10&#37; to 30&#37;&#44; and other clinical forms for 1&#37; to 2&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">16</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Sporotrichosis must be distinguished from tuberculosis&#44; leishmania&#44; tularemia&#44; cutaneous nocardiosis&#44; nontuberculous mycobacterial infections&#44; mycetoma&#44; chromoblastomycosis&#44; and lepromatous leprosy&#46; Sporotrichoid &#40;lymphangitic&#41; spread can be seen in many of these conditions&#44; which must be contemplated in the differential diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">19</span></a></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Diagnosis</span><p id="par0100" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Pus &#40;aspirated from nodules&#41;&#46; Direct microscopic examination is of no value in sporotrichosis&#44; as lesions contain very few yeast forms&#46; Sabouraud dextrose agar &#40;SDA&#41; and SDA with antibiotics &#40;chloramphenicol and cycloheximide&#41; can be used for culture&#44; which produces yeast colonies that are initially white and then darken &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Growth is characteristically quick &#40;3-5 days&#41;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">20</span></a> but 2 weeks are needed to identify the fungus and confirm diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">16</span></a> Molecular identification by polymerase chain reaction &#40;PCR&#41; analysis is also possible&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">10&#44;21</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Histology&#46; Histologic examination reveals a nonspecific mixed granulomatous reaction with neutrophilic microabscesses&#46; The fungus presents as a small cigar-shaped yeast form sometimes surrounded by characteristic radiating eosinophilic material known as an <span class="elsevierStyleItalic">asteroid body</span>&#46; While asteroid bodies can aid diagnosis&#44; they are not pathognomic&#44;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">16&#44;20</span></a> as they are also found intracellularly in sarcoidosis&#44; silicosis&#44; and lacaziosis &#40;lobomycosis&#41;&#46; Extracellular asteroid bodies&#44; however&#44; are more characteristic of sporotrichosis&#46; Several specimens may be needed to visualize the microorganisms&#44; although they are easier to find in the case of disseminated or visceral disease&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Treatment</span><p id="par0115" class="elsevierStylePara elsevierViewall">Sporotrichosis may resolve spontaneously in some cases&#44; such as during pregnancy&#44; although paradoxically dissemination has also been reported in pregnant women&#46;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">1&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Saturated solution of potassium iodide&#46;</span> Treatment with potassium iodide&#44; as a saturated solution&#44; is started at 5 drops per meal&#46; This initial dose is then gradually increased to 20 or 30 drops per meal according to tolerance levels&#46; The treatment should be maintained for 3 to 4 weeks after resolution of the clinical manifestations&#46; The mechanism of action is unknown&#44; although potassium iodide is thought to act as an immunostimulant&#46; Adverse effects include a metallic taste in the mouth&#44; rhinitis&#44; expectoration&#44; urticaria&#44; petechiae&#44; bullous or acneiform rash&#44; vasculitis&#44; and induction of hypothyroidism or hyperthyroidism&#46; Potassium iodide is contraindicated during pregnancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">20&#44;22</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">2&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Itraconazole</span> 200<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 3 to 6 months&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">22</span></a> This is the first-line treatment recommended in most treatment guidelines&#46; It tends to be a little more expensive than potassium iodide&#44; but it has fewer adverse effects&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">3&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Other options</span>&#46; Terbinafine 250-1000<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 3 to 6 months<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">23&#44;24</span></a>&#59; fluconazole 400<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 3 to 6 months<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">22</span></a>&#59; amphotericin B &#40;deoxycholate&#41; 0&#46;5-1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d for systemic disease or liposomal or lipid formulations of amphotericin B at a dose of 3-5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">22</span></a>&#59; local heat or thermotherapy for 2 or 3 months&#44;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">22</span></a> or a combination of the above treatments &#40;potassium iodide with itraconazole&#44; itraconazole with terbinafine&#44; and terbinafine with potassium iodide&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">25</span></a> The addition of photodynamic therapy with methyl aminolevulinate or even better intralesional methylene blue 1&#37; &#40;combined or not with itraconazole&#41; has produced good results in vitro and in 1 patient&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">26</span></a></p></li></ul></p><p id="par0135" class="elsevierStylePara elsevierViewall">Surgery can have an important role in osteoarticular sporotrichosis&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">22</span></a> Debridement and arthrodesis were traditionally considered the treatments of choice but prosthetic joint replacement followed by long-term antifungal treatment has also been described as a viable option</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">1&#46;1</span><span class="elsevierStyleSectionTitle" id="sect0060">Chromoblastomycosis &#40;Chromomycosis&#41;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Chromoblastomycosis&#44; also known as <span class="elsevierStyleItalic">chromomycosis</span>&#44; is a chronic polymorphic fungal infection of the skin and subcutaneous tissue&#46; It is caused by several species of melanized or dematiaceous fungi&#44; which produce a dark pigment&#46; The parasitic forms of these fungi are called <span class="elsevierStyleItalic">fumagoid</span> or <span class="elsevierStyleItalic">muriform</span> cells &#40;sclerotic bodies&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">27&#8211;30</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The most common species that cause chromoblastomycosis are <span class="elsevierStyleItalic">Fonsecaea pedrosoi</span>&#44; <span class="elsevierStyleItalic">Fonsecaea monophora&#44; Cladophialophora carrionii&#44; Phialophora verrucosa</span>&#44; and <span class="elsevierStyleItalic">Rhinocladiella aquaspersa</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">5&#44;27&#44;28</span></a> Most patients have a history of a traumatic injury involving wood or vegetation&#44; and over 80&#37; are rural workers in Africa&#44; Asia&#44; and South America who tend to walk barefoot&#46; The fungi responsible for chromoblastomycosis have been found worldwide&#44; though they are more common in tropical and subtropical countries&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">27</span></a></p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Clinical Forms</span><p id="par0150" class="elsevierStylePara elsevierViewall">The fungus generally penetrates the skin through a skin injury&#44; typically located on the lower limbs&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">31</span></a> About 1 or 2 months later&#44; the infected individual develops a papule that progresses to a slow-growing warty nodule &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The infection is limited to the subcutaneous tissue and does not spread to either muscle or bone&#44; except in immunocompromised patients&#46; Individual lesions can develop a thick cauliflower-like appearance and bacterial superinfection is common&#46; Secondary lymphedema&#44; possibly progressing to elephantiasis&#44; and squamous cell carcinoma may occur&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">27</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Diagnosis</span><p id="par0155" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">1&#46;</span><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Direct examination&#46;</span> Direct examination of crusts and fragments of skin can reveal parasitic forms that occur in isolation or form characteristic septa &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The microscopic structures observed are common to all species&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">27&#44;28</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">2&#46;</span><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Culture&#46;</span> The fungi that cause chromoblastomycosis grow slowly when cultivated on SDA with or without antibiotics &#40;chloramphenicol and cycloheximide&#41;&#59; they produce dark olivaceous or black colonies with a flat velvety surface and a raised center&#46; Distinction between species is difficult and is based on reproductive structures and molecular identification&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">30</span></a> Molecular biology techniques &#40;PCR&#41;&#44; in particular targeting internal transcribed spacer &#40;ITS&#41; regions of ribosomal DNA &#40;rDNA&#41;&#44; are also useful&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">32&#44;33</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">3&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Histology&#46;</span> Histologic examination shows characteristic pseudoepitheliomatous hyperplasia in the epidermis and a mixed granulomatous inflammatory infiltrate with giant cells containing characteristic round fungal structures &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; in the dermis&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">27</span></a></p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Treatment</span><p id="par0175" class="elsevierStylePara elsevierViewall">Chromoblastomycosis is extremely difficult to treat and is often refractory to diverse options&#44; including nonpharmacological treatments such as curettage&#44; electrocoagulation&#44; and cryosurgery&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">5</span></a> Antifungals must be maintained for at least 6 months&#44; and while they may produce a favorable clinical outcome&#44; recurrences during or after therapy are common&#46; Treatment should be terminated when all the lesions disappear&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">27</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Other treatments include surgical resection of small lesions&#59; local cryosurgery &#40;in association with an antifungal to prevent lymphatic spread&#41;&#59; itraconazole 200-400<span class="elsevierStyleHsp" style=""></span>mg&#47;d alone or combined with 5-fluorocitosine 30<span class="elsevierStyleHsp" style=""></span>mg&#47;kg 4 times a day for 6 months&#59; terbinafine 250-500<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 12 months&#44; and in the case of systemic involvement intravenous amphotericin B at a dose of 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg or liposomal or lipid formulations of amphotericin B at a dose of 3-5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">27</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Mycetoma</span><p id="par0185" class="elsevierStylePara elsevierViewall">Mycetoma is a chronic local infection caused by several species of fungi and bacteria&#46; The infection is called <span class="elsevierStyleItalic">actinomycetoma</span> when it is caused by aerobic filamentous bacteria and <span class="elsevierStyleItalic">eumycetoma</span> when it is caused by fungi&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">34</span></a> It is characterized by the formation of aggregates of the causative microorganisms in abscesses&#46; These aggregates are known as <span class="elsevierStyleItalic">grains</span> or <span class="elsevierStyleItalic">granules</span>&#46; Granules can drain through sinuses opening onto the skin or affect adjacent bones&#46; The disease advances via direct spread&#44; with very few cases of dissemination to distant sites&#46; The causative agents are generally found in the soil and they enter the body through broken skin&#46; Most cases involve rural workers&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Etiology</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">1&#46;</span><p id="par0195" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Fungi&#46;</span> The fungi that cause eumycetoma produce white or dark granules&#46; They are particularly common in Africa&#44; India&#44; and Mexico&#46; Dark granules are formed by <span class="elsevierStyleItalic">Madurella mycetomatis&#44; Trematosphaeria grisea</span>&#44; and <span class="elsevierStyleItalic">Leptosphaeria</span> senegalensis&#44;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">35</span></a> while white granules are formed by <span class="elsevierStyleItalic">Fusarium</span> spp<span class="elsevierStyleItalic">&#46;</span>&#44; <span class="elsevierStyleItalic">Acremonium</span> spp<span class="elsevierStyleItalic">&#46;</span>&#44; and <span class="elsevierStyleItalic">Aspergillus nidulans&#46;</span></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">2&#46;</span><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Filamentous bacteria or aerobic actinomycetes</span>&#46; The granules formed by these species are red &#40;<span class="elsevierStyleItalic">Actinomadura pelletieri</span>&#41;&#44; white-yellow &#40;<span class="elsevierStyleItalic">Actinomadura madurae</span>&#44; <span class="elsevierStyleItalic">Nocardia brasiliensis</span>&#44; and <span class="elsevierStyleItalic">Nocardia</span> spp&#46;&#41;&#44; or yellow-brown &#40;<span class="elsevierStyleItalic">Streptomyces somaliensis</span>&#41;&#46; Actinomycetes are found all over the world&#44; not just in tropical countries&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">36</span></a></p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Clinical Forms</span><p id="par0205" class="elsevierStylePara elsevierViewall">The clinical characteristics of mycetoma caused by fungi and actinomycetes are very similar&#46; Lesions are more common on the feet&#44; shins&#44; and hands&#46; The earliest clinical manifestation is a hard painless nodule that spreads slowly to produce papules and sinuses that discharge fluid containing granules onto the skin surface&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">35&#44;36</span></a> The original site of infection is distorted by local tissue swelling&#44; formation of chronic sinuses&#44; and late bone involvement &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Lesions are rarely painful&#44; except in late stages&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Diagnosis</span><p id="par0210" class="elsevierStylePara elsevierViewall">Mycetoma granules &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; are a key diagnostic finding and are generally found on examining discharge from sinuses or on crushing a crust taken from a lesion&#46; Microscopic examination will show whether these granules are formed by small actinomycetes or wider mycotic filaments&#46; Definitive identification requires culture&#44; which is normally carried out on SDA with or without antibiotics &#40;chloramphenicol and cycloheximide&#41;&#59; chloramphenicol alone is preferred in the case of hyaline fungi&#46; The agents can also be identified by molecular biology testing&#44; particularly PCR analysis using different markers<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">37</span></a> depending on the causative agents &#40;e&#46;g&#46;&#44; ITS regions of rDNA&#44; &#946;-tubulin&#44;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">38</span></a> and D1&#47;D2&#41;&#46; Partial ribosomal RNA gene sequence analysis&#44; by contrast&#44; can be used to identify <span class="elsevierStyleItalic">Nocardia</span> and <span class="elsevierStyleItalic">Actinomadura</span> species&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">36</span></a> Histologic findings are similar in all forms of mycetoma&#44; and include an inflammatory center rich in polymorphonuclear cells &#40;true abscesses&#41;&#44; epithelioid cells&#44; giant cells&#44; and fibrosis&#46; The granules are located in the center of the inflammation&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">35&#44;39</span></a> Imaging studies&#44; while complementary&#44; can aid diagnosis by showing soft tissue swelling&#44; osteolytic lesions&#44; and cortical thickening&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">The differential diagnosis should include bacterial osteomyelitis&#44; tuberculous osteomyelitis&#44; hidradenitis suppurativa&#44; Kaposi sarcoma&#44; and cutaneous tuberculosis&#44; among others&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">35&#44;39</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Treatment</span><p id="par0220" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Actinomycetoma</span>&#46; The treatment regimen with the strongest evidence base for nocardial mycetoma is trimethoprim-sulfamethoxazole plus diaminodiphenyl sulfone &#40;dapsone&#41; for 6 months to 2 years&#46; Amoxicillin-clavulanic acid&#44; administered over 6 months&#44; can be used for refractory cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0540"><span class="elsevierStyleSup">40&#8211;42</span></a> The treatment of choice for extensive infection and&#47;or visceral involvement is amikacin combined with trimetoprim-sulfametoxazol<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">39</span></a> or meropenem&#46;<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">43&#44;44</span></a> There have been isolated reports of successful outcomes with other agents in patients who do not respond to these treatments&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">36&#44;39&#44;45</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Eumycetoma</span>&#46; Unlike in actinomycetoma&#44; where pharmacological treatment is associated with good outcomes&#44; the standard treatment in eumycetoma is a combination of medical treatment and surgery&#46; Acceptable results have been reported for the use of last-generation triazoles&#44; such as itraconazole and fluconazole used alone or in combination with terbinafine&#46; These drugs are administered over a long period and only after exhausting all surgical options&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">35&#44;45</span></a></p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Phaeohyphomycosis</span><p id="par0230" class="elsevierStylePara elsevierViewall">Phaeohyphomycosis is a heterogeneous group of mycoses caused by dark-walled &#40;dematiaceous&#41; fungi&#46;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">46&#44;47</span></a> These fungi are found in all climates&#44; although they are more common in tropical climates&#46; There has been a recent rise in cases among immunosuppressed patients with HIV infection or AIDS&#44; transplant recipients&#44; and diabetic patients&#44; among others&#46;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">46&#44;48</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">The most common causative agents are <span class="elsevierStyleItalic">Exophiala</span> spp<span class="elsevierStyleItalic">&#46;&#44; Bipolaris</span> spp&#46;<span class="elsevierStyleItalic">&#44; Curvularia</span> spp&#46;&#44; <span class="elsevierStyleItalic">Pleurophomopsis</span> spp<span class="elsevierStyleItalic">&#46;</span>&#44; <span class="elsevierStyleItalic">Phaeoacremonium</span> spp&#44; and <span class="elsevierStyleItalic">Alternaria</span> spp&#46; The fungi are found mainly in organic debris&#46;</p><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Clinical Forms</span><p id="par0240" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">1&#46;</span><p id="par0245" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Subcutaneous phaeohyphomycosis</span>&#46; Following local trauma or inoculation with foreign material&#44; patients develop a slow-growing solitary lesion &#40;generally a cyst or a nodule&#44; or possibly a plaque or abscess&#41; normally located on the extremities &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">48&#44;49</span></a> The differential diagnosis should include lipomas&#44; epidermal or synoviale cysts&#44; fibromas&#44; foreign body cysts&#44; and bacterial abscesses&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">2&#46;</span><p id="par0250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Systemic or disseminated phaeohyphomycosis</span>&#46; While very rare&#44; systemic phaeohyphomycosis is very serious in immunosuppressed patients&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">50</span></a></p></li></ul></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Diagnosis</span><p id="par0255" class="elsevierStylePara elsevierViewall">Wet-mount microscopy shows diagnostic dark septate hyphae forming branches or chains &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; Growth is slow &#40;3-4 weeks&#41; on SDA and colonies acquire an olivaceous or dark brown color&#46; PCR analysis of markers such as &#946;-tubulin and ITS regions can be used for molecular identification&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">51&#44;52</span></a> Biopsy reveals a cyst wall formed by palisading macrophages with mycotic hyphae&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">49</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Treatment</span><p id="par0260" class="elsevierStylePara elsevierViewall">Treatment of infections caused by <span class="elsevierStyleItalic">Exophiala</span> spp&#46; is controversial&#44; and one option that has been proposed is surgical resection&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">48</span></a> There are also no standard protocols for the treatment of <span class="elsevierStyleItalic">Alternaria</span> infections&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">53</span></a> The best option for phaeohyphomycosis appears to be a combination of antifungal therapy &#40;itraconazole&#44; ketoconazole&#44; or terbinafine&#41; and surgery&#46; <span class="elsevierStyleItalic">Exophiala</span> spp&#46; strains tend to be resistant to fluconazole&#46; Disseminated infections are treated with amphotericin B&#46;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">48&#44;49</span></a></p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Hyalohyphomycosis</span><p id="par0265" class="elsevierStylePara elsevierViewall">Hyalohyphomycosis is caused by hyaline fungi &#40;Hyphomycetes&#41; that form septate hyphae in tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">47</span></a> This classification&#44; however&#44; is rather arbitrary as there are many types of terrestrial and aquatic Hyphomycetes&#46; Just a few organisms&#44; however&#44; can cause infections&#44; most of which are opportunistic&#44; in humans&#46;<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">54&#44;55</span></a> Most of the genera involved in hyalohyphomycosis are morphologically identical when observed in tissue sections and they trigger the same pathologic response&#46; Fungi that frequently cause infections or have another particularly distinctive characteristic are assigned to a different category &#40;e&#46;g&#46;&#44; aspergillosis&#41;&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">The most common agents involved in hyalohyphomycosis are <span class="elsevierStyleItalic">Aspergillus &#40;fumigatus&#44; niger&#44; flavus&#41;</span>&#44; <span class="elsevierStyleItalic">Scopulariopsis</span> spp&#46;&#44; <span class="elsevierStyleItalic">Fusarium</span> spp&#46;&#44; <span class="elsevierStyleItalic">Acremonium recifei</span>&#44; <span class="elsevierStyleItalic">Paecilomyces</span> spp&#46;&#44; <span class="elsevierStyleItalic">Purpureocillum</span> spp&#46;&#44; and <span class="elsevierStyleItalic">Neoscytalidium</span> spp&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">55</span></a> They are all widely distributed in nature&#44; and can be found in any type of soil&#44; wood&#44; or decomposing plant material&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">56</span></a> They affect individuals of either sex and at any age&#44; and immunosuppression is not a necessary condition for infection&#46;</p><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Clinical Forms</span><p id="par0275" class="elsevierStylePara elsevierViewall">Hyalohyphomycosis can be classified as superficial&#44; subcutaneous&#44; or systemic&#46;<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">1&#46;</span><p id="par0280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Superficial hyalohyphomycosis&#46;</span> Superficial infections include dermatomycosis and onychomycosis&#46; They are common in rural workers&#44; fishermen&#44; patients with severe burns&#44; and premature neonates&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">57&#44;58</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">2&#46;</span><p id="par0285" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Subcutaneous hyalohyphomycosis&#46;</span> Traumatic inoculation causes abscesses&#44; cysts&#44; and tumor-like lesions similar to those seen in mycetoma &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">56</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">3&#46;</span><p id="par0290" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Systemic hyalohyphomycosis</span>&#46; Systemic infections&#44; while uncommon&#44; are very serious&#46; They affect immunosuppressed patients and can be fatal&#46; Hematogenous and lymphatic spread leads to involvement of the lungs and central nervous system&#46;<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">55&#44;57</span></a></p></li></ul></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Diagnosis</span><p id="par0295" class="elsevierStylePara elsevierViewall">Identification of septate hyaline hyphae by microscopic examination of skin scales&#44; nail fragments&#44; secretions&#44; or fragments provides a presumptive diagnosis&#44; which is then confirmed by culture &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; Most fungi grow on SDA without antibiotics or inhibitors&#46;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">47&#44;59</span></a> As in the cases described above&#44; molecular identification is also possible&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">60</span></a></p><p id="par0300" class="elsevierStylePara elsevierViewall">The differential diagnosis should include other dermatomycoses&#44; epidermal cysts&#44; actinomycetoma&#44; eumycetoma&#44; histoplasmosis&#44; and cryptococcosis&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Treatment</span><p id="par0305" class="elsevierStylePara elsevierViewall">In immunocompetent individuals&#44; the treatments of choice are triazoles&#44; terbinafine&#44; or surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">61</span></a> When the immune system is compromised&#44; the first-line treatment is amphotericin B combined with a triazole &#40;itraconazole 200<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 6 months or fluconazole 150<span class="elsevierStyleHsp" style=""></span>mg twice a week for 6 months&#41;&#46;</p></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Lacaziosis &#40;Lobomycosis&#41;</span><p id="par0310" class="elsevierStylePara elsevierViewall">Lacaziosis&#44; which was formerly known as <span class="elsevierStyleItalic">lobomycosis</span>&#44; is a chronic granulomatous fungal infection of the skin and subcutaneous tissues first described under the name of <span class="elsevierStyleItalic">keloidal blastomycosis</span> in 1930 by Jorge Lobo in Recife&#44; Brazil&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">62</span></a> It is a rare infection found in Central and South America&#59; it is caused by <span class="elsevierStyleItalic">Lacazia loboi</span>&#44;<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">62&#44;63</span></a> a yeast that cannot be grown in culture&#46; The source of infection is thought to be in soil and vegetation&#46; The fungus probably enters through the skin following a penetrating injury&#44; such as a thorn prick or insect bite&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Lacaziosis is characterized by keloidal lesions with well-defined lobulated edges in exposed areas of the body &#40;frequently the face&#44; arms&#44; or legs&#41;&#46; The lesions spread to contiguous sites&#44; although transmission to distant sites is also possible via autoinoculation&#46;</p><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Diagnosis</span><p id="par0320" class="elsevierStylePara elsevierViewall">Diagnosis is facilitated by the identification of abundant fungal structures during direct examination and chains of diffuse round cells connected by small tubular structures in biopsy samples&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">62</span></a> Causative agents can also be identified in tissue by PCR analysis&#44; in particular assays targeting the 18S rDNA fragment&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">64</span></a></p><p id="par0325" class="elsevierStylePara elsevierViewall">The differential diagnosis should include keloids&#44; lepromatous leprosy&#44; and anergic leishmania&#46;</p></span></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Treatment</span><p id="par0330" class="elsevierStylePara elsevierViewall">Antifungals are not effective in lacaziosis and the definitive treatment is surgical resection&#46;<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">62&#44;63</span></a></p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Zygomycosis</span><p id="par0335" class="elsevierStylePara elsevierViewall">Zygomycosis is a heterogeneous group of fungal infections caused by opportunistic Zygomycetes of the orders Mucorales &#40;<span class="elsevierStyleItalic">Rhizopus&#44; Lichtheimia&#44; Mucor</span>&#44; and <span class="elsevierStyleItalic">Rhizomucor</span>&#41; and Entomophthorales &#40;<span class="elsevierStyleItalic">Basidiobolus</span> and <span class="elsevierStyleItalic">Conidiobolus</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">65</span></a> In this section&#44; we will only discuss Entomophthorales fungi&#44; as the Mucorales are addressed in the second part of this review&#44; which looks at systemic mycoses&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">Entomophthoromycosis is characterized by the appearance of a hard&#44; progressive mass that affects the subcutaneous tissues&#46; There are 2 variants&#46; The first is caused by <span class="elsevierStyleItalic">Basidiobolus ranarum</span> and is more common in children&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">66</span></a> Lesions generally appear in the shoulder and pelvic girdles&#44; and present as a slowly spreading woody cellulitis&#46; The second variant is caused by <span class="elsevierStyleItalic">Conidiobolus coronatus</span> and affects adults&#46; The primary infection starts in the lower turbinates of the nose and then spreads to the center of the face&#44; causing painful indurated swelling and severe deformation of the nose&#44; lips&#44; and cheeks&#46;<a class="elsevierStyleCrossRefs" href="#bib0665"><span class="elsevierStyleSup">65&#8211;68</span></a></p></span></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conclusion</span><p id="par0345" class="elsevierStylePara elsevierViewall">We have reviewed the main characteristics of the subcutaneous mycoses and the main diagnostic and treatment methods available &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Conflicts of Interest</span><p id="par0350" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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              "identificador" => "abst0010"
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          "identificador" => "xpalclavsec764389"
          "titulo" => "Keywords"
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          "titulo" => "Palabras clave"
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        5 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Subcutaneous Mycoses"
          "secciones" => array:9 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Sporotrichosis"
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                  "titulo" => "Diagnosis"
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                1 => array:2 [
                  "identificador" => "sec0030"
                  "titulo" => "Treatment"
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              ]
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              "identificador" => "sec0035"
              "titulo" => "Chromoblastomycosis &#40;Chromomycosis&#41;"
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                  "identificador" => "sec0040"
                  "titulo" => "Clinical Forms"
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                  "titulo" => "Diagnosis"
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                  "titulo" => "Treatment"
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              "identificador" => "sec0055"
              "titulo" => "Mycetoma"
              "secciones" => array:4 [
                0 => array:2 [
                  "identificador" => "sec0060"
                  "titulo" => "Etiology"
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                  "titulo" => "Clinical Forms"
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                  "identificador" => "sec0070"
                  "titulo" => "Diagnosis"
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                3 => array:2 [
                  "identificador" => "sec0075"
                  "titulo" => "Treatment"
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              ]
            ]
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              "identificador" => "sec0080"
              "titulo" => "Phaeohyphomycosis"
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                0 => array:2 [
                  "identificador" => "sec0085"
                  "titulo" => "Clinical Forms"
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                1 => array:2 [
                  "identificador" => "sec0090"
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                2 => array:2 [
                  "identificador" => "sec0095"
                  "titulo" => "Treatment"
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              ]
            ]
            5 => array:3 [
              "identificador" => "sec0100"
              "titulo" => "Hyalohyphomycosis"
              "secciones" => array:3 [
                0 => array:2 [
                  "identificador" => "sec0105"
                  "titulo" => "Clinical Forms"
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                1 => array:2 [
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                  "titulo" => "Diagnosis"
                ]
                2 => array:2 [
                  "identificador" => "sec0115"
                  "titulo" => "Treatment"
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "sec0120"
              "titulo" => "Lacaziosis &#40;Lobomycosis&#41;"
              "secciones" => array:1 [
                0 => array:2 [
                  "identificador" => "sec0125"
                  "titulo" => "Diagnosis"
                ]
              ]
            ]
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              "identificador" => "sec0130"
              "titulo" => "Treatment"
            ]
            8 => array:2 [
              "identificador" => "sec0135"
              "titulo" => "Zygomycosis"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0140"
          "titulo" => "Conclusion"
        ]
        8 => array:2 [
          "identificador" => "sec0145"
          "titulo" => "Conflicts of Interest"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-01-07"
    "fechaAceptado" => "2016-05-29"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec764389"
          "palabras" => array:6 [
            0 => "Deep mycosis"
            1 => "Subcutaneous mycosis"
            2 => "Systemic mycosis"
            3 => "Sporotrichosis"
            4 => "Chromoblastomycosis"
            5 => "Mycetoma"
          ]
        ]
      ]
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          "titulo" => "Palabras clave"
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          "palabras" => array:6 [
            0 => "Micosis profundas"
            1 => "Micosis subcut&#225;neas"
            2 => "Micosis sist&#233;micas"
            3 => "Esporotricosis"
            4 => "Cromoblastomicosis"
            5 => "Micetomas"
          ]
        ]
      ]
    ]
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The deep mycoses are uncommon in our setting&#46; These fungal infections occur mainly in immunosuppressed patients or in tropical climates&#44; and include subcutaneous infections and systemic infections&#46; The skin is always involved in the former&#46; In the first part of this review&#44; we describe the main subcutaneous mycoses&#58; sporotrichosis&#44; chromoblastomycosis&#44; mycetoma&#44; phaeohyphomycosis&#44; hyalohyphomycosis&#44; and lacaziosis&#46; Early recognition and treatment is important&#44; as these infections are frequently associated with high morbidity&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Las micosis profundas son infecciones poco frecuentes en nuestro medio&#46; Se presentan principalmente en pacientes inmunodeprimidos o en regiones de climas tropicales&#44; que abarcan las micosis subcut&#225;neas y las micosis sist&#233;micas&#46; Las micosis subcut&#225;neas o por implantaci&#243;n siempre producen signos de afectaci&#243;n cut&#225;nea&#46; En la primera parte de esta revisi&#243;n se realizar&#225; una revisi&#243;n de las principales micosis subcut&#225;neas&#58; esporotricosis&#44; cromoblastomicosis&#44; micetomas&#44; feohifomicosis&#44; hialohifomicosis y lacaziosis&#46; Reconocer y tratar estas micosis subcut&#225;neas de forma precoz es importante&#44; ya que a menudo est&#225;n asociadas a una alta morbilidad&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Carrasco-Zuber JE&#44; Navarrete-Dechent C&#44; Bonifaz A&#44; Fich F&#44; Vial-Letelier V&#44; Berroeta-Mauriziano D&#46; Afectaci&#243;n cut&#225;nea en las micosis profundas&#58; una revisi&#243;n de la literatura&#46; Parte 1&#58; micosis subcut&#225;neas&#46; Actas Dermosifiliogr&#46; 2016&#59;107&#58;806&#8211;815&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mycosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Main Causative Agent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sporotrichosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Sporothrix schenckii</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cultivation of pus aspirated from nodules&#59; histology&#59; PCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Saturated solution of potassium iodide for 3 wk&#59; itraconazole 200<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 3&#8211;6 mo&#59; combinations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chromoblastomycosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Fonsecaea pedrosoi</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Microscopic examination&#59; culture&#59; histology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Very difficult&#46; Itraconazole 200<span class="elsevierStyleHsp" style=""></span>mg&#47;d for 6 mo&#59; terbinafine for 12 mo&#59; amphotericin B&#59; combinations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mycetoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Filamentous actinomycetes and filamentous fungi&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Identification of mycetoma granules&#59; culture&#59; histology&#59; PCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Antibiotics for actinomycetoma&#59; antifungals<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>surgery for eumycetoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phaeohyphomycosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Exophiala jeanselmei</span><br><span class="elsevierStyleItalic">Alternaria</span> spp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Microscopic examination and culture&#59; histology&#59; PCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Controversial&#46; Surgery<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>combination of antifungals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hyalohyphomycosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Opportunistic <span class="elsevierStyleItalic">Aspergillus</span> &#40;<span class="elsevierStyleItalic">fumigatus&#44; niger&#44; flavus</span>&#41;&#44; <span class="elsevierStyleItalic">Fusarium</span> spp&#46;&#44; <span class="elsevierStyleItalic">Paecilomyces</span>&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Microscopic examination and culture&#59; PCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Immunocompetent patients&#58; triazoles&#59; terbinafine&#59; ciclopirox olamine&#59; surgery<br>Immunosuppressed patients&#58; amphotericin B combined with a triazole for 6 mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lacaziosis &#40;lobomycosis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Lacazia loboi</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Microscopic examination&#59; histology&#59; PCR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Entomophthoromycosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Conidiobolus coronatus</span><br><span class="elsevierStyleItalic">Basidiobolus ranarum</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Direct examination and culture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Surgery and systemic antifungals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Summary of the Characteristics of the Subcutaneous Mycoses&#46;</p>"
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      "titulo" => "References"
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                    0 => array:2 [
                      "titulo" => "Subcutaenous mycoses"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "O&#46; Welsh"
                            1 => "R&#46; Arenas"
                          ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.clindermatol.2011.09.005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Dermatol"
                        "fecha" => "2012"
                        "volumen" => "30"
                        "paginaInicial" => "367"
                        "paginaFinal" => "368"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22682182"
                            "web" => "Medline"
                          ]
                        ]
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                  ]
                ]
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              "identificador" => "bib0350"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Micosis importadas"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Rezusta"
                            1 => "J&#46; Gil"
                            2 => "M&#46;C&#46; Rubio"
                            3 => "M&#46;J&#46; Revillo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Bol Control Calidad SEIMC"
                        "fecha" => "2001"
                        "paginaInicial" => "1"
                        "paginaFinal" => "15"
                      ]
                    ]
                  ]
                ]
              ]
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                    0 => array:2 [
                      "titulo" => "Cutaneous manifestations of deep mycosis&#58; An experience in a tropical pathology laboratory"
                      "autores" => array:1 [
                        0 => array:2 [
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ISSN: 15782190
Original language: English
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Idiomas
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