Case and Research Letter
A Community-Acquired Tropical Skin Disease
Dermatosis tropical adquirida en la comunidad
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"apellidos" => "Toquica Díaz" ] 3 => array:2 [ "nombre" => "M.A." "apellidos" => "Ospina Delgado" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731022008067?idApp=UINPBA000044" "url" => "/00017310/0000011400000003/v1_202303051528/S0001731022008067/v1_202303051528/es/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S0001731022007645" "issn" => "00017310" "doi" => "10.1016/j.ad.2021.10.019" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "3176" "copyright" => "AEDV" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2023;114:261-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">CARTA CIENTÍFICO-CLÍNICA</span>" "titulo" => "Dermatosis tropical adquirida en la comunidad" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "261" "paginaFinal" => "263" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "A Community-Acquired Tropical Skin Disease" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1005 "Ancho" => 1505 "Tamanyo" => 451059 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Imágenes de anatomía patológica. A) Sección histológica (H-E, x40) en la que se aprecia, en el centro de la imagen, una célula gigante multinucleada con células muriformes o cuerpos de Medlar en su interior. B) Sección histológica (H-E, x63) en la que se distinguen muy bien los cuerpos de Medlar en el centro de la imagen. C) Sección histológica (PAS, x40), en la que se observan de forma detallada los cuerpos de Medlar. D) Sección histológica (metenamina de plata, x40), en la que también se observan de forma detallada los cuerpos de Medlar.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.F. Orts Paco, M.C. Soria Martínez, C. Godoy Alba, J. Navarro Pascual" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J.F." "apellidos" => "Orts Paco" ] 1 => array:2 [ "nombre" => "M.C." "apellidos" => "Soria Martínez" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Godoy Alba" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Navarro Pascual" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731022007645?idApp=UINPBA000044" "url" => "/00017310/0000011400000003/v1_202303051528/S0001731022007645/v1_202303051528/es/main.assets" ] "asociados" => array:1 [ 0 => array:19 [ "pii" => "S0001731022007645" "issn" => "00017310" "doi" => "10.1016/j.ad.2021.10.019" "estado" => "S300" "fechaPublicacion" => "2023-03-01" "aid" => "3176" "copyright" => "AEDV" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2023;114:261-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">CARTA CIENTÍFICO-CLÍNICA</span>" "titulo" => "Dermatosis tropical adquirida en la comunidad" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "261" "paginaFinal" => "263" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "A Community-Acquired Tropical Skin Disease" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1005 "Ancho" => 1505 "Tamanyo" => 451059 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Imágenes de anatomía patológica. A) Sección histológica (H-E, x40) en la que se aprecia, en el centro de la imagen, una célula gigante multinucleada con células muriformes o cuerpos de Medlar en su interior. B) Sección histológica (H-E, x63) en la que se distinguen muy bien los cuerpos de Medlar en el centro de la imagen. C) Sección histológica (PAS, x40), en la que se observan de forma detallada los cuerpos de Medlar. D) Sección histológica (metenamina de plata, x40), en la que también se observan de forma detallada los cuerpos de Medlar.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.F. Orts Paco, M.C. Soria Martínez, C. Godoy Alba, J. Navarro Pascual" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J.F." "apellidos" => "Orts Paco" ] 1 => array:2 [ "nombre" => "M.C." "apellidos" => "Soria Martínez" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Godoy Alba" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Navarro Pascual" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731022007645?idApp=UINPBA000044" "url" => "/00017310/0000011400000003/v1_202303051528/S0001731022007645/v1_202303051528/es/main.assets" ] ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letter</span>" "titulo" => " A Community-Acquired Tropical Skin Disease" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "T261" "paginaFinal" => "T263" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.F. Orts Paco, M.C. Soria Martínez, C. Godoy Alba, J. Navarro Pascual" "autores" => array:4 [ 0 => array:4 [ "nombre" => "J.F." "apellidos" => "Orts Paco" "email" => array:1 [ 0 => "jose.orts.95@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.C." "apellidos" => "Soria Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Godoy Alba" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Navarro Pascual" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario Reina Sofía, Murcia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica. Hospital General Universitario Reina Sofía, Murcia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Dermatosis tropical adquirida en la comunidad" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1005 "Ancho" => 1505 "Tamanyo" => 451059 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathology findings. A, Histologic section (hematoxylin–eosin, ×40). Note the multinucleate giant cell in the center of the image, with Medlar bodies (muriform cells) in the interior. B, Histologic section (hematoxylin–eosin, ×63). The Medlar bodies are clearly visible in the center of the image. C, Histologic section (periodic acid–Schiff, ×40) showing detail of the Medlar bodies. D, Histologic section (methenamine silver, ×40) showing detail of the Medlar bodies.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Tropical skin diseases are conditions acquired in tropical regions and countries. They affect more than 17<span class="elsevierStyleHsp" style=""></span>000 travelers per year.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> We report the case of a patient with a community-acquired tropical skin disease and comment on diagnosis and treatment.</p><p id="par0010" class="elsevierStylePara elsevierViewall">An 82-year-old man with a history of arterial hypertension, type 2 diabetes mellitus, chronic venous insufficiency, and hereditary hemochromatosis attended the clinic with an excrescent suppurative lesion on the dorsum of the left foot. The lesion had first appeared 3 months previously and had been treated unsuccessfully with antiseptics and topical corticosteroids. The patient reported not having traveled outside the autonomous community of Murcia. He kept a kitchen garden and did not recall accidental injury. The physical examination revealed a soft violaceous multilobulated nodular plaque measuring 3<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Examination of a punch biopsy specimen revealed pseudoepitheliomatous hyperplasia with intense granulomatous inflammation, foci of abscessification, multinucleate giant cells, and Melar bodies (muriform cells) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The biopsy specimen was cultured at our hospital in blood-agar and Sabouraud agar media at 30<span class="elsevierStyleHsp" style=""></span>°C. At 21 days, we observed the growth of black colonies (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), which, on examination with an optical microscope, were identified as belonging to the genus <span class="elsevierStyleItalic">Exophiala</span>. The strain was sent to the National Microbiology Center, where it was further identified using ribosomal DNA sequencing as <span class="elsevierStyleItalic">Exophiala bergeri</span>. The patient was treated with itraconazole 200<span class="elsevierStyleHsp" style=""></span>mg/d. Nevertheless, he died of septic shock secondary to septic arthritis of the knee after 8 months of follow-up. His skin lesion had improved slightly.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Chromoblastomycosis is a verrucous skin disease caused by chronic infection of the subcutaneous cellular tissue by dematiaceous fungi. The most common species are <span class="elsevierStyleItalic">Fonsecaea pedrosoi</span>, <span class="elsevierStyleItalic">Fonsecaea compacta</span>, <span class="elsevierStyleItalic">Fonsecaea monophora</span>, <span class="elsevierStyleItalic">Phialophora verrucosa</span>, <span class="elsevierStyleItalic">Cladophialophora carrionii</span>, and <span class="elsevierStyleItalic">Rhinocladiella aquaspersa. Exophiala bergeri</span>, on the other hand, is a much less common species.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The disease occurs mostly in tropical and subtropical regions (Caribbean, Africa, Australia, and Japan). The reservoir can be the ground, plants, and decomposing wood. Therefore, cases are typically reported among rural workers such as farmers, cattle farmers, and miners and mainly involve men. The portal of entry is usually a lesion on the limbs. Chromoblastomycosis is considered an occupational disease throughout the world. While there have been reports of cases in immunodepressed patients (especially those with cancer and solid organ recipients), it mainly affects immunocompetent persons.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The disease manifests clinically as a papule or nodule, typically on the leg, that progresses to form a verrucous or granulomatous plaque. Diagnosis requires a full clinical history and culture of a biopsy specimen. Histopathology findings are very characteristic, i.e., Medlar bodies (which are pathognomonic), and enable the disease to be differentiated from phaeohyphomycosis, a fungal disease caused by dematiaceous fungi that mostly affects immunodepressed patients. Moreover, it is noteworthy that the diagnosis is confirmed based on microbiological findings. The differential diagnosis includes other diseases, such as cutaneous tuberculosis, tertiary syphilis, blastomycosis, leishmaniasis, and phaeohyphomycosis.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Therapeutic options are limited.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a> In the case of localized disease, we can turn to surgical resection with suitable margins. In disseminated disease, the approach of choice comprises systemic antifungal agents, which may be combined with other treatments. The most widely used are itraconazole (200–400<span class="elsevierStyleHsp" style=""></span>mg/d) and terbinafine (250–500<span class="elsevierStyleHsp" style=""></span>mg/d). These should be administered over long periods (8–36 months), since the response is slow. The infection is cured in up to 85%–90% of cases. Itraconazole in pulses (400<span class="elsevierStyleHsp" style=""></span>mg daily for 1 week per month over 6–12 months) was recently shown to be successful. Posaconazole and voriconazole have proven effective in patients who did not respond to itraconazole and terbinafine. Amphotericin B, 5-fluorocytosine, ketoconazole, and thiabendazole are less commonly used owing to their poor risk-benefit ratio. As for physical approaches, cryotherapy and heat therapy have proven effective alone and when combined with systemic antifungal agents. A favorable response to photodynamic therapy with 5-aminolevulinic acid has also been reported, especially when combined with systemic antifungal agents.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Other treatments include CO<span class="elsevierStyleInf">2</span> laser therapy and topical imiquimod.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">We were only able to find 7 reported autochthonous cases of chromoblastomycosis in Spain.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7–10</span></a> Only 1 case involved an immunodepressed patient.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Here, we report the eighth case of chromoblastomycosis acquired in Spain. It is important to bear this diagnosis in mind when addressing a suppurative nodule or papule that progresses to a verrucous or granulomatous plaque on the lower limbs, even in cases with no history of travel to a tropical region. The characteristics of autochthonous patients do not differ from the prototypical model. The relationship with the rural environment and associated professions should be stressed.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 605 "Ancho" => 755 "Tamanyo" => 59023 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical image. Excrescent violaceous lesion on the dorsum of the left foot.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1005 "Ancho" => 1505 "Tamanyo" => 451059 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathology findings. A, Histologic section (hematoxylin–eosin, ×40). Note the multinucleate giant cell in the center of the image, with Medlar bodies (muriform cells) in the interior. B, Histologic section (hematoxylin–eosin, ×63). The Medlar bodies are clearly visible in the center of the image. C, Histologic section (periodic acid–Schiff, ×40) showing detail of the Medlar bodies. D, Histologic section (methenamine silver, ×40) showing detail of the Medlar bodies.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 914 "Ancho" => 1740 "Tamanyo" => 137367 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Macroscopic images of the microbiology culture. Note the characteristic black color and hairy surface of the colonies.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spectrum of disease and relation to place of exposure among ill returned travelers" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.O. Freedman" 1 => "L.H. Weld" 2 => "P.E. Kozarsky" 3 => "T. Fisk" 4 => "R. 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