2015, Volume 31, Number 3, Page(s) 223-225
Cutaneous Chromoblastomycosis Mimicking Tuberculosis Verrucosa Cutis: Look for Copper Pennies!
Arghya BANDYOPADHYAY1, Kaushik MAJUMDAR2, Mimi GANGOPADHYAY1, Sabyasachi BANERJEE3
1Department of Pathology, North Bengal Medical College, WEST BENGAL, INDIA
2Department of Pathology, G B Pant Hospital, NEW DELHI, INDIA
3Department of Dermatology, North Bengal Medical College, WEST BENGAL, INDIA
Keywords: Chromoblastomycosis, Dermatomycoses, Infectious skin diseases
Chromoblastomycosis is a rare chronic fungal infection of skin and
subcutaneous tissue. It is primarily a disease of tropical and subtropical
regions and affects mainly the agricultural workers following trauma
with vegetable matter. Cutaneous Chromoblastomycosis may
clinically mimic cutaneous tuberculosis as both the condition usually
presents with hyper pigmented verrucous lesion of skin.
Here in we report a case of chronic cutaneous Chromoblastomycosis
in a middle aged woman from north eastern part of India, who
was initially misdiagnosed as Tuberculosis verrucosa cutis. In
histopathology characteristic brown colored spores of the fungus
(also known as copper pennies) were seen within dermal abscess.
The organism isolated from culture of the biopsy material was
Fonsecaea pedrosoi thus confirming our diagnosis of cutaneous
chromoblastomycosis. The patient responded well to oral Itraconazole.
The dermatologists and pathologists should be aware of this
condition especially when dealing with verrucous lesion of the skin.
The pathologists should search for fungal spores in cutaneous lesion
with pseudoepitheliomatous hyperplasia and dermal abscess.
Chromoblastomycosis is a localized chronic infection of
skin and subcutaneous tissue caused by any of the several
related dematiaceous (pigmented) fungi1
. Cases have
been documented from several states of India1-5
The characteristic lesions are warty papules, verrucous
plaques or solid nodules developing in the skin at the
site of traumatic implantation of the fungus, usually at
. Diagnosis depends on demonstration
of the fungus in histopathological section or in culture1
. The condition is often misdiagnosed as it is clinically
indistinguishable from cutaneous tuberculosis1,3
in we report a case of cutaneous Chromoblastomycosis from sub-Himalayan region of West Bengal, India, presenting
with multiple hyperpigmented verrucous plaques and was
initially misdiagnosed as tuberculosis verrucosa cutis and
offered treatment for the same.
A 50-year-old lady who was an agricultural worker presented
to the dermatology outpatient department of North Bengal
Medical College hospital with multiple hyperpigmented
verrucous plaques in her right arm (Figure 1
). The lesions
initially appeared erythematous, and gradually became
verrucous during a period of one and half years. She had
no regional lymphadenopathy. Cutaneous tuberculosis was diagnosed in a rural health centre and subsequently
treated with anti-tubercular drugs for 6 months, without
any response. Her routine hematological and biochemical
parameters were within normal limits. Direct KOH
mount for fungus were negative. Histopathology (HP)
section of the skin lesion revealed marked acanthosis
with pseudoepitheliomatous hyperplasia. Dermis showed
inflammatory infiltrate comprising of neutrophils,
lymphocytes, histiocytes and foreign body giant cells. At
places, microabcess formation along with multiple round
thick walled dark brown sclerotic bodies resembling
“copper pennies”, in accordance with the morphology of
chromoblastomycosis were seen (Figure 2
). These fungal
spores were 5-12 μm in diameter, present in singles, small
chains and small clusters (Figure 3
). The spores also showed
intracellular wall formation, that indicates reproduction.
Ziehl-Neelsen (ZN) stain for acid fast bacilli (AFB) was
negative. The organism isolated from culture of the biopsy
material was Fonsecaea pedrosoi thus confirming our
diagnosis of cutaneous chromoblastomycosis. The patient
responded well to Itraconazole 100 mg twice daily and she
was on monthly follow up. The lesion gradually subsided
by 6 months.
Click Here to Zoom
|Figure 2: Scanner view of the histopathology section showing
pseudoepitheliomatous hyperplasia, dermal abscess formation,
collection of multinucleated giant cells (arrow) and barely visible
fungal profiles (encircled) in this magnification (H&E stain, x40)
Inset: Brown-colored spores of Chromoblastomycosis (copper
pennies) (H&E stain, x400).
Click Here to Zoom
|Figure 3: Higher magnification showing brown-colored spores
of Chromoblastomycosis (copper pennies) within dermal
microabscess (H&E stain, x400x).
Chromoblastomycosis was first described in 1914 by Max
Rudolph in Brazil2
. Subsequently Medlar described the
characteristic histological appearance of sclerotic bodies,
which thereafter were named as ‘Medlar bodies’. Other synonyms
are “copper-pennies” or “mauriform” cells2
is belong to phaeohypomycosis group
and caused by dematiaceous (naturally pigmented) fungi
such as Fonsecaea pedrosoi, Phialophora verrucosa, Fonsecaea
compactum, Cladophialophora carrionii, Exophiala jeanselmei, E. castellanii and Rhinocladiella aquaspersa.
Fonsecaea pedrosoi is the most common causative agent of
Chromoblastomycosis is an indolent cutaneous infection,
which can present as nodular, plaque like, verrucous,
or cicatrical lesions6. The disease is cosmopolitan in
distribution but most cases are encountered in tropical or
sub-tropical regions. Mode of transmission is inoculation
of soil or vegetable matter contaminated by the pigmented
fungi though minor trauma8. Our patient being an agricultural worker, may have encountered a similar trivial
injury which she could not recollect.
Primary lesions develop at the site of injury and remain
localized for many years8. New lesions develop by
autoinoculation or through propagation by lymphatic
vessels causing elephantiasis; hematogenous spread
can also occur rarely. Development of squamous cell
carcinoma had also been reported in the long standing
cases9. The HP of cutaneous Chromoblastomycosis
reveals pseudoepitheliomatous hyperplasia, dermal abscess
formation, chronic granulomatous inflammation with
multinucleated giant cells and diagnostic ‘copper penny’
bodies1,2,10. In this case though well defined granuloma
was not observed, histiocytes and foreign body giant cells
were noted. As the spores are naturally pigmented with
melanin, diagnosis can be made on morphology alone; no
special stains are required to demonstrate the fungi10.
The brown colored sclerotic bodies are best demonstrated
in H&E sections and easily identified in colorless
background of unstained or de stained sections10. Thus
examination of unstained or de stained sections for spores
after their detection in H&E section provides confirmation
of diagnosis without the use of unnecessary special stains10. Causative agents of chromoblastomycosis can be
distinguished in culture but their tissue forms are identical.
Culture of the organism show slow growing green to
black colonies, and microscopic appearance of the conidia
formation identifies the species1,4.
Clinically the condition may simulate tuberculosis
verrucosa cutis, squamous cell carcinoma, plamoplantar
psoriasis and sporotrichosis1,2,3. This case was
misdiagnosed as tuberculosis verrucosa cutis clinically
and undergone treatment for the same, with no response.
Pradeepkumar et al.1 and De et al.3 also reported
cases of Chromoblastomycosis mimicking cutaneous
Treatment of Chromoblastomycosis is not well established3. Previously radical, often mutilating surgery was
considered as the optimal approach4. Recently
itraconazole (200-400mg/ day) has been effectively used
with 80-90% success rate3. This patient also responded
well to itraconazole, with resolution of lesion within 6
In conclusion, physicians, dermatologists and pathologists
should consider chromoblastomycosis as one of the
differentials during work up of verrucous lesions of the
skin. The pathologists should purposefully search for the
fungal profiles and ‘copper pennies’ in verrucous cutaneous
lesions with pseudoepitheliomatous hyperplasia and
We wish to thank Prof. Mamata Guha Mallik, Professor,
Department of Pathology, North Bengal Medical College
for her help and support.
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